Amanda Judd tells about her mission with Refuge International

We arrived excited to get the San Raymundo temporary hospital up and running. We had lost time with flight delays and reroutes due to Hurricane Patricia, which was pounding Dallas with an unexpected wallop and caused baggage to be delayed and people to be stranded. Fortunately, thanks to the well-oiled machine that is Refuge International, we were up and running by Sunday afternoon. 

The San Raymundo facility is run by a local group of citizens who open up the compound about every 2 months to Refuge International’s medical staff and alternately with a group of Italian medical staff who helps in the San Ray facility. While unpaid volunteers provide all of the care, the local group charges a very nominal fee to the patients to cover the costs of the building, maintenance, and upkeep. Having vested interest in the medical care for the community, the locals seem to respect and appreciate the volunteers from Refuge International. The community organization provides Refuge with a locked storage room to keep supplies safe when Refuge is out of the country. This was a good thing, too, since many of our supplies were delayed for 5 days with all of the reroutes. 
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This is a view from the roof of the temporary hospital, overlooking the cafeteria, the adjacent school (in green), and some of the sleeping quarters.
Early morning OR setup.
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This is me, ready to go on day 1.
As an ICU nurse, I was assigned to the PACU, and I was able to observe some of the earliest procedures prior to having patients. I was lucky enough to be on a mission with Dr. Cockburn, a urologist, and his lovely wife Judy. Judy was such a warm, inviting person. She managed intake flawlessly while Dr. Cockburn did consults and surgeries. 
One of the first patients to get a procedure was done by Dr. Cockburn and had a softball-sized fatty tumor removed from his buttock. Dr. Cockburn and the patient allowed us to watch the procedure. The patient was numb but awake. He remained very stoic throughout the procedure and was hesitant to admit that he could feel the removal, at times. It’s interesting how different pain is perceived culturally. As Americans, we would probably yell out and make them stop the procedure until we were completely numb, this patient tolerated it until we asked him and was grateful once the procedure was done.
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Dr. Cockburn operating.
We did many procedures throughout the week. Of course, the kids always capture your heart. The little boy seen below was named Franco. He awoke quite confused from anesthesia but was quickly captivated by one of the games on Eleanor’s phone. He was excited to tell us a story about his “pets”. He has 2 chickens and 3 fish. One day he decided to take one of his chickens to school for show-and-tell, but was bemused to find that the chicken had laid an egg at the school. In some ways, I think that it’s the sharing of experiences that may have a more lasting impact than the medical procedures themselves.
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Franco with Eleanor, the NP who worked as an RN in the PACU, and Ashley, the translator. 
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A beautiful little girl who had a tumor behind her ear removed. She and her mother were an absolute joy to care for. She awoke from surgery happy, smiling, and full of giggles. 
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San Raymundo at sunset.
Of course, there are stories that are gut-wrenching, and make you wonder if our best intentions are not always in the best interest of the people.
With the exception of my luggage showing up, this day was fairly routine in the way that medical clinics become very routine after a few days when everyone knows their places and jobs. I had retired early to enjoy a shower with my own bath products and had crawled into bed to read my newly arrived book when Nancy (the trip leader) came in and asked Dr. Janet Sweetman, ER doc, to please come to the PACU where a baby that had just been delivered today was retracting with an SpO2 of 50%. For those that don’t know this is bad, very bad. 
Evidently, the baby was not trying to latch a number of hours after she was delivered by c-section. Eleanor, the NP working in the PACU, is a lactation specialist at home. Her gut told her something was wrong, so the baby was hooked up to a pulse oximeter. That was when the dangerously low O2 levels were discovered. 
This is when teamwork and ingenuity become really important in a resource-poor environment. 
We managed to get a modified O2 hood on the baby, but had to figure out how to transport the baby to the nearest hospital for more intensive care. Someone was able to get an ambulance, which was more of a regular vehicle than what we think of as an ambulance, to transport the baby The final piece of the puzzle was how to keep the baby warm on the 20 minute transport to the hospital. We all looked at each other and collectively said, “Skin to skin, ” but who was going to do this? The mother was unable to travel with the baby because she was still recovering from her c-section. One of the midwifery students immediately volunteered and we quickly moved to the other room where I held up a sheet for her to tuck the baby into her shirt and they were off in the night to the hospital.
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It is a very helpless feeling to do all that you can do and still know that it might not be enough. To know that the randomness of birth would likely give this baby every chance in the world at home but here life hangs by a thread. That Guatemala has the worst newborn mortality rate in the Western Hemisphere and how none of that matters when the mother is looking at all of us wondering if her baby will die and all there is to do is pray. And you pray regardless of what you believe because that’s all that you can do. 
When a nurse volunteers to take the baby to the nearest hospital on her bare chest because that’s the best chance to keep the newborn warm and alive until it arrives. And it is all that we can do to not break down and cry because of the life that hangs in the balance. 
We were all restless in bed while holding our breaths waiting for news of the baby. 
I always think of things that I have read when I have experiences like this.
“so much depends
upon
a red wheel
barrow
glazed with rain
water
beside the white
chickens.”
-William Carlos Williams
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In the morning, after transferring the baby to a local hospital, along with some of our L&D and neonatal nurses who stayed for a few hours, the baby did well and was nursing. 
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This baby was the 7th daughter of a couple who had so desperately hoped for a son. The only son that they had was stillborn. You couldn’t help but notice the tears and ambivalence of the father when he found out that it was a girl. The mother had opted to have a procedure so that she would no longer get pregnant, so this baby was their last chance for a boy.
A few days later, the father came back to the hospital desperate because the nearest hospital was a private hospital. The hospital was pressuring him for money that he didn’t have before they would release the baby. The baby wouldn’t have survived to make it to the government hospital over an hour away. We couldn’t help out the father with money because that would set a bad precedent and be unethical. 
 
This brought up many ethical questions. Should we have even tried to help the baby, if the parents couldn’t afford the care and we couldn’t give them money to help? Had the baby taken an anoxic hit that would cause complications for life? The issues of ethics comes up in one way or another while doing medical work in underserved areas. It is a tough thing and lends itself to criticism and the concept have having an overall code of conduct on these trips.
Guatemala is such a beautiful country but it’s tough here. Really tough. We have people coming from Altaverapaz- a few hundred miles away. The national cancer center is not functioning. Treatable cancers are now a death sentence in Guatemala. People in government hospitals are expected to pay for and bring their own suppose including sutures, etc. If you cant afford private care, you are up a creek without a paddle.
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And then there is happiness:
One of the days midweek was a 14 hour day today with one amazing highlight. A woman walked in with imminent labor and delivered her baby within about 20 minutes. She rested in recovery for about 3 hours and she walked home with her husband, mother, and healthy baby. This was a picture of the beaming abuela with her new grandson.
Joy is contagious. She hugged and kissed all of us even though we had nothing to do with the delivery. This work is the antidote to compassion fatigue. 
I thought of a book that I read, “Maybe that was how to heal. I told myself stories and learned that I could be made of the ones I chose to tell, not simply the ones that life had laid haphazardly around me.”-Francisco Goldman, The Long Night of White Chickens

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Abuela with her newborn grandchild.
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San Raymundo, Guatemala
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San Raymundo, Guatemala
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San Raymundo, Guatemala
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San Raymundo, Guatemala
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San Raymundo
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San Raymundo
The improvisations:
One of the nurse anesthetists had to give a patient a nerve block. He rigged a machine that was like a train of four to a long needle to locate the nerve. He injected the patient and it worked beautifully.
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We needed some y-tubing in the PACU because we had only one air compressor and 2 patients that needed O2. Some tubing, a syringe, and a few minutes later, we were in business.
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The last day during the last surgical recovery, the power went out. Cell phones lit the OR. Iphones were finally used for a greater good.
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We wrapped up after 4.5 days of clinical. Hopefully some lives were changed and maybe made better with this Refuge Mission. The team was a huge part of the success of the visit. It was a great experience and I hope to do it again.
Final tally:
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And a great team:
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Thanks to One Nurse at a Time for giving me the scholarship and the opportunity to participate in this great mission with a wonderful organization. I will definitely work with Refuge again and I would highly recommend them for future scholarships.
Happy Thanksgiving,
Amanda Judd