THE MOORE PEDIATRIC SURGERY CENTER BELMONT MEDICAL MISSIONUNIVERSITY TRIPSCHOOL OF GUATEMALA CITY,PHARMACY GUATEMALA ANDTHE SHALOMFOUNDATION STUDENT MANUAL
TABLE OF CONTENTSOVERVIEW Page 3WHAT TO EXPECT Page 4BUDGETING & CASH NEEDS Page 6PACKING Page 7ACCOMDATIONS Page 8MAPS AND KEY LOCATIONS Page 8CELL PHONES & INTERNET Page 10HEALTH & SAFETY Page 10TIMELINE OF EVENTS Page 10ADDITIONAL ADVICE Page 12
OVERVIEWWhat Are We Doing?The Belmont University School of Pharmacy (BUSOP) and The Shalom Foundation (TSF is a Franklin,Tennessee based not-for-profit organization committed to serving the children of Guatemala) have beenextending a long-standing TSF and Belmont University (BU) partnership to include, among otherinitiatives, adding pharmacy (distributive & clinical services) to each surgical mission team that uses theMoore Pediatric Surgery Center (MPSC) in Guatemala City, a three operating room, ambulatory surgerycenter built and managed by TSF. The MPSC pharmacy was designed by BUSOP student Chris McKnight(CO2012). Since the center’s first full-scale surgery event in May 2012, BUSOP has provided pharmacyservices to each medical mission team.BUSOP’s commitment is to continue this staffing pattern byemploying the talents of its students, faculty, alumni and friends.TSF provides medical mission teams with a state-of-the-art surgical facility in which to perform freesurgeries for Guatemalan children in need. Annually, teams from institutions as varied as Monroe CarellChildren’s Hospital (Nashville), Vanderbilt Medical Center, Austin Smiles (Austin, TX), Mayo Clinic(Syracuse, MN) partner with TSF to meet the medical needs of hundreds of Guatemalan children.BUSOP’s role has emerged to support the surgical teams and the MPSC medical team in caring for eachchild before, during, and after surgery.Surgery trips usually follow a nine-day pattern: 2 travel days; 1 screening day; 4.5 surgical days; 1.5 R&Rdays. Pharmacy often arrives one day before the full surgery team in order to ensure that all neededmedications and supplies are in place, or under order; therefore, for pharmacy participants, most tripsare ten-day commitments.Why Are We Doing This?Caring for those in need is at the heart of the pharmacy profession; however, it is also at the core ofBelmont University’s and BUSOP’smissions. We recognize that we lead lives that are blessed withopportunity and access, and that we have a moral obligation to give back. One way of giving back isthrough the use of our talents to improve other’s lives. Investment in improving the health of childrenresults in great possibilities for a return on that investment: healthier children are better able to learn,better able to be productive members of their communities, and to take the lead in helping others inrecognition of the ways in which their lives were changes by other’s generosity. Finally, we are doing thiswork because it is simply the right thing to do.Why Should You Be Part of This Project?If you feel a need to make an immediate difference in the life of a child with life-limiting healthproblems, if you have never participated in medical mission work, but would like to do so, or, if youwant an opportunity to see how your professional skills translate into myriad other ways to serveothers, then joining a BUOSP-TSF surgery team may be for you. You will not be the same person whenyour return as when you left. And, you will begin to look for other opportunities to do more.
How Does This BUSOP-TSF Partnership Work?Each partner focuses on what it does best: BUSOP, talent development and recruitment; TSF, logisticsmanagement. We take on the task of finding people with the talents, skills, and interest to providepharmacy services as part of a surgical team, while TSF manages all aspects of logistics required toassemble, transport, house, and feed its volunteer teams. More specific responsibilities are spelled outbelow: The Shalom Foundation will: Arrange travel-airline tickets, ground transportation in Guatemala, lodging Create an online fundraising page to assist you in raising money for the trip Determine trip cost Provide a team t-shirt Provide a team manual Trip Participants will: Attend a training meeting with a staff member of The Shalom Foundation Be responsible for payment for the trip Arrive in Guatemala 1 day in advance of the surgical team in order to set up the pharmacy Belmont School of Pharmacy will: Provide training for participant laying out responsibilities, authority and interaction with Moore Center Staff and Surgical team Hold a meeting with trip participant with participant(s) from past trips WHAT TO EXPECTWhat are your Roles:BUSOP team members are the face of pharmacy for the surgical team and provide a range of distributiveand clinical services. These include, but are not limited to the following: Participate in pre-trip planning and post-trip follow up meetings as required. Supervise medications supply, storage and accessibility. Partner with trip/team leader and head nurse to ensure proper medication supply. Support care providers’ clinical decision making. Dispense medication to hospital staff (permanent & team members). Ensure appropriate weight-based dosing of medications used during and after surgery.Typical Activities:While no two surgical trips are identical, each TSF-managed surgery team adheres to a trip schedule thatusually follows a standard script:Pharmacy, Day 1 (Pharmacy usually arrives one day before the full medical team; usually on Friday):Arrive in Guatemala City. After retrieving luggage and clearing customs, a TSF driver will take you to theMoore Pediatric Surgery Center. At the center, you will meet the staff, tour the facility, and then getdown to work. You will “open” the pharmacy and begin to work through the “before the team arrives”activities described in the TMPC Pharmacy Operations guide. While there is a lot to accomplish, Day 1 isextremely quiet and peaceful. At the end of the work day, you will be taken to your hotel to check in,relax, and get dinner (possibly on your own).
Pharmacy, Day 2 (Saturday):Your TSF driver will pick you up at the hotel at a pre-arranged time and take you to the hospital. Themorning is spent at MPSC continuing to prepare the pharmacy for the full surgical team’s arrival in theafternoon: you need to complete the activities list begun the day before, because once the full teamarrives, you have to tackle a number of demanding tasks in fairly short order.The team will bring suitcases containing supplies and medications that the surgeons andanesthesiologists have identified as essential to the type of surgery the team will focus on during theirtrip (each trip has a different surgical focus). Following team introductions, facilities tours, and otherteam planning meetings, you will need to integrate the newly arrived medications and supplies into thepharmacy’s inventory.Once the team has completed its unpacking and initial facilities prep work, youand the team will return to your hotel. Make an effort to meet with both the lead anesthesiologist andlead nurse on the team; these will be important partners during the week, and they need to know therange of support that you have to offer them.Pharmacy, Day 3 (Sunday):For the rest of the surgery team, Day 3 is devoted to screening children who are candidates for surgery.While pharmacy does not participate directly in patient screening, you will be busy: you have tocomplete the “screening day” tasks listed on theTMPC Pharmacy Operations guide; and, you can expectto be consulted by the team’s surgeons when they run into patients suffering from malnutrition ordehydration/electrolyte depletion, who may be scheduled for surgery if their health status can bestabilized in time. The pace at the MPSC picks up: children and their parents, staff and the team will beall over the place. Things will seem a little chaotic compared to the prior days. Depending how patientscreening moves along, you should be headed back to your hotel about 6:30pm.Pharmacy, Day 4 (Monday):The trip’s first surgeries begin between 7:00-7:30am. To keep this schedule, you will leave the hotel at6:30am. Eat breakfast before leaving the hotel because lunch is not provided until noon. Once at thecenter, you will begin the check list off of the “surgery days” tasks listed on the TMPC PharmacyOperations guidehanging in the pharmacy. Once completed, the rest of the day is spent supporting thepharmaceutical needs of the team and patients.Lunch is served between 12pm and 12:30pm and team members grab a meal as they can between (orduring) surgeries). Drinks and snacks are provided throughout the day in the upstairs conference roomrefrigerator. Depending on the number of surgeries scheduled and on how each goes, your day will endbetween 6:30pm and 9:30pm. You will get dinner after you are finished at the center for the day. Dinnercan take place at various locations depending on how tired you are (in this case you will want to getroom service)or how early you leave (in this case the team might go out to dinner). This will be thepattern for each surgery day.Pharmacy, Day 5-8 (Tuesday-mid-day Friday):Surgery days continue, through Friday midday. These days are the same as Day 4 listed above, exceptthat there are now post-op patients to care for. Make morning rounds to check on the care providedovernight and to plan for patient therapeutic needs leading up to, and including, discharge.Pharmacy, Day 8-9 (Friday afternoon – Saturday):You will probably check out of your hotel before heading to the MPSC for the last half-day of surgeryactivity and packing up. There is a list of “last day before leaving the pharmacy” activities that you must
complete before the pharmacy can be “closed” for the trip. Many of these can be started on Day 8 in theafternoon, if you budget your time to allow for it.Once the surgical team leader signs off on the last patients’ post-op care, thus “closing” the medical carecomponent of the trip, you and any team members who have chosen to stay in Guatemala will boardthe van/bus and travel to Antigua for a rest day and sightseeing. The bus ride to Antigua is about 30minutes. Your activities for the day depend on the team. In past trips, the time in Antigua has includedexcursions and shopping in the market.Pharmacy, Day 10 (Sunday):Day 7 begins around 8am depending on what time your flight leaves. You will be driven to the airport inGuatemala City, from where you will fly home. BUDGETING AND CASH NEEDSTrip Costs:The Shalom Foundation will determine the cost of the trip. Historically, trip costs average about$1,800.00. The cost will cover the following: Travel: airfare, hotel, ground transportation, R&R day Food: breakfast at the hotel, lunch at the surgery center Food: dinner at a Thank You event for the surgical team Communications: you will be provided with a Guatemalan cell phone with ~$20 worth of minutes. Generally, most hotel payments include internet access. You will be able to use the Wi- Fi at the surgery center.The cost does not cover the following (trip participant must provide): Food: dinners during work week or during R&R days Food: meals on the airplane and at the airport Spending moneyDinners, incidentals and shopping: Expect to pay between $20 (US) per night for dinner o Note the $1 equals about Q7. This will vary depending on where your money is converted Hotel front desk staff can exchange $ for Q Most places accept credit cards. However, your credit card company might charge an international transaction fee. Some places will take US currency. Be aware that if the bill is torn or looks worn they will not accept the payment.R&R Days in Antigua: Possible Excursions: Zip Lining in Antigua $35 (US) Coffee Plantation Tour $18 (US)Cash on Hand: You should be able to manage the trip comfortably with between $200-250 (US) cash, in a mix of denominations (don’t bring bills bigger than $50).
Having about $20 (US) in one-dollar bills can be useful if you are shopping in the markets. You can often name a price in US dollars, and not have to deal with a pocket full of Guatemalan coinage. PACKINGPack only the essentials:Pack light and efficiently. You really won’t need much in the way of clothes and other supplies duringthe trip because your activity most days will be confined to the MPSC. Focus on comfort and mix andmatching outfits. If you don’t feel the need to be a fashion plate, you can amaze yourself with how lightyou can pack for this trip. That said, however, the following are suggestions of things not to forget topack: Bring a notebook and writing utensils to use in the pharmacy. Scrap paper is needed often. Camera and batteries. Note that I-phone cameras may not function in airplane mode. Umbrella and/or rain jacket during the rainy season (Mid-May throughLate-October). Scrubs are provided by The Moore Pediatric Surgery Center each day; however, unless you have a need to go into the surgery suites, there is no reason to wear anything other than comfortable street clothes. Plan to have one outfit for dinner with the entire team. Jeans and a nice shirt are sufficient. Most team members dress casually in jeans and polo shirts/t-shirts, while others opt for more “business casual” for the team “thank you” dinner hosted by TSF staff.Carry-On Baggage Restrictions:On instructions from the Transportation Security Administration, airlines advise customers that thefollowing items are permitted inside the “duty-free” area through the screening checkpoint: Liquids, gels, and aerosols in small containers (3oz/90ml or less) in a clear re-sealable 1 quart/1 liter plastic bag. The bag with its contents must be subjected to inspection separate from carry- on bags. Medications (including non-prescription medicine) without the requirement that the customer’s name appear on prescription medicine. In U.S domestic airports, liquids (to include beverages), gels and aerosols purchased in the “duty-free” area of the airport may be taken on board the aircraft. Leaving Guatemala, liquids (to include beverages), gels and aerosols purchased in the area may not be taken on board the aircraft. o Exception: Alcoholic beverages purchased in this area will be given to you as you board the aircraft.Baggage Allowance 1-carry-on plus 2 checked bags per person. o Because pharmacy participants almost always begin their travel in Nashville, and because many pharmacy participants can pack for the trip in one backpack or carry-on bag, we have been able to let TSF use our baggage allowance to ship needed supplies for the MPSC or their other projects. Checked baggage size and weight restriction: o Maximum 50lbs and 62 linear inches (total length +width + height) per piece. o Each team member is asked to utilize their second checked bag for team or Moore Center supplies. For international flights, all bags must be checked a minimum of 60 minutes before departure time.
ACCOMMODATIONSHotel accommodations are reserved at one of the hotel chains listed below. Please note that hotelaccommodations are subject to change at any time. You may share a room with someone you have notmet before. Clarion Suites Hotel: http://www.clarionguatemala.com/ (Red Star on Map Below) Best Western Stofella: http://www.stofella.com/(Purple Star on Map Below) Intercontinental Hotel: http://www.ichotelsgroup.com/intercontinental/en/gb/locations/guatemalacity (Yellow Star Below) In Antigua, Guatemala: Porta Hotel Antigua: http://www.portahotels.com/content/porta-hotel- antiguaAlthough you will not spend much time at your hotel, each offers many services such as: High speed internet Gym Air conditioner Room Service Business Center Laundry MAPS OF KEY LOCATIONSMap 1: Moore Pediatric Surgery Center & Hotels Red Star: Location of Moore Pediatric Surgery Center This area is referred to as Zone 1 Blue Star: Location of Hotels listed above This area is referred to as Zone 10, Business District
Map 2: R&R Day in Antigua, GuatemalaPoint A: Antigua: R&R Day 22.3 miles from the Clarion to Antigua ~40 minutesPoint B: Location of Airport 2.6 miles from Airport to ClarionMap 3: Hotels Purple Star: Hotel Stofella Yellow Star: Intercontinental Red Star: Clarion
CELL PHONES AND INTERNET SERVICEU.S. based cell phones may not function in Guatemala City without additional service fees and priorarrangements with your provider. There are fees for international calls, email and texting services. TSFprovides you access to a cell phone from Guatemalan provider service that can be used to contact TeamLeaders. These phones can also be used to make calls home. However, these phonesare pre-loaded withminutes. Once those minutes are used, you must purchase more if you require additional use of thephone. Each phone inside MPSC includes a US phone line from which you can make calls home. Internetconnectivity is available at the hotel and at the center. Beware, however, that some hotels in Antigua,Guatemala charge for internet service. HEALTH AND SAFETYHealth Issues/Advice In Guatemala, drink only purified water; use ice only from purified water. First aid kits will be available (Cipro, Immodium, Tylenol, etc). o The items in the kit might not be available when needed. Therefore bring these items with you. Do not eat any foods from street vendors. You can get sick. Eat only fruits that can be peeled. Take and use hand sanitizer often.Safety Issues/Advice Never go anywhere alone; remain in the group at all times. Before you travel, clean out your wallet/purse. Take only necessary identification, credit card(s) or cash. It is advisable to purchase a special pouch or belt for the purpose of discreetly carrying your valuable items. A good packing rule is, “If you don’t need it, don’t take it”. Leave all non-necessary valuable at home, including jewelry. Use the in-room safe in your hotel room to store any valuables that you brought to Guatemala, but that you do not have to have with you that day. Keep your US passport in the safe; keep a photocopy on your person. When possible, always ask permission before you take a picture of someone: “Un photo, por favor?” Do not use any ATMs outside of hotel to prevent identity theft/fraud. Things are different in Guatemala than in the U.S. You will see guards armed with shot guns outside of many businesses, including the surgery center. TIMELINE OF EVENTS3 MONTHS BEFORE TRIP (If possible) Complete the team volunteer application form (application, responsibility release, photo release, participation guidelines) at the Shalom Foundation website: www. theshalomfoundation.org o Make a copy for BUSOP (Provide to Dr. Hobson, unless directed otherwise). Send in the signed and dated “What to Expect On Your Trip” form (Belmont Pharmacy Medical Mission Trips) to TSF. (Provide a copy to Dr. Hobson, unless directed otherwise). Turn in non-refundable deposit of $300 to The Shalom Foundation Receive recommended vaccinations o By university policy, as a pharmacy student you already have two of the vaccination listed below*. It is optional to receive the other two
o Recommended vaccinations: Hepatitis A Typhoid Hepatitis B* Tetanus* o More information about vaccination and travel health can be found at the CDC’s website: http://wwwnc.cdc.gov/travel/page/vaccinations.htm You set up a travel medication consult with Belmont University Health Services to discuss health concerns/needs of trip. Ask them to give you a prescription for Cipro. Please note that this medication is dispensed free of charge at any Publix Pharmacy.Publix Pharmacy staffcan provide you with a vaccine card to take with you on the trip. Fundraising activity: o Email Kevin McQuaig at firstname.lastname@example.org to set up a donations web page Donations are tax deductible for you and any others who wish to support your trip o Submit Gebhardt application o Funding providing by Belmont University Ministries o Please note that this source of funding may not be available o University ministries website http://www.belmont.edu/universityministries/index.html3 WEEKS BEFORE TRIP 50% of trip cost are due to The Shalom Foundation1 WEEK BEFORE TRIP Full balance of trip cost is due to The Shalom Foundation Email Kevin McQuaigabout the logistics of picking up materials that you will carry into the country. Contact your credit card provider to inform them of your travel to Guatemala . Make copies of your passport and any credit cards you plan to use and leave these with a family member or trusted friend. o Leave a copy of your passport with BUSOP (Provide to Dr. Hobson, unless directed otherwise). To reduce the unlikely, but possible, effects of altitude sickness, begin drinking anextra bottle of water or two a day. Guatemala City’s elevation is approximately 5,000 feet above sea level, compared to Nashville, TN’s highest point at just over 1,000 feet above sea level. o Altitude sickness is a condition that occurs when you are exposed to low partial pressures of oxygen at high altitude. It commonly occurs above 8,000 feet. Dehydration due to a higher rate of water vapor lost from lungs at higher altitudes may be the main contributor to altitude sickness. Symptoms include headache, fatigue, stomach illness, dizziness, and sleep disturbance. Exertion aggravates the symptoms. Symptoms often manifest themselves 6 to 10 hours after ascent and generally resolve in 1 to 2 days. Purchase a special pouch or money belt for the purpose of discretely carrying your valuable items.
Additional AdviceBecoming Part of the TeamGet involved early. Be assertive with introductions and overview of the role/services pharmacy willprovide as part of the surgical team. Never position yourself as “just a student”. While most U.S.providers are used to working with pharmacy in their home practice settings, it is likely that you may bethe first pharmacist that the team has worked with as part of a medical mission trip. It is important toshow them the importance of having you there, so get involved!Working with the Moore Pediatric Surgery Center Permanent StaffWithin the MPSC, you will interact with a variety of Guatemalan men and women who are joining yourefforts to serve children in need. The MPSC staff includes a mix of permanent, trip-specific, andvolunteer staff. These include medical doctors, medical residents, medical students, nurses, socialworkers, and translators. Some staff members speak fluent English, while others do not.Use translators when you speak with the permanent staffwhoare not fluent in English. Some teams arelarge enough and diverse enough that they will have one or two U.S. nurses on the first floor taking careof patients; often, however, surgical teams will rely on the Guatemalan nursing staff to care for pre- andpost-op patients. Of course, it is easier for you to work with U.S. nurses (and other providers) because ofyour shared language and practice expectations. Yet, you must accept that you and the entire surgicalteam are guests in the MPSC, and that its permanent staff is made up of licensed health careprofessionals who are legally responsible for all activity in the center. Treat them with the respect anddeference that they deserve, even as you encounter language barriers and medical beliefs/practicedifferences. There is much to be learned from each other.The MPSC has a permanent medical director and a permanent head nurse. You will work with both agreat deal during your trip, so make a concerted effort to meet these people.Working with a TranslatorCarrying out any conversation through a third-person translator is challenging. Doing so when importantand technical information is being shared or decisions are being made is even more so. Whether or notyou have experience working with a translator, the following are tips that you can rely on to make thisinteraction as productive as you can: When speaking through a translator, speak to (face and maintain eye contact with) the person of interest (i.e., healthcare provider, patient, caregiver, etc.) and not the translator. “Read” their face and body language to help you gauge their understanding. Make sure the translator translates both sides of the conversation with the same precision. Use the “teach/talk back” active listening strategy to help you to know that both you and your conversational partner are “on the same page” at all points in the conversation. Ask, “Would you please repeat back to me what you think I just said, so that I can make sure that we are in agreement?” Avoid using medical “technobabble”; doing so only increases the likelihood of miscommunication. Keep your terminology as simple as possible because you may not have access to a translator with medical/health care training. Slow down you speaking pace (take your time); pause often to let the translator keep up; and try to “chunk” information as much as possible into specific packets/moments within the conversation.
Anxieties are NormalIt is normal to be nervous about this experience. Most pharmacy participants worry aboutnot having ananswer to everything before the trip. Know that you have safety nets in place to help with any questionsthat you may not know. Just remember that you cannot know everything: just know where to find theinformation you need.Safety NetsAlthough you may be the only pharmacist at the MPSC, and do not have all of your normal hard-copyresources in the center’s pharmacy, you are not working without a complete set of safety nets. Thefollowing are a sample of the resources on which you have to draw while you are in Guatemala: Electronic resources o There is Wi-Fi at the surgery center; therefore, any resources Belmont offers are available, includingLexi-Comp, Micromedex, etc. o Skype works well on the MPSC’s wireless network, and BUSOP has an I-Pad that is designated as a travel resource. Belmont Univeristy’s Pharmacy o (615) 460-6040 o Dr. Bryant: (615) 460-6129 email@example.com Belmont University’s Drug Information Center o Dr. Ficzere: (615) 460-6531 firstname.lastname@example.org Dr. Hobson (615) 693-9888 (cell)email@example.com Facebook o Pharmacy friends on Facebook who can help answer questions. Team Members o Anesthesiologists are a great source of information ranging from disease state, to medicinal product options preferred in surgical settings, to dosing options and alternatives.Commonly Seen MedicationsBecause the MPSC is an ambulatory, pediatric surgery center that focuses each medical mission trip onone surgery category, the variety of cases and medical intervention situations that you will be part ofwill almost always fall within a fairly narrow scope. Typically, the primary pharmacotherapeutic concernsfall into three domains: post-op anesthesia tolerance/recovery; antimicrobial care; and painmanagement.Commonly Seen Dosing IssuesAt the start of post-op patient care activity, pay close attention to all medication orders originating fromfirst floor (recovery rooms). Check to see if medication requests are coming from U.S. or Guatemalanpractitioners (medical residents, nurses, etc.). Prior pharmacy participants have reported a general lackof awareness of weight-based dosing among the Guatemalan medical community. Concern aboutpotential over/under dosinghas been an on-going issue, and pharmacy has developed a reputation ofholding a firm line on all medication orders being weight-based. This means that pharmacy has tomonitor the floor to know who are the patients (take time to read the charts) and take the opportunityto teach how to do effective weight-based dosing of the most-commonly requested drug products (theGuatemalan medical student volunteers have been excited about learning how to do this, as have thenursing staff).
The doses for the medications listed below may vary depending on the patient and convenience for thepatient. For example, if a calculated dose for Amoxicillin came out to be 11.5ml po q12h, the teamwould round to 10ml because the dose range was 20-40mg/kg and the biggest dosing syringe we hadwas 10ml. It is confusing for the patient’s caregiver to give one dose of 10ml plus 1.5 ml. Lortab o 0.2mg/kg per dose every 4 to 6 hours Amoxicillin o 20-40mg/kg divided in two doses (q12h) x 7 days Augmentin o 8mg/kg/day (based off of the trimethoprim) in divided doses q12h Motrin o 10mg/kg/dose po q 6 to 8 h Tylenol o 10-15mg/kg/dose po q 4 to 6 h prn Bupivacaine with or without Epi Propofol FentanylWhat to Brush Up OnYour training has prepared you to handle nearly every foreseeable patient need, and your access tostrong resources has you prepared to react to most unforeseen needs. That said, you can help to reduceyour anxiety about your ability to perform at the levels needed as part of the surgical team by spendingtime before the trip brushing up on the following topics: Weight-based dosing for children. Pharmaceutical calculations, particularly for IV delivered agents that you may be called upon to craft from pharmacy stock to meet surgeon/anesthesiologist preferences. This has occurred on each trip, to date. Pain management protocols for children depending on the type of surgery (note that pain management for soft tissue surgery is much different than for orthopedic surgery). Antimicrobial therapy protocols for children depending on the type of surgery (note that antibiotic therapy for oral surgery is much different from lower extremity surgery or from urological surgery). Your options for antibiotic are also determined by two variables with which you do not usually work: what products the team brought into Guatemala with them (they may or may not have packed enough product to meet all needs), and what products are readily available through the Guatemalan pharmaceutical supply chain. Brush up on older agents.