Rounding and Oh my God...

I arrived to the clinic really early on both Monday and Tuesday.  By 5:30am, my room had turned into a sweat lodge.  Dona Espiranza prepared for me a typical Nicaraguan breakfast of an egg sunnyside-up on fried ham, gallo pinto, a tortilla,  papaya, mango, and a banana. Coffee with an overload of sugar. And cold glass of sugar with some pitaya juice.  Really healthy:) but so delicious.  I reluctantly put on my scrub pants, and walked outside into the surface of the sun. The clinic was even hotter. As much as I wanted to take the one fan on the intake side of the clinic, I positioned it to circulate air to the whole area to get some flow towards the patients.  Everyone was sweating.  I think Mondays are big blood sugar days.  We tested almost all 60 patients. 

Around 9:30am, Mario shared with the French baby-MDs and me that we were heading to Hospital Amistad in the afternoon!  My stomach dropped.  Spanish is hard enough to just comprehend when you aren't fluent. But now I am leaving the comfort of the clinic to have to survive the wrath of tired doctors and overworked nurses whose last thing they want to do is deal with a Gringa. I am was also very excited about stepping into the unknown.  Boy, were we all in for it. 

Front of the hospital.
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Mario drove us over to the hospital and introduced us to the head of nurses. Then he left. Jefa took us to the cafeteria, which was more like a street taco stand in the parking lot.  She left. After a couple of enchiladas with gallo pinto and a cup of water covered with a baggy to deter the flies, we went to look for her. We had no idea what we were doing. Once we found her, she pawned us off to the Sub-Director of the hospital.  His office was a closet shared with 3 other people.  It smelled of cigarette smoke and heat... Very straightforward, fast speaking, and left little time for questions.  He is a busy man.  He told us to go to Emergency. Then took a phone call.  I'll just say we did a lot of figuring shit out that day. All part of the experience :) 

Emergency.  Emergency was more like a triage in a place of war or refugee camp.  People were herded onto benches outside in the heat, and their cases were ranked by some degree of seriousness. The floor, as one would call it in the States, is just a room. Some areas are separated, but most of it is open and cramped and hot.  We found 3 doctors to shadow.  I got lucky.  Etienne and Anne were with docs who could care less about having them around. It was probably a long day for them though.  And I'm not happy when I am stressed and hot, so I can't imagine them being any different. Plus, no one told any of the hospital "floors" that we were coming.  I had a pretty nice doctor.  He took me back to radiology. Showed me some X-rays of broken bones.  He also showed me how to set a broken arm on a 2 year old without waking him up. We had another patient who had fallen off a ladder and sliced his hand open.  The doctor explained to me the many of accidents they see are work-related, usually involving machetes, ladders, or machinery.  

I couldn't believe the ER. It was filthy. Soap and betadine were stored in old, used Aplina water bottles.  Used gauze was stuffed in the corners and needle caps were laying on the floor.  I saw one person wash their hands the 45 minutes I was in there. People hooked up to IVs were sharing hospital beds. They were slammed. About 80 to 100 patients were waiting outside to be seen by the 3 doctors, and it was already 2. Etienne and Anne couldn't handle it anymore, so they talked me into leaving to go and check out other areas. We figured that we would have more luck with the docs in Internal Medicine.

During our retreat from emergency, we all started to really see this hospital.  The hospital reminds me more of a huge high school in the states.  The hallways are covered sidewalks outside.  The waiting rooms are benches on these sidewalks.  

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There really is no indoor area.  The rooms have windows without glass.  They kept cool-ish by fans and open air.  No AC, except for in the ICU and OR.  Stray dogs and cats were going in and out of hospital rooms. Flies and mosquitos outnumber the patients.  There is a very faint scent of vomit that flutters around as well. 

We went to ICU, Internal Medicine, Surgery, and OB/GYN.   Etienne did most of the talking. While both he and Anne are fluent, he's took the lead and received most of the looks while we were there. No one knew why were there, nor knew what to do with us.  Most of them ignored us with look of annoyance.  We later figured out that everything happens in the morning.  There was one doctor per unit around, and he or she was doing paperwork. The ICU doctor and the OB nurse were the nicest and did their best to fill us in on the doings of their wards.  We were urged to come back in the morning.  I left feeling miserably confused and defeated. So did my French counterparts.  Anne was so turned off by the experience she wrote off going back again. 

On Tuesday all 3 of us stayed in the clinic. We explained to Mario what happened.  Etienne and I asked if it would be okay to go in the mornings. Sure!!  I saw some cool stuff in the clinic on Tuesday but I'll save that for another day. 

This morning I hopped on a chicken bus heading to Managua and jumped off 10 minutes later at the entrance to the hospital.  Etinne and I met out front and bravely walked upstairs to meet El Jefe. He told us to go down to Internal and find the residents and they were rounding at 9.  Then he looked at Etienne and said "You cannot wear this".  Etienne was wearing surfer shorts, flip flops, and a t-shirt.  He brought scrubs with him.  But no white coat for this Frenchman. 

In the residents' lounge, we heard all about the typical cases they saw. TB. Pneumonia. AIDS. Dengue. Ulcers. Strokes.  Then we started rounds. At first it was pretty typical.  Then we entered the ICU. Only 6 beds, and no dividers. There was a kid who drank pesticides and was in a coma. Two elderly women with extremely bad cases of pneumonia and emphysema.  A man who had a stroke leading to him being in a level 3 coma.  A man with unmanaged diabetes who had both legs amputated, suffering from AIDS, and pneumonia. And I'm not sure about the last one. It was difficult to be in a room surrounded by audible suffering and pain.  Flies were zipping around everywhere.  It was hard.

We rounded some more, and we saw and examined some more stroke patients. It's amazing the different symptoms and levels of extreme a stroke can cause. After about 2 hours of seeing and learning, we hit the big daddy.  

My life will never be the same after seeing this.  A man in his 20's fell from a ladder and shattered his spine, leaving him paralyzed from the waist down.  While on bedrest, whoever was caring for him did not move him enough.  He developed a bedsore within 2 hours, and soon after, the ulcer turned necrotic.  When the resident turned him over, I expected to see the usual bed sore you would find in geriatrics.  Not so.  It was like my second block in anatomy lab when we dissected the lower back and buttocks region of our cadavers, except this was a living, breathing, talking young man in some real pain. The medical team had to dig out all of the necrotic tissue to reach unharmed tissue.  His wound, I don't even know what to call it, went covered the entire width of his back and went from L3/L4 to S1/S2 as well as to the top part of the coccyx.  You can look of the dermatome guy for reference.  It was so deep that we could see muscle tissue of the back and glutes and parts of his sacrum and coccyx.  Adipose tissue, muscle, arteries, bone.  All of this was contained with a tiny strip of gauze. There was no sterile field prepared while we watched the residents clean it. Flies were landing on it. This poor man had diminished sensation, but he could still feel this gaping hole in his lower back. Etienne and I were almost sick to our stomachs.  His mother had tears streaming down her face.  She knows the high probability of infection. As well of the high probability of losing her son.

It's terrible to see things like this.  You want to judge. You say things like, this would never happen in ____, why don't they do this procedure, why are they using this and not this?  But we have to remember that when we study in 3rd world countries, we are going to see things we won't ever see in our bubbles.  We study in top notch universities of top notch hospitals. The public hospitals here are doing the best they can for the very sick, the very hurt, and the very poor.  I am humbled at how resourceful these doctors and nurses need to be.  

Etienne and I talked Anne into coming with us at lunch today (somehow we got our appetite back).  I think we are going to learn quite a bit about medicine in the 3rd world at Hospital Amistad, as well as a lot about ourselves.