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.

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.”

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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 : )