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. 

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!

Carita Feliz, Sex Ed, Bicycle Rights, y Cafe del Tiempo

Carita Feliz is a school that goes from primer to 8th grade on the weekdays, and on the weekends, they offer practical knowledge and skills classes for older adolescents and young adults. The classroom is like an old school house in the way that everyone is together.  They have separated teachers for different grades and subjects, but everyone is in the same place pretty much.    A lot of people in one place, trying to learn different things.  Needless to say, the teachers are really good at what they do.  Here is an article on Peder Kolind, the guy who started it all.  It's in Spanish, but try and translate it!  It is very inspiring!

Sex Ed... Yesterday, I bounced around classes and age groups, and one of the classes was very interesting. I was with a group of 9 year olds, when I entered into something completely foreign to me. They were given a Sex Ed presentation.  This wasn't anywhere close to the vagueness of a US lesson.  This presentation was straightforward, honest, and not sugar-coated.  Latin America has more problems with STIs and pregnancy within a much younger population than in the US.  This discussion was great, because it opens up discussion at an age where pregnancy and STIs are more common than you would think.  These pages from Advocates for Youth  has some good facts (*a wee bit outdated). Same with this WHO factsheet  that compares all countries (*also a bit outdated).  I am starting to see potential for some good research here :)

mi bicicleta

Bicycle Rights? Nope. I rode by bike all morning and rode it to Carita Feliz.  I ended up in a class on Turismo with other young adults who want to learn skills to work in food and bev and tourism.  It was more a Spanish comprehension class for me.  Anyway, there are no rules for cyclists or for drivers when it comes to watching out for bicyclists.  No one pays attention to stop signs, uses blinkers, looks to see if anyone is coming. So you keep your eyes open and head up and hope for the best while on a bike.  Despite the craziness, drivers here are pretty good at last minute reactions and horns. No close calls yet :)

Free time... I explored Granada for the rest of the day. I bought a chip for my phone, ate another great Dona-prepared lunch, and went back out to get lost. 

Main Square 

I was walking down to the lake and it started raining hard.  I'll have to try that again when it's drier or bring a raincoat. Granada is pretty safe town.  Super chill.  You can always find someone taking a nap or relaxing on a bench.  No rush here. If anyone bothers you, just give the Nica Finger, which is a wave of your index like saying no no no. What is interesting is that I keep seeing Americans, Canadians, and Europeans.  No one will really make eye contact with each other, because most of the people who travel to rustic countries like Nicaragua are trying to get away from their world.  I found some really cool places to eat that will be visited tomorrow.  I had coffee at a really neat place in the center of town called Fitzcarraldo.  They serve coffee that is in the Specialty Coffee Association of America.  

 Then I came back and hung out with my house family.  Dona Espinoza had her son and his family over.  Their youngest son, who is 9, speaks near fluent English. Very impressive. Now I am resting, and I will spend my evening learning some medical Spanish so I am not a total dumbass on Monday.

Lastly, here's the bird

I can't spell his name... but it starts with an S... I call him Shh