A little bit of this and that...

I have a nice long post coming up about Clinica Alabama probably this weekend.  I keep forgetting to do this everyday, like I said I would.  So family and friends, this one is for you so you know I'm still here and haven't expatted/ faked a mysterious disappearance... yet. ;)

I've been hanging with the docs the past few days. And next week Frenchies and I get to venture to the big hospital.  One of the students, Aurhencuruvru (something beautiful in French that I don't know how to spell), is a 6'3'' man who not only forgot his white coat but also scrubs.  I, too, did not bring my white coat.  Since I am bit over the average height of a woman here, it was difficult to find one that fit me.  Dr. Villareal did bring one to me.  It can fit a teenager in the states.  Not great for one who has broad back and shoulders due to swimming and rock climbing. But it works.  For Frenchie... he could barely find scrubs long enough.  And they still look like high-waters... is that what they are called?  We are supposed to go to the hospital next week, so we might trek into Managua before to see if we can't find a mutant size of  white coat. 

We have had some interesting cases.  They are interesting because the people who come to this clinic are so poor.  So they have conditions that are totally mismanaged, or not managed at all, and would otherwise go unseen. Blood sugars close to 400. Systolic blood pressures close to 200. Diastolic at 100.  Vomiting for 5 days. Parasites for months.  25 year old women who weigh 70 to 80 pounds, not because they have an eating disorders. Abscesses. Unmanaged osteoarthritis. Malformed anterior fontanelles. Completely debilitating ocular conjunctivitis, resulting in near blindness.  Possible breast cancer. Prostate cancer. A variety of things every day. 

I have worked in free clinics in the states.  Even though I saw a lot of the same things, like hypertension and diabetes, most of it was managed.  Or at least the option was there.  Think of one free clinic serving all of Greenville, Pickens, and Oconee counties.  That's kind of like this Clinic.  They get patients from Nadaime, Masaya, Granada, and little towns and villages all around. There are some other free clinics around, but this one is the one to wake up for at 4 or 5 in the morning to get started on a long walk to be there at 8am.  Then possibly have to sit around until 12:45 to be seen. All while being sick. Long day...

Some friends and family have expressed interest in donating to the Clinic.  I will post wither tomorrow or Monday some history on the clinic and ways to do that.  I appreciate all of the support I am getting for this trip.  I have received many thoughtful emails, and I hope that one day you can experience this country.  There's really nothing like it :)

The kids at Carita Feliz on a summer vacation for a week. I did not know this until I walked, rather than bike, to school.  Upon arrival, two of the students in the 4th grade class were riding their bike, and say "Ashley..... Fuiste???  Jajajaja!" 

To pass the time in the afternoons, I have been spending my afternoons sick.... and also exploring the streets.  So kind of good timing for whatever bug crept it's way inside me- los banditos. Whilst exploring, I got a little obsessed with the wooden doors and iron gates. I take after my papa :) I live in a city obsessed with these creative doors and sidewalks (just wait for it) and paint jobs.  So colorful, just like her people. I took like 50 pics of doors, but I'll spare you..

Also here is video of the endless rain monsoon of today.  You'll notice 2 buckets.  Those are filled from today, and they will be used tomorrow for cooking, cleaning, washing, and drinking. Free water!! Thank you mother nature! Click This.

Iglesia  de Xalteva

color and horses

another Mombacho.. love a good Cloud Forest

This is a papaya. I usually can't stand the taste of this fruit.
It tastes like a mucous covered dirty sock.
But...
If you score the outside a little with a machete,
and allow it to sit in the sun for a day...
and it's not GMO...
it is juicy and delicious. 

Relationships

I want to talk about some of the people, specifically non-Nicas, who I have met here.  This is my 4^th visit to Nica, and my 2^nd extended stay here.  I swear every time I come, I meet so many people who reaffirm why I keep coming back and inspire me to stay on this path  of improving health in Nica.   People like the ones I am about to talk about, and myself included, come here for a reason that is surprising to most.  Yes, Nicaragua is beautiful, physically.  It even sounds exotic to say Nicaragua, and people think you are adventurous for traveling here. However, there are plenty of other countries that are much more "USA and general-traveler friendly", accommodation-wise (AC, hot water, sewage, potable tap water, on-time transportation, less encounters with starving children and stray dogs.  So why do people keep coming back instead of checking out these easier places?  

After a little more than a week of being here, I have realized that the true purpose, for me, is  becoming less about learning medicine.  Instead it is about witnessing the true needs here, so that in the future when I am more adept to impact, I will know how.  The trip is so different from all of the others.  When I came down here with Manna Project, Inc, we were working with the poorest of the poor Nicas.  But I was living with 10 other USAmericans.  This trip I am alone.  I have “telenovela hour” with the ladies of the house: Esperanza, her mother, Yelena, and Maria. I watch Amores Verdaderos”… so good.  I eat my meals with my host family.   I get ice cream with Yelena.  I sleep in the hottest room, sharing it with mosquitos and lizards.  I wake up to the smell of gallo pinto and burning trash (bad as it sounds, I kind of like "Burning trash" smell.  I literally eat, sleep, and breath Nicaragua.  What have I learned?

Nicaragua is about relationships, love, humility, and patience.   Even though I am learning about drugs and diseases, I am learning more about how to build lasting relationships with the people I am treating.  Medicine is intimate. In order for those who you are caring for to trust you and tell you what they truly need, beyond the obvious, you must have a relationship.  That is key especially in Nicaragua.  

I have met some other people who are here to build those mutually nurishing relationships and to empower people to make culturally appropriate changes to improve their communities. 

Cheri Mauldin, Missions of Grace
In an earlier post, I talked about the lack of specific services here, such as mammograms and ultrasounds, referencing the patient with the lump in her breast.  After that experience in the clinic, I went to the 4th of July party at Eliza's house. At some point during the party, I ended up talking to a woman who I can honestly say is true a hero.  Cheri is from the states.  In 1994, Sherri and her husband moved their immediate family of 12 to a rural region of Northern Nicaragua. They lived without running water and electricity for a number of years, becoming humbled by a foreign and indigenous people.  She told me a story of how she took this gardening class before coming here thinking she could spread her Western knowledge.  Upon their arrival, she threw on her longest skirt and developed a plot of land for gardening.  She had noticed how there were no other gardens anywhere, so she thought " wow, I'm really gonna change some lives".  The Nica women just looked at her like she was crazy.  Well, her garden was planted, things grew, and then promptly, everything died.So she tried it again, this change changing her technique.  She gave her garden more attention and encouraging prayers. Same result.  Finally she did something that is surprisingly very rare of NGOs and missions to do when they come here.  She asked for help. THe women smiled, quietly forgave her :), and explained that their soil was not good for growing vegetables during that season.  and all she had to do was mix the soil with lime.  

I could write a novel on her. I hope someone will one day.  Her philosophy is one that humans should follow everyday. She believes n respecting cultures and traditions and knowledge.  Rather than showing people how to to something, she empowers them to do it their way, sometimes with a little tweeking. 

Most importantly  she believes life is about relationships.  It doesn't matter if you have it all or have nothing, as long as you have relationships with people, you have everything. 

Update: She is now a grandmother of 5. All of her family is back in the states after spending most of their lives in Nica, except for one daughter.  Sara just had her 1st child and lives with her husband in San Juan del Sur. 

Nishant, Peace Corp, Virginia

Nishant is probably one of the tallest people living in Nicaragua at the moment;) Nishant hails from Virginia, USA and is a recent graduate of William and Mary.  Next August he will be matriculating to Emory University to achieve a Masters in Public Health (whoop whoop!!) with a concentration in Global Health.  Currently, he works in the Peace Corp office in Managua.  He also has a resident card for Nica… jealous.  He knows 2 dialects of Indian and Spanish, along with English. He loves learning about the culture of Nicaragua and loves the nature in this country as well. His job is all about developing rapport.  

Juan and Becky, Venezuela and Massachusetts

Jaun and Becky live in Granada and work for an NGO that supports small businesses in Nicaragua.  Becky received her MBA with a concentration in International Business and wants to continue work in Latin America.  They both have a deep appreciation and respect for Nicaragua and all of Latin America.  They are a power couple and they are so cute in love with each other it was gross, (in a awww kind of way).

Stephanie,  Canada

Stephanie is a 22-year-old McGill graduate. She also works for an NGO that support small businesses and another that supports the arts within education here in Nicaragua.  She has been living in Esteli since May, and she has lived and traveled all over Latin America. Relationships. Empowerment. Feminist. These are all terms that have profound meanings for her. I had the opportunity to have a great dinner with her and listen to some wise words. I couldn’t say anything because I was so impressed by her passion and beliefs.  Literally, I was speechless.

This country is great for the people.  THe natural splendor, food, and views are extras.  The people here are gracious, kind, and respectful of each other and really everyone.  Family is number 1, next to God. You'll see people at 2 and 3 in the afternoon and think, "Why aren't they working" and "Maybe this is why they are poor".  But you see them sitting in the shade with their children and friends.  Teaching each other handicrafts or enjoying a snack or a beer (not the kids...jeje). 

Steph reminded me of this story from Mexico, and I have heard derivations of it from many other Lating American cultures. But I believe we all have something to learn from it regardless form where it comes from...

An American investment banker was at the pier of a small coastal Mexican village when a small boat with just one fisherman docked.  Inside the small boat were several large yellowfin tuna. The American complimented the Mexican on the quality of his fish and asked how long it took to catch them. 

The Mexican replied, ‘only a little while.’ 

The American then asked why didn’t he stay out longer and catch more fish? 

The Mexican said he had enough to support his family’s immediate needs. 

The American then asked, ‘but what do you do with the rest of your time?’ 

The Mexican fisherman said, ‘I sleep late, fish a little, play with my children, make love with my wife, Maria, stroll into the village each evening where I sip wine, and play guitar with my amigos. I have a full and busy life.’ 

The American scoffed, ‘I am a Harvard MBA and could help you. You should spend more time fishing and with the proceeds, buy a bigger boat. With the proceeds from the bigger boat, you could buy several boats, eventually you would have a fleet of fishing boats. Instead of selling your catch to a middleman you would sell directly to the processor, eventually opening your own cannery. You would control the product, processing, and distribution. You would need to leave this small coastal fishing village and move to Mexico City, then LA and eventually New York City, where you will run your expanding enterprise.’ 

The Mexican fisherman asked, ‘But, how long will this all take?’ 

To which the American replied, ‘15 - 20 years.’

‘But what then?’ Asked the Mexican. 

The American laughed and said, ‘That’s the best part. When the time is right you would announce an IPO and sell your company stock to the public and become very rich, you would make millions!” 

“Millions - then what?” 

The American said, “Then you would retire. Move to a small coastal fishing village where you would sleep late, fish a little, play with your kids, make love with your wife, stroll to the village in the evenings where you could sip wine and play your guitar with your amigos.”

source

Laguna De Apoyo

After this crazy week, I needed some decompression.  This is the 2nd time for me to Laguna.  I tried to take public transport, as I have done before but from Managua. However, the Masaya station with buses to Masaya is located at the market block, and this place on a Sunday in Granada is INSANE.  So many people crammed onto one tiny street with buses, vans, motorcycles, bikes, babies, stray dogs, more babies, really poor people, nuns, birds, and more motorcycles and bicycles. Was not happening for me.  After I escaped the chaos, I found Hostel Oasis not far from the market square.  They provide a shuttle to Hostel Paradiso for 13 bucks. I was down for that. They carted 10 travelers and hippies from all corners of the globe to share in a little piece of paradise. We had Germany, USA, Canada, Ireland in one bus. 

Here is some info on the Laguna!! Crystal clear water in the 200 meter deep crater of an inactive volcano.

I kayaked. Swam. Relaxed on a floating dock.  Met a kick-ass young woman from Canada whose name is Stephanie. Mediatated. Read Ishmael. All in all, a pretty awesome day.  Laguna de Apoyo is definitely one of my favorite spots everrrrr,  Here are some pics :)  They do not do this nature treasure justice. 

Volcan Mombacho

On the 4th I met an awesome dude from VA and I asked if I could tag along with him to go hike around Mombacho.  On Saturday morning, he and two of his friends picked me up outside of Kathy's Waffle House.  Great breakfast.  Good place to go if you need a breakfast that isn't automatically served with gallo pinto.  Note: I evaded public transport. lazy me... I'm sure within my 40 day stay, my time will come.  Granada to Managua was easy... straight shot, window seat.  I know the difficult is coming :)

taken from Travel Virgins

I have been to Mombacho before, but I had never done the hike we planned on doing... the Puma Trail.  And yes, there have been puma sightings and attacks.  We paid the $15 each to take the truck up to the top via steeeeep roads and hair pin turns on bumpy, pot hole riddled roads. Like most, public transport, we are crunched in like little sardines. The ride was like the uphill part of a roller coaster, execpt in a Nica truck while spinning tires thanks to it being the rainy season.

At the top of the Volcano, we hired a guide.  Being the true gringa that can be sometimes, I am thinking, "What the hell do we need a guide, this isn't my first rodea with nature"... Here and here is some info on the volcano. Over 100 or something different species of orchids. Thousands of species of animals, reptiles, amphibians, plants. All set in an enchanting cloud forest on a volcano with 3 craters.  Yet again, Nicaragua has humbled me. Our guide, Agostino, was necessary.  This was the steepest trail I have ever done.  The most slippery. And the fear of an unaided puma attack was lessened by the presence of someone who does 3x a day while equipped with a walkie talkie. It was a tough hike.  It stormed and monsooned on us for a good 45 minutes.  And it was humid.  I lost count on the number of "steps" we went up and down.  My calves are still burning.  Here are some pics.  I'll post more on Flickr.... when I get a chance. :)

                                        

 Two different types of Orchids in a tree

Que dices?

What a couple of days.  First I will talk about my first day with las doctoras.  I followed Dr. Garcia On Thursday.  At first glace, she appears to be a stern, serious woman.  When I walked over to her side of the room to reintroduce myself and let her know I would be with her that day, I jumbled all of my words up to an incomprehensible word soup.  She gracefully smiled at me, and said “Que bien!” She introduced me to each patient, and each patient was kind and gave me an appreciative smile.  Nicaraguans are a appreciate people as a whole; the position of a student of medicine is pretty much the same thing as a doctor to them, respect-wise.  A lot of pressure. 

During each patient exam and interview, Dra. Garcia went over the science and impact on lifestyle behind the health problem.   It was mostly diabetes and heart issues, so picking out clues from her rapid Spanish was too difficult.  Then came the drugs.  During the first year of medical school, we learned ~5% of the drugs we will end up knowing by the end of 2^nd year.  Listening to a Wikipedia page’s worth of information on each drug, in Spanish, was insane. It's hard enough in English.  Every time I started getting frustrated with myself, I had to make myself remember that I am here to learn. Furthermore,  I had to keep telling myself, I am not here to only learn Medicine, but more importantly (for now) to learn about the Nica people, culture, and the language.  Dra. Garcia was very patient with me and was able to help me through the headful of knowledge. 

Anyway, some cool things I was able to do, besides dissect Spanish on drugs and natural remedies. I learned how to perform an injection in a booty while avoiding the sciatic nerve; Differentiate pathological breathing sounds (I need more practice); I set someone up on a nebulizer; I found a pea-sized lump during a manual breast exam in the upper right quadrant of a patient’s left breast proximal to her areola. That was pretty intense.  

After we dismissed the lady with the lump, Dra. Garcia talked with me about the lack of services in Nicaragua regarding women's care and cancer screening.  Many people have never even known or thought about getting a mammogram or ultrasound or a pap smear (let alone can they afford those types of services nor are they available).  So there isn’t anything we, as a clinic, can do for her.  We tell her where she can go and hope she can get a free or greatly reduced service.  I hated sending someone away with so much uncertainty.  But that’s the way it is here.  The degree of lack of resources puts a lot of responsibility on the doctors to be empathetic as well as serve as a beacon of support and guidance.

I am hiking Mombachu tomorrow, so I need to sleep.  Cars are not allowed up and it's a pretty long and vertical road up to the top. If you miss the Jeep rides (only 4 of those a day), then you are hiking. Then there are the actual hikes once you get to the top-ish region.  And getting there will be a good bus ride experience : )

Happy 4th Eve!

The last two days have been 2 of the most tiring days of my life.  I am only in the clinic for 5 hours a day, but we pack in at least a whole days worth of patients and work into a 4 hour time period.  Since we only have two doctors on hand, sometime the other student and I have to perform preventive measures while the patient waits.  For example, if someone has a systolic blood pressure over 155 or diastolic over 95 (healthy <120/90), they get a beta blocker under their tongue.  And if someone’s sugar is over 300, they get an insulin shot.  Over 400, someone walks them to hospital.  Diabetes is surprisingly prevalent.  Surprising because the food they eat seems so much healthier and more natural.  However, the street vendor food is not so healthy. It’s like the most delicious smelling bread doused in sugar and honey as well as yummy Nica doughnut treats.  Thank God for Celiacs, because I would come back diabetic and muy gorda.

Another thing that this clinic lacks, that I have never thought about being a helpful tool, is a scale for babies and toddlers.  Kids get scared seeing a huge scale for the first time, so they won’t stand there for long.  Babies can’t stand obviously.  So we have to weigh them with their mom and then either I or Rachel hold the baby while we weigh mom without her kid. Also, on the note of parenting, we had a 13-15 yr old breastfeeding a 2 year old in the clinic. Obviously, I know teen pregnancy is a thing, especially here, but I have never seen someone so young breastfeeding before. 

 There is a limited supply of gloves, which I think are reserved for the doctors.  We only use them when we are slammed and do all of the diabetic’s blood sugar at once. And we only wear one. Dealing with needles is scary, even if it's for a simple finger stick.  We use the One Touch system and something like this at-home finger pricker.  Our are older versions, and we don't have the option of an automatic release of the used lancet. Needless to say, we are super careful and try to take our time.

Sidenote.  I am sure Anne and my Aunt Denise can relate to this.  We have some really really old people come into clinic.  Fully functioning 95+ year olds.  Every time I do a blood pressure, I think I am going to break an arm because they are so thin!!! I could wrap the BP cuff around their arms 3 times.  One time my dad and I saw the oldest couple in the world in Mexico, but I think these Granadians have them beat.

I helped out in the pharmacy as well.  We get the Rx’s from the doctor, and put the pills in baggies.  On a piece of cardboard cut from a box that onc housed medicine, we write down the name of the drug and the directions: “Un tab, tres veces diario”.  Marvin is the pharmacist.  I am pretty sure that he hasn't gone to pharmacy school.  He volunteers his time in only air conditioned, non-Doctor area in the clinic.  He looks up interactions on the computer while listening to Bob Marley and reggaeton. He's knows quite a bit about the drugs he is prescribing.  And he’s hilarious.

I have also been visiting Carita Feliz a lot.  I am helping the 4^th grade class.  They are a crazy bunch of kids.  Miguel has become a favorite of mine. And 2 other little girls, Maria and Audelis.  They are great dancers. What am I saying, I can;t pick favorites.  I love this class. I tried to take pics today, but Miguel kept taking my camera to take pictures of his mouth.  I am supposed to be helping in pre-school too on some days, but I can't stay away these cuties!

Miguel and Kenner(?). They dont sit still.

Tomorrow, Rachel and I will switch with the French MD’s, and I’ll get the chance to have no clue what’s going on with the Docs.  Rachel is a 4th year med student in England, and she is fluent in Nica Spanish. Then later in the afternoon, I’m taking the Express Micro-bus to Managua to hang out with Bob and Claudia and celebrate Amerrrrka.  Happy 4^th!! 

Here's videos taken by Miguel and David!  They are in the process of learning a new traditional dance. Here are Youtube links for a little beter quality: Video 1  Video 2

First thoughts on healthcare in Nica..

First whole day in the clinic!!

I totally forgot about “Nica-time” thing.  This is something that would drive most Americans I know crazy.  Por ejemplo, our family has some friends who decided to stay in Nicaragua and make a life here.  Claudia is Nica and Bob is USAmerican.  They joke was that when they were planning their wedding, they told their Nica guests that the wedding ceremony was at 4, when in fact it was at sunset.  They wanted to make sure everyone showed up on time.  Just as he and Claudia, no one showed up by 4, but came rolling in until about 6:00.  PS. The wedding the the best I have ever been to.

Clinic is the yellow building,
standing out of my home.

I was told to be at the clinic at 7:15.  My breakfast ran over and I showed up at 7:30.  Almost 100 people were waiting outside the clinic, which is right across the street from my house. Not all were patients.  Some were family members. Some were just hanging out.  I learned today that people leave their homes at 5 am to wait in line to be seen. I shuffled my way through the crowd and found the doors to the clinic to be locked.  So I waited. Only 45 more minutes though.

I got situated. Gathered my supplies. People started filtering in and I was starting to realize that I would be alone in this.  The other med student still hadn’t shown up.  Later I found out that, as expected here, her bus was 2 hours late getting her from Ometepe.  We ended up seeing 52 patients in 5 hours.

One could write a whole book on healthcare for the poor here. So much in the US is taken for granted. Privacy for one. The patient intake is completely out in the open.  Weights are yelled out across the waiting room. Reasons for visits are discussed next to your seat neighbor.  People look over the shoulder of the patient in front of them to take a peek at a chart.  When a patient goes back to see one of two doctors, it is in one big room.  One area is separated by an armoire or bookcase to allow different space for the doctors.  Towards the back of the room, an area for more intimate patient examinations is separated by bed sheets. Children are crying.  No HIPPA here. No time for it.

AC for another.  It’s hot and the air feels thick to breath.  Babes with high fevers have to endure a room with 80 people at a time that is well over 85 degrees with no circulating air.  Some people step outside to get some air but with little relief of temp.  I have the opportunity to sneak back into the pharmacy, which is only AC’ed during business hours.

Cotton balls.  The clinic has to try and cut costs wherever they can.  So instead of buying cotton balls for finger pricks, we take the stuffing out of pill bottles.  People get the bare minimum.  It’s not that big of a deal in practice, but it puts in perspective the difference between the US health care and 3^rd world health care. 

Women's care.... There is a great need, just like everywhere else.  

Obviously there are more differences.  I will write about those as time goes on.  This clinic is amazing though.  They see it all and they have to be able to handle it all with limited resources. Some things that go on here would never fly in the US. Like 90 degree waiting rooms and needles disposed of in empty clorox wipe containers. 

I am going to try and do a huge blog entry on the history and people of the clinic.  I need to do some more research.  So expect that soon. And once people get used to my presence, I will take some pics.  Right now I am the Chela, or Gringa, who can’t pronounce names and who sweats frequentemente.  One thing you have to learn FAST when you travel or live here is to have a sense of humor about yourself.  Nicas love calling each other out, and no one is exempt. 

Granada is beautiful!  I took dance class today at Carrita Feliz.  The little 4^th graders taught me some traditional moves and dances, and then they tried to teach me how to twerk...

Peace!  Hasta Manana!