Day 10: Enhancing neonatal care

We had another successful day at Roosevelt. Upon arriving to our work area in the old ICU we turned on the incubator we repaired yesterday and tested its ability to both heat up, stay and change temperatures. It was successful on all accounts!

It successfully heated up to the desired 37 degrees Celcius

We then continued working on two patient monitors from the infant neonatal critical care unit. We were soon ready to return to the unit and test the monitors. This critical care unit seems to be one of the busiest places in the hospital, partially because it is a relatively small unit, and because there always seem to be a dozen doctors running around and mothers anxiously awaiting news. A resident assisted us in testing the monitors on a patient, an adorable baby named Daniel, who was almost ready to go home. The monitors proved to detect his heart rate, SPO2 levels and print ECG patterns correctly. We gave the unit 2 more usable monitors!

One of the monitors was almost 30 years old.

The two monitors we fixed, on a cart ready to use!

Checking the readings of the monitor.

After returning the repaired monitors we returned the repaired incubator as well. Returning equipment after fixing it is extremely rewarding. Our help is appreciated immensely and there is no doubt that the equipment we were asked to fix (and was completely out of use) will help Roosevelt provide to care to the countless number of patients seeking care daily. We spent the rest the day at Roosevelt working on some ECGs we were just given- unfortunately they are missing essential parts and are hard to troubleshoot, but we are doing our best.
Before we left we had to say goodbye to the fabulous Jose who has been our point person throughout the trip, he has been an integral part of making us feel welcome here and helping us whenever any problems arise. We also met with Dr. Mejia about the potential of UVG entering the hospital to work us. Last summer we had meetings between the deans of UVG, Directors of Roosevelt, myself and the mechatronics students interested in working at Roosevelt. By the end of our trip they had been granted full access to the hospital. Since the change of security at Roosevelt they have been unable to reenter the hospital. Dr. Mejia confirmed that, due to the tough political times in Guatemala, granting the students access to help in Roosevelt will be difficult and will have to be postponed for at least a couple of months. Politically, Guatemala is in a state of flux, as I have mentioned in previous posts. In fact, tomorrow, we have been told not to go to Roosevelt at all.

The notice about the protests.

There will be mass protests all along the routes to the hospital, in the capital and at the hospital (a public institution that suffered due to government corruption). The number of warnings we received tonight about the protests and the fact that everyone insisted we stay at the hotel tomorrow has been sobering. We are disappointed we will be unable to return to Roosevelt tomorrow, we are close to repairing an ECG, but understand that we must put safety first. We will keep everyone updated tomorrow. To read more about what is currently going on in Guatemala: Read this.

Day 9: Week Two Begins!

A guest blog entry from Ananya and Caroline:

Today we set up camp in the old ICU, which is now empty and is being used as a storage area for old, broken equipment.  It was great to see that the new ICU, which was our work area last year, is now in use, after much petitioning on Carolyn’s and others parts.

Entering the old ICU which was fully functioning about 6 months ago.

This area has become another warehouse for broken equipment

With the help of our new maintenance friend Horacio, we began work on two incubators. We determined One  could not be fixed, as it is ancient, and had evidently been previously tampered with.  There were screws missing, things were put back together incorrectly, and parts of the circuit board has been detached and broken. The second incubator was successfully repaired, after much battery work and sodering by Mark and Ananya!  

Working hard.

Good work, team!

We were also given another ECG from the pediatric ICU and two monitors from the Neonatal Intensive Care Unit to look at.  We are still working to determine exactly what is wrong with each, and plan to continue working on them tomorrow.  Unfortunately, poor Horacio got stuck in an elevator trying to bring us the equipment.  This, along with no working lights in the old ICU, exemplify the daily problems that the people of Roosevelt have to face. 

On a happy note, we visited Gastro to deliver and officially donate some pulse oximeters and a blood pressure cuff.  Our three favorite nurses were happy to see us and told us that both monitors and the endoscopes we worked on last week are officially working!  Together we worked with them to test the blood pressure monitor we saw last week.  It can now also be used. 

A monitor we fixed now in use.

Testing the Blood Pressure monitor we fixed, it worked!

Afterwards we got some delightful homemade popsicles from the food stand outside the hospital.  Everyone enjoyed the delicious mango.  For dinner we returned to La Chapinita for traditional guatemalan fare and Mark was finally able to get that Hard Rock Guatemala pen that he wanted  We look forward to another productive day tomorrow! 

Day 6: Moving Right Along

It is crazy to think that it’s already Friday and our first week at Roosevelt has come and gone. We spent the morning in Gastro working on the remaining broken equipment there. It’s amazing that in only 3-4 days we have made a significant impact on their equipment. Today we fixed another monitor, tested outlets, worked on a blood pressure monitor that is more than 50 years old and potentially repaired the last broken monitor they have, we will find out on Monday if it’s functioning after it’s new batteries recharge. 

Before we fixed the monitor Imani's heart beat was a little spastic...

Working in gastro has been extremely rewarding for a number of reasons: we have successfully fixed 2 endoscopy towers, 2 monitors (potentially 3), we work along side a wonderful staff of nurses who have always been welcoming and informative while working along side us, we have been told countless times, particularly after a repair, that we are a “blessing” and that we are saving the hospital and patients thousands of dollars and directly impacting the state of the unit. We have promised them filters for their respirators, a new bp cuff and pump and a pulse oximeter we have brought with us. 

The WUGI team with the wonderful gastro nurses.

They definitely have a great sense of humor that's made gastro (of all things) fun.

We spent the second part of our day touring the infant ICU that actually has large plastic crates full of broken equipment. The infant ICU and maternity wards are extremely crowded—there is hardly room to stand. It is clear that any help we can provide them will be appreciated.

Outside the entrance of the maternity ward.

Inside the infant ICU.

They decorated for mother's day in the marternity ward.

We left Roosevelt a little early to get ready for our weekend of truly being tourists. We are headed to Panajachel, a beautiful town on Lake Atitlan. More to come on our trip, breathtaking pictures guaranteed!

Day 5: Success

Today was all around a fabulous day. It was beautiful outside, we were successful in our repairs and met with our friend, Andres, for dinner. We started our day at Roosevelt, instead of heading straight to gastro to continue our work on the endoscopes, we had a meeting with Dr. Mejia, the director of Internal Medicine, and toured the women’s ward which was nicely decorated with mother’s day banners. The nurses there brought us a broken ECG and a broken SpO2 sensor. 

We discovered that the ECG was missing a number of important parts including a paper role, pin, and battery. We asked a nurse whether she could locate a paper role and the pin, but apparently the pin has been lost making the thermal printer of the ECG unusable. It was also particularly interesting to see that the battery was simply missing from the machine. A general consensus from the staff was that the battery had to have been stolen and sold on the market. However, as this model of ECG is no longer manufactured we are having a lot of trouble even locating a replacement battery. Unfortunately the ECG battery was not an unique case, the SpO2 sensor was also missing a battery. It had also clearly been opened up before and put back together ad-hoc. It led us to many questions about how this equipment has been treated and who has damaged it in the past. For now, there is unfortunately nothing we can do except look to order more parts for these machines.

What we found where we expected to find the battery of the SpO2 sensor

We then returned back to gastro, determined to make headway. We are happy to report that by the end of the day we fully repaired two endoscopes!!! It was incredibly rewarding to see just how grateful the nurses and doctors were for our help and the machines are immediately being  put to use for procedures tomorrow.  Each endoscope we repaired saved the hospital about $4,500, money they truly do not have to spend.

We fixed it! Don't worry, Mark was happier than he looks

We left the hospital with more spirit than we’ve had the entire trip. We were feeling useful, needed, appreciated and finally confident in our abilities. We spent of the day completing research until we met up with Jorge Andres Bonilla, a friend from last summer who took us all out to dinner and drinks. It was great seeing Andres again and great to hear how successful he’s been since he finished his residency at Roosevelt. After a great night of catching up we’re all tired and ready for our last work day of the week.

Thanks for a great night, Andres!

Day 2: A little bit of everything

Today was definitely a full, albeit incredible, fun and productive day. “It really flew by”-Connie. We started our day at the hospital and made a considerable amount of headway. Upon entering the new ICU we found 3 new ventilators waiting for us. It was clear that staff had heard we were there and jumped on the chance to get at least one piece of equipment fixed out of the steadily increasing piles.

We had contacted Ron and Margarita (our amazingly supportive and responsive clinical engineers from BJC healthcare) last night about some specific error codes we came across and to ask them whether they had any insight or manuals. They responded extremely quickly with suggestions giving us a lot of insight into equipment that was foreign to us. We spent the majority of the morning troubleshooting, running diagnostic tests, finally hooking the vents to air and oxygen sources and even getting messy with the circuit boards of a specific model (go team go!). We were successful in eliminating a considerable amount of error messages, and we look forward to testing the ventilators tomorrow to achieve full functionality.

In the middle of the morning a nurse and intern stopped by the ICU with a defibrillator and ECG (electrocardiogram). It was incredibly helpful to be able to speak with the nurse about exactly what her experience was with the equipment and what errors she suspected.

ECG machines are used to detect arrhythmias in the heart, to detect ECG morphology changes, and to measure the heart rate. The flow of blood through the heart and to the rest of the body is regulated by the electrical conduction of the cardiac tissue. In underdeveloped countries these machines are mainly used to monitor patients suffering from other health concerns. As the country develops and the life expectancy increases, the ECG machines are becoming increasingly valuable to physicians in the developing world. We had learned that when an ECG is producing a “noisy” waveform the problem is usually a result of faulty electrodes of the leads. The electrodes used for the ECGs in Roosevelt are currently banned from the united states. In the US we solely use single-use electrodes. These bulbs have been used for as long as the nurse could remember and had obviously not been cleaned.

Residents later confirmed that they are hardly ever cleaned after use and are reused over and over on different patients. They also told us that ECGs are used at least 100 times a day and there is currently only one, but potentially two that are functional. We had a few ideas as to how to fix the ECG and the residents insisted in trying to test the machine, on a patient, even though we had only been looking at it for 15 minutes. This was an experience within itself.

The defibrillator was also having trouble working and in fact had stopped working in the middle of use yesterday. We’re trying to recharge it now and will have updates tomorrow! Throughout the day we had a number of residents, nurses and maintenance staff check-in on us. They were all extremely helpful and ready to support us in any way possible (they even hunted down circuits with wye tubes and connectors to the air and oxygen supplies in various parts of the hospital).

After a long day of intense work the residents invited us to watch the world cup semi-finals with them (Germany vs. Brazil if you haven’t been following fútbol). It was great to see a different side of the residents. Over the past couple days in the hospital we have observed just how hard these residents work every single day. We are so grateful we were able to get to know them on a personal level as well. It was a blast and also really interesting that a fair amount of them were Germany fans considering how close Brasil is. We shared Dr. Palma’s pain as the Brasilians were essentially demolished. Regardless, watching the world cup in a country that is truly passionate about soccer was an awesome break before we left to research for the rest of the night.

Watching the World Cup with the residents

Day One in Roosevelt

Today was truly a Monday. It was the start of a new week, the start of a new rotation, a lot of work, pretty tiring but also incredibly indicative of what our next two weeks will look like here in Guatemala City...not to mention we survived a earthquake this morning!

We started our day at Roosevelt Hospital at 7:30AM with a site meeting with Dr. Carlos Mejia, Dr. Soto and the two chief residents, Dr. Maynor Palma and Dr. Manuel Osorio. We are literally in awe of all the work they do on a daily basis and could not thank them enough for taking time out of their days to welcome us and support us through this rotation. Our meeting was followed by brief introductions in the ICU (our main work site). We came here with the expectations and training to work on patient monitor displays, ECGs, operating lamps and defibrillators. However, upon arriving to the ICU we were told that their real priority was respiratory ventilators.

            The new ICU looks almost identical to how it was when I was working here last, over a year ago. We even found some post-it notes I had used to label and describe error codes on the ventilators from the prior year. This new ICU is still not furnished, is being used primarily for storage, and still houses all of the broken ventilators I saw last year. For me this wasn’t entirely surprising; however, it was discouraging particularly because prior to this year’s trip we did not train on any type of ventilators. 

The amount of error codes we were receiving on each vent was, excuse the pun, alarming

Ventilators exactly where I left them last summer

            But, like I’ve learned is necessary in this type of environment, you must always always be ready to adjust to every situation and have, or come up with, a plan B (or C, D, E, etc.). We spent the majority of the morning troubleshooting the ventilators. There were 5 Viasys VELA ventilators, 4 Esprit ventilators and 7 Hamilton Medical ventilators. All of these models are not supported nor were we able to find through BJC or in the Barnes systems prior to the trip. Regardless we’ve made some progress and used every troubleshooting technique we know. Now it’s time for some research.

I am legitimately scared that we will be successful in detecting exactly what is wrong with each machine but will be unable too access the proper parts to repair them. The majority of the equipment in use is extremely old and outdated and the original companies often no longer manufacture the parts necessary to complete the repair nor do modern hospitals (where the majority of the equipment is donated from) see the use in keeping these parts.

            After doing everything we could in the ICU we met up with chief residents Palma and Osorio to discuss what we need to make the trip a success. As always, communicating through different levels of the hospital will be difficult and complex; but will be essential for the most effective rotation. It is vital that we are perceived well by the rest of the faculty and staff in the hospital, it is clear that we are visiting, especially as we are a truly diverse group. The hospital operates on formalities that I have not yet mastered nor that I can always anticipate but are signs of the courteous nature of the Guatemalan people.

            We were able to walk through much of the hospital and observed much of what a typical day in the hospital is like. We arrived to the hospital a little after 7AM but it was already packed with patients. Every hallway we passed through was full with patients waiting to be seen, many of whom had traveled for hours to come to the hospital in hopes of a cure for the wide array of ailments seen daily at Roosevelt. It is incredible just how many people come to the hospital everyday and the amount of work and responsibilities the doctors, residents and nurses are given on a daily basis. Carlos, a third resident told us he has 36-hour shifts. Unlike in the US, Guatemala does not have any regulations on the number of hours or consecutive hours medical professionals are permitted to work to ensure the well being and quality of the individual.

Entering the hospital, far from the actual offices or procedure rooms

            Going forward we need to see whether we will be able to locate and then gain access to the equipment we originally came to fix. If we cannot work on these models we will continue to work on the ventilators, work with engineering students from La Universidad del Valle (UVG), assess the hospital for a power grid and hopefully work on a project I’ve been hoping to complete for some time now. I have proposed spending a day to go visit the countless makeshift warehouses and departments in the hospital and on the hospital grounds to start a database, or at least a record, of absolutely every piece of equipment owned by the hospital. I would like to at least include basic details including model numbers, the condition of the equipment, and its location. It is currently nearly impossible to locate a piece of equipment or to even estimate how many of a certain type of a model there are. It is extremely common for doctors to be in need of a certain type of equipment but not being able to find it nor even know if there is a piece that exists. This record would be a great way enhance the organization of the hospital. The one important question that remains is whether this record and system would continue to be used after we leave and whether we could convince faculty and staff to adapt the system and utilize it. The goal of the program is to support the hospital in ways that are realistic and most importantly, sustainable.

            After a long morning we are at Oakland Mall, less than an hour away from the Hospital but the most luxurious and largest mall all of us have ever seen in our lives. This mall has ever designer store imaginable, multiple stories, dog bakeries, cupcake shops and security guards all dressed in tuxedos. It is interesting to see the contrast between the rich (quite literally the 1%) and the poor in one day. Regardless, it’s a great place to get some research done for tomorrow. Wish us luck!