THE MOORE PEDIATRIC

SURGERY CENTER

MEDICAL MISSION TRIP

GUATEMALA CITY, GUATEMALA

STUDENT MANUAL

BELMONT UNIVERSITY SCHOOL OF PHARMACY

AND

THE SHALOM FOUNDATION

TABLE OF CONTENTS

OVERVIEW Page 3

WHAT TO EXPECT Page 4

BUDGETING & CASH NEEDS Page 6

PACKING Page 7

ACCOMDATIONS Page 8

MAPS AND KEY LOCATIONS Page 8

CELL PHONES & INTERNET Page 10

HEALTH & SAFETY Page 10

TIMELINE OF EVENTS Page 10

ADDITIONAL ADVICE Page 12

OVERVIEW

What 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 been extending a long-standing TSF and Belmont University (BU) partnership to include, among other initiatives, adding pharmacy (distributive & clinical services) to each surgical mission team that uses the Moore Pediatric Surgery Center (MPSC) in Guatemala City, a three operating room, ambulatory surgery center 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 pharmacy services to each medical mission team. BUSOP’s commitment is to continue this staffing pattern by employing 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 free surgeries for Guatemalan children in need. Annually, teams from institutions as varied as Monroe Carell Children’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 each child 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&R days. Pharmacy often arrives one day before the full surgery team in order to ensure that all needed medications and supplies are in place, or under order; therefore, for pharmacy participants, most trips are 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 of Belmont University’s and BUSOP’s missions. We recognize that we lead lives that are blessed with opportunity and access, and that we have a moral obligation to give back. One way of giving back is through the use of our talents to improve other’s lives. Investment in improving the health of children results 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 in

recognition of the ways in which their lives were changes by other’s generosity. Finally, we are doing this work 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 health problems, if you have never participated in medical mission work, but would like to do so, or, if you want an opportunity to see how your professional skills translate into myriad other ways to serve others, then joining a BUOSP-TSF surgery team may be for you. You will not be the same person when your 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, logistics management. We take on the task of finding people with the talents, skills, and interest to provide pharmacy services as part of a surgical team, while TSF manages all aspects of logistics required to assemble, transport, house, and feed its volunteer teams. More specific responsibilities are spelled out below:

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 EXPECT

What are your Roles:BUSOP team members are the face of pharmacy for the surgical team and provide a range of distributive and 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 that usually 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 the Moore Pediatric Surgery Center. At the center, you will meet the staff, tour the facility, and then get down 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 is extremely 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. The morning is spent at MPSC continuing to prepare the pharmacy for the full surgical team’s arrival in the afternoon: you need to complete the activities list begun the day before, because once the full team arrives, 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 and anesthesiologists have identified as essential to the type of surgery the team will focus on during their trip (each trip has a different surgical focus). Following team introductions, facilities tours, and other team planning meetings, you will need to integrate the newly arrived medications and supplies into the pharmacy’s inventory. Once the team has completed its unpacking and initial facilities prep work, you and the team will return to your hotel. Make an effort to meet with both the lead anesthesiologist and lead nurse on the team; these will be important partners during the week, and they need to know the range 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 to complete the “screening day” tasks listed on the TMPC Pharmacy Operations guide; and, you can expect to be consulted by the team’s surgeons when they run into patients suffering from malnutrition or dehydration/electrolyte depletion, who may be scheduled for surgery if their health status can be stabilized in time. The pace at the MPSC picks up: children and their parents, staff and the team will be all over the place. Things will seem a little chaotic compared to the prior days. Depending how patient screening 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 at 6:30am. Eat breakfast before leaving the hotel because lunch is not provided until noon. Once at the center, you will begin the check list off of the “surgery days” tasks listed on the TMPC Pharmacy Operations guide hanging in the pharmacy. Once completed, the rest of the day is spent supporting the pharmaceutical needs of the team and patients.

Lunch is served between 12pm and 12:30pm and team members grab a meal as they can between (or during) surgeries). Drinks and snacks are provided throughout the day in the upstairs conference room refrigerator. Depending on the number of surgeries scheduled and on how each goes, your day will end between 6:30pm and 9:30pm. You will get dinner after you are finished at the center for the day. Dinner can take place at various locations depending on how tired you are (in this case you will want to get

room service) or how early you leave (in this case the team might go out to dinner). This will be the pattern 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, except that there are now post-op patients to care for. Make morning rounds to check on the care provided overnight 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 surgery activity 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 the afternoon, 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 care component of the trip, you and any team members who have chosen to stay in Guatemala will board the van/bus and travel to Antigua for a rest day and sightseeing. The bus ride to Antigua is about 30 minutes. Your activities for the day depend on the team. In past trips, the time in Antigua has included excursions 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 in Guatemala 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 money

Dinners, 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 during the trip because your activity most days will be confined to the MPSC. Focus on comfort and mix and matching outfits. If you don’t feel the need to be a fashion plate, you can amaze yourself with how light you can pack for this trip. That said, however, the following are suggestions of things not to forget to pack:

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 through Late-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 the following 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.ACCOMMODATIONS

Hotel accommodations are reserved at one of the hotel chains listed below. Please note that hotel accommodations are subject to change at any time. You may share a room with someone you have not met 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-antigua

Although you will not spend much time at your hotel, each offers many services such as: High speed internet Air conditioner Business Center

Gym Room Service Laundry

MAPS OF KEY LOCATIONS

Map 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, Guatemala

Point A: Antigua: R&R Day

22.3 miles from the Clarion to Antigua ~40 minutes

Point B: Location of Airport

2.6 miles from Airport to Clarion

Map 3: Hotels

Purple Star: Hotel StofellaYellow Star: IntercontinentalRed Star: Clarion

CELL PHONES AND INTERNET SERVICEU.S. based cell phones may not function in Guatemala City without additional service fees and prior arrangements with your provider. There are fees for international calls, email and texting services. TSF provides you access to a cell phone from Guatemalan provider service that can be used to contact Team Leaders. These phones can also be used to make calls home. However, these phones are pre-loaded with minutes. Once those minutes are used, you must purchase more if you require additional use of the phone. Each phone inside MPSC includes a US phone line from which you can make calls home. Internet connectivity 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 EVENTS

3 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.orgo 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 staff can provide you with a vaccine card to take with you on the trip.

Fundraising activity:o Email Kevin McQuaig at kmcquaig@theshalomfoundation.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 Ministrieso Please note that this source of funding may not be availableo University ministries website

http://www.belmont.edu/universityministries/index.html

3 WEEKS BEFORE TRIP

50% of trip cost are due to The Shalom Foundation

1 WEEK BEFORE TRIP Full balance of trip cost is due to The Shalom Foundation Email Kevin McQuaig about 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 an extra 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 will provide 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 be the first pharmacist that the team has worked with as part of a medical mission trip. It is important to show 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 your efforts to serve children in need. The MPSC staff includes a mix of permanent, trip-specific, and volunteer staff. These include medical doctors, medical residents, medical students, nurses, social workers, and translators. Some staff members speak fluent English, while others do not.

Use translators when you speak with the permanent staff who are not fluent in English. Some teams are large enough and diverse enough that they will have one or two U.S. nurses on the first floor taking care of patients; often, however, surgical teams will rely on the Guatemalan nursing staff to care for pre- and post-op patients. Of course, it is easier for you to work with U.S. nurses (and other providers) because of your shared language and practice expectations. Yet, you must accept that you and the entire surgical team are guests in the MPSC, and that its permanent staff is made up of licensed health care professionals who are legally responsible for all activity in the center. Treat them with the respect and deference that they deserve, even as you encounter language barriers and medical beliefs/practice differences. 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 a great 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 important and technical information is being shared or decisions are being made is even more so. Whether or not you have experience working with a translator, the following are tips that you can rely on to make this interaction 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 about not having an answer to everything before the trip. Know that you have safety nets in place to help with any questions that you may not know. Just remember that you cannot know everything: just know where to find the information you need.

Safety NetsAlthough you may be the only pharmacist at the MPSC, and do not have all of your normal hard-copy resources in the center’s pharmacy, you are not working without a complete set of safety nets. The following are a sample of the resources on which you have to draw while you are in Guatemala:

Electronic resourceso There is Wi-Fi at the surgery center; therefore, any resources Belmont offers are

available, including Lexi-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) 460-6040o Dr. Bryant: (615) 460-6129 ronda.bryant@belmont.edu

Belmont University’s Drug Information Centero Dr. Ficzere: (615) 460-6531 cathy.ficzere@belmont.edu

Dr. Hobson (615) 693-9888 (cell) eric.hobson@belmont.edu 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 on one surgery category, the variety of cases and medical intervention situations that you will be part of will almost always fall within a fairly narrow scope. Typically, the primary pharmacotherapeutic concerns fall into three domains: post-op anesthesia tolerance/recovery; antimicrobial care; and pain management.

Commonly Seen Dosing IssuesAt the start of post-op patient care activity, pay close attention to all medication orders originating from first floor (recovery rooms). Check to see if medication requests are coming from U.S. or Guatemalan practitioners (medical residents, nurses, etc.). Prior pharmacy participants have reported a general lack of awareness of weight-based dosing among the Guatemalan medical community. Concern about potential over/under dosing has been an on-going issue, and pharmacy has developed a reputation of holding a firm line on all medication orders being weight-based. This means that pharmacy has to monitor the floor to know who are the patients (take time to read the charts) and take the opportunity to teach how to do effective weight-based dosing of the most-commonly requested drug products (the Guatemalan medical student volunteers have been excited about learning how to do this, as have the nursing staff).

The doses for the medications listed below may vary depending on the patient and convenience for the patient. For example, if a calculated dose for Amoxicillin came out to be 11.5ml po q12h, the team would round to 10ml because the dose range was 20-40mg/kg and the biggest dosing syringe we had was 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

Amoxicillino 20-40mg/kg divided in two doses (q12h) x 7 days

Augmentino 8mg/kg/day (based off of the trimethoprim) in divided doses q12h

Motrino 10mg/kg/dose po q 6 to 8 h

Tylenolo 10-15mg/kg/dose po q 4 to 6 h prn

Bupivacaine with or without Epi Propofol Fentanyl

What to Brush Up OnYour training has prepared you to handle nearly every foreseeable patient need, and your access to strong resources has you prepared to react to most unforeseen needs. That said, you can help to reduce your anxiety about your ability to perform at the levels needed as part of the surgical team by spending time 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.

MOST IMPORTANTANTLY:

HAVE FUN!