During my last Turno, I saw two patients who had clear diagnoses and needed transfer for care that I could not provide in Santiago Atitlan, but whose families refused to allow the patient to go.

The first was an 80 year old female with acute left eye pain, headache, and photophobia. She had acute narrow angle glaucoma on exam, although I was not able to check intraocular pressure. After searching the pharmacy, I was only able to find one medication out of 3-4 recommended medications for this condition, which helped some but didn't fix the problem. She was going to require treatment by an ophthalmologist if she was going to keep her vision. I discussed this with the patient and her family. The family decided that they did not want to have the patient transferred, nor did they want to take her themselves, despite understanding that she would likely be blind in her affected eye without treatment. I believe it may have been related to financial concerns, however, they would not tell me this. Care in the national hospitals is free; the family only has to pay for transfer to the hospital (which is 200Q or about $30). The patient left the hospital with her family, with a bottle of the only medication that we had to treat her condition and the invitation to return should they change their minds.

The second patient was a 3 year old female with abdominal pain, fever, and anorexia for one day. Her examination was very consistent with appendicitis. I discussed the diagnosis and need for treatment with antibiotics and surgery with the patient's mother and grandmother. They declined any treatment of the child until they were able to discuss the problem with the child's father, who was out of town for a few days and not able to be reached. Despite repetitive explanations about what could happen to the child without treatment and pleas to at least allow antibiotics to be given until they were able to reach the child's father, they left without any treatment.

After a wonderful few days to spend time with my family and friends and recover from jet lag, I have arrived in Lwala, a small village in Western Kenya. My month in Lwala will be a combination of serving along side the clinical officers (similar to a nurse practicioner or physician assistant in the US) and nurses in clinic as well as a project focusing both public health and clinical services for malaria prevention and treatment.  I thought I would provide a little context for my work this month.


Propelled by their father’s dream and the loss of their parents, Milton and Fred Ochieng’, friends and recent Vandy alumni, founded the Lwala Community Alliance in order to bring health care to their community. The health center opened in April of 2007 and offers primary outpatient care, maternal health services, and HIV treatment, serving more than 1,000 patients each month, 55% of whom are children under 5 years. Patients are most frequently treated for malaria, respiratory infections, parasites, diarrhea, HIV, and TB. In my first few days in Lwala, in addition to the routine outpatient complaints I see in the US, I have seen many patients with malaria, typhoid and several with HIV, both those with new diagnosis of HIV and those who are followed on antiretroviral treatment here. It’s amazing the amount of health care that is provided from this little clinic.

Malaria in Kenya

Malaria is the number one cause of death in Kenya and one of the main barriers to economic and social development. It accounts for ~34,000 deaths among children under five years and 8 million outpatient treatment visits each year. Lwala is in an area of Kenya where malaria is endemic, meaning that there is malaria transmission occurs every year. Immunity is often acquired before adulthood, so the greatest burden of disease and death is amongst children and pregnant woman.

During pregnancy, malaria causes anemia, miscarriages and can result in preterm or low birth weight infants. Children under five years have not yet developed immunity to the parasite and are thus most likely to suffer from severe malaria, which can be life-threatening. The parasite prevalence in children often exceeds 50%.  Because of the significant burden of the disease in Lwala, I will spend some of my time here focusing on malaria from 2 aspects:

  1. Community Health Education: Lwala has had a successful community health education program on basic lifesaving skills for mothers and infants called “umama salama”, and the clinic staff go out into the local schools to provide community health outreach; I hope to utilize those existing networks to implement malaria education focusing on malaria prevention and target health-seeking behaviors to ensure prompt and effective treatment for pregnant women and children.
  2. Clinical care:  One of the challenges of treating malaria in Kenya is the emergence of drug resistance; the first-line treatment in Kenya is now arteminisin-based regimens which while effective, bring new challenges in that this treatment is more expensive and fear of developing drug resistance to one of the last remaining effective treatment regimens in the region. By observing and collecting data on current diagnostic and treatment practices in the clinic, I hope to help identify any areas for improvement.  The head clinical officer has also invited me to help with the weekly continuing medical education sessions for the clinic staff which will be a great opportunity to help make sure they are all practicing updated malaria treatment guidelines, along with targeting some other common clinical problems.



lightner hospital

A previously healthy 29 year old female arrived in the ED via motor taxi, accompanied by her family, early in the afternoon on a day I was working in the outpatient clinic. I stopped by the ED on my way home, and saw that Turno doctor had her hands full with the patient, so I stopped to help. The patient was hypoxic (74%), tachypneic (58 breaths per minute), and somewhat hypotensive (90/50). She complained of chest pain and shortness of breath for 3 days, and also thought she may have had a fever although she was afebrile on arrival to the ED. Her EKG showed sinus tachycardia, but was otherwise normal (we were only able to obtain limb leads). She appeared chronically ill. We were unable to get labs because of the time of day, and the patient was too unstable to transport for a chest x-ray. Pulmonary embolism was a major concern even though she had no risk factors, thus we gave Heparin for anticoagulation and started to arrange transfer to Guatemala City for diagnostic testing and treatment. After two hours of preparing for transport, collecting supplies (as there are none on the ambulance), and deciding which family member was going to accompany the patient, we were finally ready to go. Just prior to departure, the lab was able to run a rapid HIV test, which came back positive. This added more to the list of possible diagnoses. By this time the patient was on 10L O2 and a Dopamine drip. We added on several antibiotics for possible infection, and started the journey.

The ambulance is a van without the back seats. There is a bench next to the stretcher for family and medical staff. Our crew consisted of the driver, his co-worker, a nurse from the hospital, and me. The patient's husband accompanied us in the back of the ambulance. The terrain in this area of Guatemala is incredibly rugged, and the roads suffer much damage during every rainy season, thus the ride was anything but smooth. During the first 30 minutes of the 3 hour trip, the batteries to the portable pulse oximeter died. I was able to replace these with batteries from my flashlight. A few minutes later, the patient's oxygen saturation dropped from 80% to 60%, signaling that the first oxygen tank of three partially full tanks was empty. The driver pulled over, the other bombero jumped out and changed the tank, the patient recovered, and we got back on the road. We realized that we should have been able to go about twice as long on that tank of O2, meaning we had a leak or a problem with the regulator. If the next two tanks had the same problem, we were not going to have enough O2 to make it to the city. During the next few minutes, the infusion pump stopped working due to dead batteries meaning I had to push medications through a needle into the established IV. After another hour, the second oxygen tank ran out, leaving only 1000L of O2 in left on the ambulance enough for about 30min and we still had more than an hour to go to the hospital in Guatemala City. We had to find a closer hospital that would either care for the patient overnight or give us an oxygen tank so we could make it to the city. The bomberos took us to a nearby hospital, we wheeled the patient inside, and explained our situation. They were happy to give us the oxygen tank; their beds appeared full and their staff already too busy for a very sick patient. The last hour went as smoothly as could be expected under the circumstances. We arrived at the hospital in Guatemala City, took the patient inside, and told the doctors there what we knew. The bed we took the patient to was in the middle of a room full of ill appearing patients. There were no monitors, no private rooms, and very little space to move around. They started her on oxygen and got to work with labs and medications. The nurse and I walked out of the hospital, relieved that our patient had survived the trip.

I don't know what the diagnosis of the patient was or if she survived. At home, this patient would have undergone imaging of her chest, lab testing, been transferred to an ICU, and would have received the appropriate care for the diagnosis found on labs and imaging within hours of arrival in the ED. In Guatemala, she received 3 hours of supportive care in the back of an ambulance, nearly died twice when we ran out of O2, and hopefully was able to receive a diagnosis and care at a hospital hours from her family and home. The nurses and local physicians back in Santiago Atitlan were doubtful that the patient would receive much, if any, treatment given her HIV diagnosis.

Santiago Atitlan, Guatemala

liz lightner

I have spent the last three weeks working in the Hospitalito in Santiago Atitlan, Guatemala. Santiago Atitlan is a city of 50,000 people, located on beautiful Lake Atitlan, surrounded by three towering volcanoes. The hospital consists of a four bed ED, two labor and delivery rooms with two beds in each, three inpatient rooms, and an operating room. The two upper levels are currently under construction, but will greatly increase the capacity of the hospital. The staff consists of mainly volunteer physicians and local nurses and technicians. The main language spoken by the patients is Tz'utujil, which is then translated by the nurses to Spanish for the physicians. Patients came to the hospital from towns all around the lake and surrounding area. They often arrived via Tuc-Tuc (motorcycle-taxi), but sometimes walked, were carried by family members, or arrived by Bomberos (volunteer firefighters without medical training or resources).

Resources in the hospital were limited, thus the methods diagnosis and treatment of patients varied greatly from what I have become used to at Vanderbilt. Most of the medication and supplies for the hospital are donated by volunteers when they come to work, thus there were times when items that were needed were not available. There are no ventilators or cardiac monitors, mainly because there is no one there to maintain this type of equipment. Laboratory studies are only available Monday through Friday 8-12am and 2-4pm. Imaging is limited to occasional x-rays and a later model ultrasound. There were several OB physicians available at all times to manage obstetrical issues, and a general surgeon every two weeks. Patients requiring a higher level of care or a specialist have to be transferred to one of the national hospitals in Solala or Guatemala City, 2 or 3 hours away by ambulance. The staff did everything possible to conserve available resources, such as cleaning and reusing endotracheal tube stylets (there was only 1 in the hospital), making their own cotton balls, and using suction cup EKG leads rather than disposable stickers for the leads. Adjusting to the differences in practice was challenging for me. In our medical culture, labs and imaging guide treatment. Suddenly, I was unable to use these tools in my medical decision making process. I was also not able to tell patients to go see their doctor or a specialist for follow up; most of them did not have the money to see another doctor or undergo further testing.

I mainly worked in the Emergency Department (ED), but also spent a few days working in the outpatient clinic. Each day one person would be "Turno", which meant they were in charge of the ED as well as all of the patients admitted to the hospital (post-op patients, post partum patients, neonates, and medical patients). Turno is a 24 hour shift. The majority of the patients would arrive between 7am and 9pm, the hours that the Tuc-Tucs run. Those that came outside these hours were generally very ill, as they would have to find private (and expensive) means of transportation. On each of my 24-hour shifts, I saw about 15 patients in the ED. Many of these patients had problems such as vomiting and diarrhea, sprained ankles, cough, and lacerations. A few patient encounters were remarkable, I will discuss them below. 

I have been back in the United States for a week and a half now. Coming home from Guatemala during the holiday season is a strange transition. I couldn't help but look at all of the (admittedly exciting) products and services being offered, and think "oh, that money for that completely useless thing could pay for 'x' children's medicine, or food." I have been trying to adjust to life in the US, and accept the differences between life here and the poverty in places like Xela, trying to enjoy the luxury but maintain the perspective. In the midst of all of this enjoyment, I am reminding myself periodically that too much acceptance of this sort of disparity leads to complacency, which only further harms people.

The last couple of weeks in Xela were exciting. I worked hard on wrapping up the malnutrition project, and Cody and I got the suero (oral rehydration solution or ORS) going at the clinic. We got materials together and taught clinic staff how to mix up the bags of powder for families to make in their homes. All children with diarrhea, vomiting, or risk of dehydration can now be given enough suero to prevent dehydration, or treat mild to moderate dehydration. The families add one bag of ORS mix into one liter of water, and it is good for 24 hours. We can now make suero for 1/10 of the cost of the previous supply, which means that $1 allows us to make 20 liters of suero, which treats 5-10 children for a day. The project was well-received at the clinic, and may be shared with other clinics after we get things running smoothly at Primeros Pasos.

Now that I am at home, and see how much $1 and some hard work can buy, I have been trying to be careful about my spending. I have encouraged my friends and family to consider giving money to organizations such as Primeros Pasos (or Hope Through Healing Hands) to help support projects like this suero project or malnutrition treatment, and clean water initiatives. I'm not trying to advertise for any specific organizations, but I think that this sort of giving is extremely important. Here is a link to donations for Primeros Pasos, if you are interested. http://www.primerospasos.org/donate.

I would like to thank Hope Through Healing Hands for the opportunity to do such rewarding work in Guatemala. I hope that the work that was done was as helpful for the community as it was inspiring for me!

eppinger 6

As I am nearing the end of my time in Guatemala, I have been wrapping up all of the projects I have been working on here. Cody Bowers has been writing about the Oral Rehydration Solution (ORS) project, so I will let him update about that in a different blog. The project that has been taking most of my time here is the creation and implementation of protocol for the screening and treatment of malnutrition.

After participating in care of children at the clinic, and talking with the clinic staff it was apparent that the solution to the inadequate treatment of these children would need to be multi-disciplinary, to address the problem from multiple angles. The clinic's previous protocol was to do exams, give vitamins, and educate the patients. These are all important things to do for the treatment of malnutrition, but the guidelines were so vague that they were rarely being implemented fully. After looking over the current research and discussing ideas with the directors at the clinic I developed a detailed treatment plan, and set out to identify available resources.

In speaking with patients, it became clear that there was a huge deficit in nutritional knowledge. Most people didn't know the difference between protein and carbohydrates. In order to fulfill the clinic's need for an educational plan, I designed one that could be made into a handout and used as a guideline for discussions in the clinic. I made up a food pyramid that was specific to the needs I saw at the clinic, and I included information about each food group, the functions of the nutrients, effects if deficient, examples of the foods in the group, and daily requirements. The other side of the food pyramid handout has information on malnutrition and hygiene, as well as a table to keep track of the child's weight. The clinic now has a sheet for each malnourished child's chart, and a master spreadsheet to keep track of the patients with malnutrition. The educational materials are now stored in each exam room, and a color laminated copy of the pyramid is on the wall in each room.

Another part of the project involved researching ways to get vitamins to these children. Due to supply issues, the clinic was only getting occasional bottles of B vitamins, but no multi-vitamins, and no iron for anemic children. I checked all of the local pharmacies and found an inexpensive multi-vitamin that we are looking into purchasing for the clinic. At the very least, we can write a prescription for the vitamin, and families can purchase it for $1.60 a bottle. Even if we have to wait on more donations or funding, it was important just to know what the local supply was. Previously, no one at the clinic knew what multi-vitamin was affordable, or even how to dose it. This information is very product-specific, and the foreign volunteers really struggled with it. The same thing was done to research an appetite stimulant.

Last Friday the whole clinic came together for a meeting. One of the most important parts of initiating a change like this is having the support of the people who will be doing the work. I was lucky to have support from the entire clinic. They realized the huge need for a specific treatment program, but didn't have the time or resources to create one on their own. Once everything was complete, we held a training session, where the medical students, volunteers, and medical director (head doctor) all took part in learning about how to institute this treatment protocol.

A major part of the training session was reminding people how to help motivate families to return for follow-up, and to have parents take a part in this process. It's easy for people to think there's an element of neglect involved when the parents do not bring their children in for follow-up, but I think it is much more complex. We have to win the trust of the families, and show them that the child's health is a collaborative process. We don't want to take all of the control, nor do we want to be left out when we are needed. There seems to be a stigma here about malnutrition, and many mothers are anxious to see the child's weight, and know if he is at a healthy weight. Any interventions we have to resolve malnutrition seem to be very well received.

In my last few days at the clinic I will be able to help make sure that the new malnutrition treatment program gets going smoothly. It has been exciting already to see families walking away with their educational information. Education is one of the best tools for health promotion, and I look forward to seeing it put to use in a variety of ways here.

bowers 6

I have put my faith in my education and dedicated myself to continuing the effort of supporting people's health with the knowledge imparted to me over the past two years. Doubts certainly cross my mind as I question if what I am doing is effective, right or even necessary, whereas other times my faith is supported by the curative effects of medicine. There are nuances to the body which we cannot control, but we must rely on continued research to improve best practice techniques. Despite occasional skepticism and my desire to permit my body to heal without medicine, I will take cold and flu medication just to reassure myself that I support the practice that I preach. The advancement of science has helped us prolong life and alleviate illness, but occasionally signals are left unnoticed or the wrong test is ordered, despite the good intentions and full payment of diligence. Sometimes medicine can't control everything it encounters and last week entailed two very difficult patient cases who were both attended to properly, but something was missed.

The first day of last week brought a newborn child into the world who was the child and grandchild of two very close friends of the clinic. Being a boy in Guatemala, he was the prize of the family and of course incurred a higher cost from the birthing midwife. Tuesday the warmly wrapped baby was seen by a medical provider because he was crying a lot which worried the family, but everyone at the clinic received reassurances from the mother she had been told his crying was merely part of his adjustment to a whole new world. We received word that he had no fever, his lungs sounded good, heart sounds were regular, and there were no abnormalities upon exam. But modern medicine missed something with this newly born human being and with Thursday morning came the devastating news that he had passed during the night. Thursday morning was brutal for the clinic as we were slammed with patients, a new group of medical students started their first day at Primeros Pasos and there was a penetrating cloud of sadness pushing into the conscience of every team member at the clinic as we dwelled on the well-being of our close friends.

Almost everyone involved with Primeros Pasos attended the burial, which was held 10 hours after the baby's passing. The sadness of this death was not directly penetrating to my emotional core, but watching people I care about suffer so acutely pulled tears from my less than stoic eyes. The casket was tiny, emotions were high and the grandmother of the baby was as strong and beautiful as I've ever seen her. She was not visibly weeping, but her soul was drenched in tears as the trauma of losing her 2 day old grandson wore heavily upon her posture. We slowly followed the casket from the front gates to the back hill of the giant cemetery and the whole time Lauren, myself and another medical provider all watched the sadness, absorbed the pain and questioned what had the modern techniques of medicine missed on this precious child that could have prolonged his life. We wished we had more information or could review charts and have a long discussion trying to discover the cause of this death, but we were not working, we were mourning.

The other patient that pushed our emotions into a puddled mess was a 5 year old boy. He came from a town over an hour away and his mother spoke for him because the boy only spoke Kiche. I went in to see this patient alone, but I retreated within minutes for the assistance and expertise of the medical director. He was cute, just as most of the children we see at Primeros Pasos, and he was still shy at his young age, but quick to smile and laugh. As I was speaking to the mother, I realized his expressions were becoming more worried and he started to tear up. I asked him if he was scared and he nodded and I reassured him that there would be no shots or painful procedures and he brightened up. After his mother told me he had swelling near his neck, I began my exam while she finished telling me his story. There was a hard and barely mobile mass at the base of his neck on the right side and he flinched when I touched it. Upon examining his axillary region, I noticed a 3 inch scar, which his mother remembered to notify me was from when surgeons removed a mass 3 months ago. My heart dropped and I asked her what the doctors said about the mass after pathology and she didn't have any idea. She said they hadn't told her what the growth was and after the surgery they just sent him home without further treatment. No chemotherapy, no radiation and no extra patient education except a discharge three months ago and now I may have lied to this child about there not being any painful procedures, I just wouldn't be part of the process.

I palpated along his small chest between his armpit and the mass on his neck and found other small masses, then excused myself with my head low and desperately needing the doctor's second opinion. The medical director entered, examined the child and then we stepped out to discuss treatment options. It was either an ultrasound and biopsy or a direct referral to the hospital. Since he wasn't eating well because it was painful to swallow, we elected for the hospital. It was likely that this child had some form of cancer that was initially in his axillary lymph nodes and it spread before the surgeons could remove all of the cancer cells. Now the growth was in his cervical lymphatic chain and would be a much more complicated treatment, especially since he was having trouble swallowing. In August he had zero follow up care or pathology results to confirm any form of diagnosis, but he was back in the medical system 3 months later with swelling of other lymph nodes in his lymphatic chain. The medical director and I sent the mother and child to the hospital and hung our heads for a 10 minute discussion that basically entailed multiple derivations of, "What can we do?"

It was a week of what ifs and how comes as we watched children struggle. We pondered what type of care the child with the likely cancer would have received in the United States. What if he had the resources for prolonged treatment and follow up chemotherapy? Or how come children are suffering? How come nothing was picked up on the exam of the newborn? Because sometimes medicine misses, but oftentimes it misses something that we cannot yet see. Thankfully medicine usually remedies most ailments and with more research, better resources and continued diligence, we will continue to prolong life and alleviate illness, but for now we share condolences and look to the future from Xela Guatemala.

by Jenny Eaton Dyer, Ph.D.

This week, CIFA released the long awaited strategic framework report entitled:

"Many Faiths, Common Action: Increasing the Impact of the Faith Sector on Health and Development."

This report was presented on November 23rd the at a meeting with high level United States Government representatives at the White House. Following a welcome from Reverend Joshua DuBois, and remarks by representatives from the Departments of State, Health and Human Services, USAID, and the White House Office of Faith Based and Neighborhood Partnerships. Bishop Dinis Sengulane of Mozambique, Ruth Messinger of American Jewish World Service, Abed Ayoub of Islamic Relief and Bill O'Keefe of Catholic Relief Services speaking on behalf of GIFHD Task Force presented specific asks of the USG, including requests for a high level Working Group for ongoing consultation with the faith sector in policy planning, support for the creation of multireligious collaborating mechanisms at the country level, and support for tools and research supporting congregation mobilization for health and development at the local level in developing countries.

The group was addressed by Dr. Nils Daulaire, USDHSS; Ms. Gayle Smith, NSC; and Dr. Rajiv Shah, USAID. It was clear they were taking the Strategic Framework for Action Report very seriously. Ms. Smith commended the value of the faith sector approach as a strategy for increased public sector engagement with the faith community, and Dr. Shah called for a roundtable to advise on the implementation of the recommendations at USAID. 

Senator Frist currently sits on the board of directors of CIFA, and Jenny Eaton Dyer, Ph.D. sits on the steering committee and task force for the Global Initiative for Faith, Health and Development.

eppinger los vahos

One of the interesting things about being in Xela is the high volume of foreigners living and working here. Xela is rather well known for its Spanish language schools, which draw people from around the world. In addition to the linguistic draw, Guatemala is filled with NGOs, and there seems to be an especially high concentration in this area.

The clinic where Cody and I are working has something of a partnership with a local group of hiking guides called Quetzaltrekkers. This group of outdoor-friendly hikers throws fundraising parties and divides the proceeds between the Primeros Pasos clinic and a school for children who otherwise would have no access to education. In return, medical volunteers from the clinic give classes on wilderness medicine.

A few weeks ago when Cody an I were asked to teach this class, we were a little bit caught off guard, because neither of us had had any specific educational training on the topic. But after a few hours of research, we were able to focus in on some important topics (fractures and sprains, concussions, and allergic reactions). The class went so well that we were invited back for a second one, and given specific topics to cover.

The opportunity to work with a different population (hiking guides who will be in charge of the safety and wellbeing of groups of people venturing out into the nearby wilderness) has been exciting. Our latest class was on medications to use while hiking, and some information about common illnesses. It has been interesting to work with this group because we can easily see how important it is for them to have this information. We are working on a lot of emergency management, and safety.

Xela, Guatemala

bowers pump

Primeros Pasos is a clinic that charges $0.62 cents for a pediatric consultation and $3.75 for an adult to see a provider. Any medicine in the pharmacy is free with the cost of admission and some remedial laboratory work is included in the nominal fee as well. The clinic is constantly receiving miscellaneous grants and substantial financial support from Inter-American Health Alliance (IAHA) to pay the salaries of the few employees that run the place and then volunteers take care of the rest. Lauren and I noticed two issues at the clinic that we felt we could address to cut costs and improve patient care. She moved directly into improving malnutrition treatment protocol and wrote an entire study that is waiting approval. We also have found that the clinic is frequently without oral rehydration salts (ORS) used as treatment for people, but especially children, with diarrhea. Lauren and I were frustrated by the absence of ORS packets in the pharmacy, which led us to create a project to expand care at Primeros Pasos. Finding the perfect recipe for ORS and buying 100 pound bags of salt and sugar is our immediate goal.

Severe diarrhea causes extensive loses of fluid and electrolytes and a child's body does not have the reserves to compensate for missing essentials. Before ORS (known as suero in Spanish) was instituted, intravenous fluids were used to correct diarrheal dehydration and millions of children were dying because they didn't have access to technical medical care. Now we can remedy the situation with salt, sugar and clean water. Rehydrate.org quotes that ORS therapy saves 1 million lives a year, costs about 10 cents per liter of solution and can prevent about 90% of diarrheal deaths in children. The initial recipe for ORS included 8 teaspoons of simple sugar, 1/2 teaspoon of table salt and one liter of pure water. Through many research studies and trial and error efforts, the recipe has been refined and enhanced to optimize diarrheal treatment for the vulnerable, yet resilient bodies of children. There are websites suggesting that vitamin C and zinc can be used to diminish the length and severity of diarrhea by up to 25%. Other sources have been adding artificial flavorings and additives to make ORS more palatable, but in our search for the best recipe we have chosen to abide by the most trusted and overarching source of pediatric medical care. The World Health Organization and UNICEF have combined to create a 123 page manual about oral rehydration therapy and this is now our guiding light. The WHO and UNICEF offer a simple recipe of 2.6 grams of salt, 1.5 grams of potassium chloride, 2.9 grams of trisodium citrate dihydrate and 13.5 grams of glucose. Four ingredients with life saving potential, all of which are usually available at any nearby grocery store.

The two ingredients that are rather abnormal for a grocery store are the trisodium citrate and potassium chloride, but thankfully there is research suggesting that baking soda can be substituted for the trisodium compound. Trisodium serves as a buffer for the acidosis of severe diarrhea and thus baking soda can serve the same purpose. Potassium being the second issue was not a worry because in the United States we prescribe large quantities of potassium chloride to patients on diuretic therapy and potassium chloride can also be bought as a salt substitute in most stores. Furthermore, I can walk into any pharmacy in Xela and buy almost any medicine I desire, except of course potassium chloride. I felt very few qualms about finding a source of potassium, but I should have realized that the recipe wouldn't be so easy to complete. Potassium chloride seems to be non-existent in Guatemala after a long and thorough search throughout the medical and scientific community.

We started this project with the idea of having four ingredients locally available and we would then have an suero recipe working at the clinic within a week, but the obstacles to our creative alternatives are becoming all too common. These barriers we have found are very frustrating because it is yet another reflection of the restricted resources in comparison to what is at our medically oriented finger tips at home. We have visited a half dozen pharmacies, called local laboratories, considered having volunteers bring prescription potassium from the states, but all proved to be without potassium chloride or expensive, unsustainable and hapless. Lacking a reliable source of potassium chloride has forced us to be inventive in our search for this electrolyte and our team has been delving through research studies as we attempt to compensate for the missing ingredient. Due to the importance of potassium, we want to include as much of it as possible even if we cannot add the 1.5 grams stated in the WHO/UNICEF recipe.

There is a unadulterated, unprocessed sugar in Guatemala called panela or piloncillo and it is apparently loaded with potassium and could be perfectly useful, if we only knew how much potassium there is in every gram. Panela is a locally grown, produced and useful ingredient for the ORS suero recipe, which would keep cost down, make the recipe useful for other clinics in the area and be a culturally sound contribution to the medical efforts in Xela. And knowing that the original life-saving recipe lacked any form of potassium, we are confident that the increased amount found in panela will be very beneficial as long as we keep the osmolarity balanced. Along with the potassium in panela, we can also include potassium iodized salt as another minimal, but useful source of the vital electrolyte.

We still need to standardize and exact the recipe, but thankfully we have a Phd trained chemist back in Nashville to calculate the exact osmolarity (number of solutes per liter of water) to ensure that the amount of additives we are using will be perfectly therapeutic and beneficial for patients with diarrhea. The osmolarity must be kept below 245 per liter of pure water to avoid dehydrating the body further and the chemist will be able to give us the weighted measurements for a safe recipe including sugar, salt, panela and baking soda. We shall continue to seek the answers to our long list of questions and we hope that this research experiment will soon produce necessary results to cut costs and increase the availability of oral rehydration therapy at the Primeros Pasos clinic in Palajunoj Valley, Guatemala. 

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