By Rebecca L. von der Heyde, MS, OTR/L, CHT

From July 11-21, 2006, the Guatemala Healing Hands Foundation successfully completed its' third medical mission. The team consisted of over 40 members, including surgeons, therapists, nurses, and volunteers. Together, we successfully completed surgical procedures on 44 children, saw 101 therapy patients, and fabricated 102 splints. In addition, over 400 doctors, therapists, and students attended a two- day educational conference. The following paragraphs narrate the story of a morning at the Roosevelt Hospital Burn Clinic.

As we entered the campus of Roosevelt City Hospital, bicycle taxis passed by quickly and food stands of various shapes and sizes came into view. Fruits and vegetables were being sold in long, thin cellophane wrapping; small children sold gum and candy of all kinds; and picnic tables were arranged haphazardly around grill stations offering an array of grilled meats and sausages.

We arrived at the outpatient clinic and an armed guard opened a gate surrounded with barbed wire to permit our entry. As a medical professional, it was difficult to comprehend that protection is necessary in a place where healing occurs. It seems strange to say that I never felt concerned for my safety; I believe that my heart and mind were focused on the service that I might offer and how much I could learn from this experience.

The walk through the clinic building offered an immediate reminder of my clinical experience at Los Angeles County Hospital. The sheer volume of people waiting for care was overwhelming at the very least. Most interesting was the fact that the room was seemingly calm and the families and children waited patiently for their opportunity for care.

Tucked away in a tiny, freestanding building is the burn clinic. Established by Physicians for Peace, the clinic includes a part-time physical therapist, Marco, a seamstress, and two plastic surgeons. Children visiting the clinic receive therapy services, are seen by the physicians, and are custom fitted for pressure garments made by the seamstress.

As I worked many hours with Marco on our last visit to Guatemala, I was thrilled to see him again. His job is a difficult one, as he is responsible for the care of all the children with burns, both inpatient and outpatient. Marco only works part-time at the hospital as he receives a greater income as a swimming instructor, his afternoon job. Despite this fact, Marco is eager to learn as much as possible about splinting during our visits, as he has an amazing amount of supplies but has had minimal training in splint fabrication. The majority of his time is spent creating uvex masks for the children, a time-consuming task that he has perfected with much practice. Working with Marco is like spending time with an old friend; he willingly creates space for us, collaborates on treatment planning and splint fabrication, and takes diligent notes and photos when offered a new idea.

During the morning, we worked with Marco to treat many scheduled patients. The patients that are scheduled during our visit are considered to be those who would benefit most greatly from our consultation. Sometime in the midst of the morning, I noticed a small girl with an uvex mask and significant burns to her face and hands in the yard outside the clinic. She was accompanied by a man and a teenaged boy who appeared to be Americans. What I did not realize at first glance is that she would become someone I will not forget.

As she entered the clinic, I introduced myself to her caregivers. After a short discussion, I learned that the man was a missionary originally from Waterloo, Illinois; a town 30 miles from my home in St. Louis. I was struck by how truly small our world actually is. He came to Guatemala 6 years ago as a medical and religious missionary with his wife and family. They currently live in a remote mountainous village called El Quiche among an almost completely indigenous population. Their mission is to provide basic healthcare, nutrition, and education to the people of this area, and they have built multiple medical clinics for this purpose.

The child was named Martina, and the missionary told me the long and painful story of her existence to date. Martina's parents live in an indigenous Mayan farming village and speak the language of the K'iche, one of over 20 Amerindian languages recognized in Guatemalan culture. Soon after Martina was born, she began to have seizures, and her mother presumed that she was possessed by demons according to the beliefs of her people. For this reason, Martina was tied to a tree and food was thrown to her. The missionaries heard the story of this child and visited her home in an attempt to educate the parents about her medical condition and needs. Unfortunately, once the family released Martina, she had a seizure and fell into a fire, severely burning her left hand and face. She was treated for her initial burn injuries at Roosevelt Hospital and returned home with her family. The missionaries received word that the mother had again tied Martina to a tree, and once they arrived at the home and witnessed this for themselves, they took her into their home to care for her.

Martina was dressed in a shirt embroidered with the words "Camp Sunshine" and a textile fabric skirt typical of rural Guatemalans. She looked at me inquisitively as I invited her inside, touching my name tag that was adorned with many stickers and smiley faces. I offered her some crayons and we showed her how to scribble on the paper, to which she responded "Oko, oko!" According to the missionary, despite the fact that she had a young helper who spoke fluent K'iche, she said few words. They had come to understand "oko" as a happy word for Martina, and it had taken a significant amount of time for her to respond to their family in any way.

After examining her hand, I determined that she had significant scarring on the dorsal aspect which limited her MP flexion and, therefore, functional grasp. The scar was still maturing and her MP joints could be passively ranged into flexion with moderate effort. The resting hand splint she had from her inpatient stay was no longer providing the necessary, intrinsic plus position to facilitate function. After a brief discussion of my findings with her caregivers, we agreed that I would modify the splint and teach them a home program for range of motion and functional use. Communicating our intentions to Martina was an amazing task. Sentence by sentence, I spoke to the missionary in English. He translated my words in Spanish to the young helper, who translated them in K'iche to Martina. The difference in the languages was striking, and I found myself intrigued with the sounds and intonations of this ancient dialect. I wondered how much she understood, and I found myself having to trust that she knew I wanted to help her, even though the procedures of exercise and splinting might cause her discomfort.

After practicing the home program without incident, it was time to modify her splint. I was extremely nervous as we began the process because I knew that I could not communicate verbally to Martina, only through my expressions and body language. During our first two attempts, I am sure that Martina sensed my discomfort as she kicked, screamed, and cried out loudly in words I could not understand. Trying to maintain her arm and hand in the desired position was a nearly impossible task, and it became clear that I needed to relax and also try to put Martina at ease. I sat down with her and fed her Cheerios with her helper, gently holding her hand and intently looking at her to express my warmth, care, and empathy for the pain she had endured in her 8 years of life.

Before I attempted to make the splint a final time, I gave each person a specific task. The missionary would hold Martina gently, yet firmly and attempt to keep her arm supinated. Her helper would talk soothingly in K'iche to remind her that this would help her. I would use an ace wrap to secure the forearm and wrist trough so I could focus my efforts on her fingers and thumb. I believed that we were going to be successful, and I'm positive that Martina sensed my feelings. She kept her eyes locked on me, but did not move. The splint was finally complete, and we thanked and praised her for her good work.

After saying goodbye to Martina, the missionaries, and her helper, I headed to the sink to clean up. As I was washing my hands, tears flooded my eyes. Tears of empathy for Martina, for her family, for her hardships. Tears of joy for the work of the missionaries. Tears of frustration and relief after our treatment session.

As I sit at my desk writing this narrative, I have Martina's scribbles posted above my desk. They remind me of many things; including how diverse and complex our world is with many cultural beliefs, languages, and people. They also remind me of small our world is; that people are people and that we all have a responsibility to care for one another.

About the Author
Becky is an Assistant Professor of Occupational Therapy at Maryville University in St. Louis, Missouri. She also maintains her clinical practice at the Milliken Hand Rehabilitation Center and is pursuing her PhD in Education at Saint Louis University. For more information on this article, please contact Becky at: rvonderheyde@maryville.edu.

	The Pediatric Clinic at Roosevelt Hospital
	Fruits and vegetables for sale
	Marco, creating a uvex mask
	Custom fabrication of pressure garments