Help Nicaragua Children

Leishmaniasis

2012-02-01T05:38:00.000-07:00

"The various clinical forms of leishmaniasis are also on the rise; the number of reported cases has tripled over the last 10 years." I read this in a 2008 Pan American Health Organization (PAHO) report on Healthcare in Nicaragua.

Leishmaniasis, I thought.
I don't know anything about leishmaniasis.

So, learning about leishmaniasis became a learning project. Below is a summary of my reading.

Leishmaniasisis caused by a protozoa transmitted to mammals via the bite of the femalesandfly of the genus Phlebotomus in the Old World and Lutzomyiain the New World.

Female Sandfly

Formost species of Leishmania, an animal reservoir is required for endemicconditions to persist. Common New World hosts include sloths, anteaters,opossums, and rodents. Humans are considered incidental hosts.

Leishmaniasiscan be divided into cutaneous, mucocutaneous, visceral, and viscerotropicforms.

Parasitesexist in the promastigote stage in sandflies and transform to the amastigoteform in animal and human hosts.

Femalesandflies can transmit the parasite 7-10 days after feeding on an infectedhost. The promastigotes migrate from the gut to the proboscis and areregurgitated during the next meal into the new host's tissue.

Afterinoculation, parasites infect the reticuloendothelial system and live in theintracellular lysosomal organelles of macrophages.

Parasitesmay incubate for weeks to months before presenting as skin lesions or as adisseminated systemic infection involving the liver, spleen, and bone marrow.

Pathogenesisappears related to T-cell cytotoxicity. The extent and presentation of diseasedepend on several factors, including the humoral and cell-mediated immuneresponse of the host, the virulence of the infecting species, and the parasiteburden.

Infections mightheal spontaneously or might progress to chronic disease, often resulting indeath from secondary infection.

New Worldleishmaniasis exists throughout the Americas, with the exception of Canada,Chile, and Uruguay.

Cutaneous Leishmaniasis

Inoculation occurs after a sandflybites an exposed part of the body, usually the legs, arms, neck, or face.

Incubation occurs over weeks tomonths followed by the appearance of a solitary erythematous papule, which canevolve into a plaque or ulcer.

The skin lesion begins as anontender, firm, red papule several centimeters in size at the site of the sandflybite.

In time, the lesion widens withcentral ulceration, serous crusting, and granuloma formation.

The border often has a raisederythematous rim known as the volcano sign.

Lesions can be wet or dry and becomefibrotic or hyperkeratotic with healing.

Satellite lesions might be present.

Wound progression occurs over timeand might exhibit localized lymphangitic spread.

Lesions are usually without pain orpruritus, although secondary bacterial infection can complicate the wound.

Systemic symptoms are absent.

Healing can occur spontaneously over2-12 months and is followed by scarring and changes in pigmentation.

New World disease can progress tomucocutaneous leishmaniasis.

Mucocutaneous Leishmaniasis

Most commonly causedby New World species.

Can arise afterinadequate treatment of certain Leishmania species.

Initial infection is characterized by a persistent cutaneous lesion thateventually heals, although as many as 30% of patients report no prior evidenceof leishmaniasis.

The initial skin lesion is often notable for its prolonged healing timeand large size. In most cases, a healed scar can be identified based on carefulexamination.

Oral and respiratory mucosal involvement occurs months to years laterand causes inflammation and mutilation of the nose, mouth, oropharynx, andtrachea.

Patients develop rhinorrhea, epistaxis, and nasal congestion.

Examination reveals excessive tissue that obstructs the nares, septalgranulation, and perforation.

Nose cartilage might be involved, giving rise to external changes knownas parrot's beak or camel's nose.

The palate, uvula, lips, pharynx, and larynx might exhibit granulation,erosion, and ulceration with sparing of the bony structures.

Hoarseness might be a sign of laryngeal involvement.

With prolonged infection, death occurs from respiratory compromise,malnutrition due to dysphagia, and secondary infection.

Visceral Leishmaniasis

The most devastating and fatal form, classically known as kala-azar orblack fever.

The incubation period varies after infection and might depend on thepatient's age and immune status and the species of Leishmania.

Results from systemic infection of the liver, spleen, and bone marrow.

Pentad of fever, weight loss,hepatosplenomegaly, pancytopenia, and hypergammaglobulinemia.

Patients present with recurrent high fevers, wasting, anorexia, nightsweats, diarrhea, and malaise.

Patient is thin and cachetic with abdominal distension andprotuberance due to massive hepatosplenomegaly.

Epistaxis and petechiae from severe thrombocytopenia.

Melanocyte stimulation and xerosis causes characteristic skinhyperpigmentation.

A progressive disease with the mortality rate ranging from 75-95% ifuntreated. With appropriate therapy and supportive care, the mortality rate is5%.

Death usually occurs from malnutrition, immunosuppression, and secondaryinfection.

Alwaystreat visceral, mucocutaneous, and severe forms of cutaneous leishmaniasis.Given its potential to progress into mucocutaneous leishmaniasis, treat New World cutaneous leishmaniasis.

Therapiesavailable are limited.

The mainstays are the pentavalentantimony compounds, sodium stibogluconate (Pentostam) and meglumine antimonate(Glucantime), which have similar efficacy. Cure rates of 80-100% have been reported.

Other therapies include amphotericinB (AmBisome) and pentamidine.

Orally administered ketoconazole,itraconazole, fluconazole, allopurinol, and dapsone have been examinedinternationally, but none is as effective as the pentavalent antimonycompounds. However, given their minimal adverse effect profile, these agentsmight be useful to accelerate the cure in patients with cutaneous leishmaniasisthat does not progress to mucosal disease and tends to self-resolve.

The recent discovery of anaffordable, orally administered, and well-tolerated therapy for visceralleishmaniasis has made mass treatment in the developing world a reality. Miltefosineis a phosphocholine analogue originally developed as an antineoplastic agentthat interacts with membrane synthesis and signal production.

Insect repellent, protectiveclothing, and permethrin-impregnated mosquito nets offer some protection forvisitors to endemic areas. The female sandfly is small enough to pass throughstandard mosquito nets, thus requiring specially designed netting.

Wages in Nicaragua

2012-01-25T05:20:00.000-07:00

The Nicaraguan Gross Domestic Product in 2005 was $4.9 billion dollars, or about $860 dollars per person.
This modest amount implies that wages must be very low and this is the case.

According to WHO data, the average monthly minimum wage (Nicaraguan Cordobas converted to Canadian Dollars) in 2006 was $45 for an agricultural worker and $101 for a fisherman. This information supports other data that I have read that a substantial percent of the population earns less than $500 a year. The WHO also reports that the average cost to meet the basic nutritional needs of a person is $133 a month. Therefore those individuals who are paid the minimum wage are starving.

The child labor market includes an estimated 240,000 children and adolescents of whom 61.4% do not receive any remuneration at all.

Many Nicaraguan men work in Costa Rica, where the wages are much higher. The economy in Costa Rica has blossomed in the last few decades courtesy of tourism and foreign investment. The Nicaraguan government has actively encouraged tourism and foreign investment since 2006. Americans, Canadians, Australians, and Europeans are traveling to Nicaragua in record numbers. American Airlines recently started a non-stop flight to Managua from Miami.

The clinic where I help out is located in Limon, a community on the north-south Pacific coastal road. The clinic is only about five km inland from the coast. The region has a lot of tourist potential. San Juan del Sur, a coastal community further to the south has boomed over the last decade and now has cruise ships that stop every week.

The low cost of land and labor are attractive for foreign investors. I have talked to numerous Americans who have built or who are building in Nicaragua. The current wage for an unskilled worker at a building site is $150 a month. Doesn't sound like much, but this is at least more than the cost of the basic nutritional needs for an individual. However, what if this person is the sole wage earner for a family of 4. That means the family is still starving.

Tourism and foreign investment imports much needed dollars into Nicaragua and increases employment at higher than the minimum wage. Is this good? The money and employment is good, but there is always a cost. The Nicaraguan people are selling their prime real estate to improve their standard of living.

Blue Crab, Callinectes sapidus, watched me carefully for a moment,

then disappeared into the sand within a few seconds.

Pan American Health Organization (PAHO) Data 2008

2012-01-15T08:10:00.002-07:00

Health Systems Profile - Nicaragua

Monitoring and Analyzing Health Systems Change

Pan American Health Organization/World Health

OrganizationPAHO/WHO

May 2008

MINSA is the Department of Health in Nicaragua. MINSA targets primary and secondary levels of care in Nicaragua. This makes sense. When the resources are limited, the best approach is to focus on the basics. However, this implies that tertiary level care is not available to the public, unless this is provided by a private physician, clinic, or hospital. This means for instance, that dialysis would not be available for a child with kidney failure.

The table below outlines who pays for the health care in Nicaragua. MINSA pays for the majority. The total does not add up to 100%, which implies that no one pays for the missing 20%. This actually might imply that one fifth of the population does not receive any care! I suspect that these are the individuals who are not registered with MINSA. Unless you have a number you do not exist. This is a real concern because without a MINSA registration, an individual cannot access care, and individuals are actually turned down in this situation. Ridiculous bureaucratic obstacles exist in every jurisdiction.

	Percent
MINSA	60
Nicaraguan Social Security Institute INSS	8
Government and Military	8
Private	4
Total	80

MINSA has a list of essential drugs and reviews what should be included every two years. MINSA likely only chooses generic medications. Cutting edge (read expensive) therapies are not likely considered. Every month the local MINSA physician reports data on the patients and medications dispensed and the supply for the next month is based on this data. I learned that the supplies always run out well before the end of the month. I imagine the more organized patients turn up in the first week to obtain their chronic medications.

The inventory of equipment at the first level of care failsto meet user demand for these services. My experience certainly confirms this.

At the second level of care serious obstacles hinder effortsto maintain existing equipment, including a lack of qualified equipmentmaintenance personnel. I am sure this is the case. There are no parts or personnel to fix any out-of-the-ordinary mechanical or electrical device, much less sophisticated medical equipment. For example, if I were to purchase a car in Nicaragua, there are only a few makes and models that would routinely have parts and service available. Why would anyone purchase something different?

Physicians per 10,000 population increased from 4.0 in 2000 to 4.7 in2007. By comparison, the number of physicians in Canada per 10,000 population is 22.

In 2007 there were 1376 male physicians and 1231 female physicians in the public health sector. Many of these are brand new graduates. I learned that physicians who graduate from medical school in Nicaragua are obliged to serve for two years in a MINSA clinic. The physicians are posted to a clinic immediately after they graduate and the public service is therefore their postgraduate training program. I graduated from a first class medical school that included a lot of clinical experience prior to graduation but I spent 6 more years of postgraduate training before the Canadian Medical Profession let me practice my specialty without supervision. For general paediatrics at that time the minimum duration was 4 years and for family medicine the duration was 2 years. Posting brand new graduates to meet community needs sounds ridiculous, but any knowledge and help, however inexperienced, is better than no knowledge or help.

Great Egret on a windy day.
The wind is only apparent with the feathers behind the neck.
The branch was really swaying and the egret needed to
brace the legs and lean into the wind to keep steady.

Community Outreach Program

2012-01-09T06:51:00.002-07:00

This trip was far more successful than my prior efforts.Experience counts.

From the outset I decided that I wanted to find a locationwhere I could return and continue to work as a paediatrician. I desiredcontinuity.

I did not aspire to visit foreign places once and then moveon, although this is the most common pattern for a medical volunteer. For somevolunteers the destination country is the reason for the trip and eachvolunteer opportunity is a location on the volunteer’s bucket list. I get that.Help is help and always appreciated.

However, for me, I desired continuity. I knew thatcontinuity would educate me and that really making a difference always requiresknowledge. When a patient returns improved this is affirmation of success; whena patient returns and is not improved, this means I need to improve. Continuityis a great teacher. My ground rules are to improve the quality of my care witheach subsequent visit. There is no reason why I cannot continue toimprove.

I have only seen a tiny tip of the iceberg of poor health inthe region. The mothers who came to the clinic had to hear about my visit andthey needed transportation. Communication and transportation are key issues that need ongoing improvement.

One way to improve transportation and communication is for me to travel to the patients. If I travelto a community, this solves the transportation problem and local communication will be simpler. As such, with my next trip I want to start a Community Outreach Program.

The Goals of the Community Outreach Program will bePaediatric Health Screening and Paediatric Health Education

Paediatric HealthScreening

Check the immunization cards of the children.

Check height, weight, and head circumference and plot the data on a growth chart.

Check a stool specimen for parasites and worms.

Check a dipstick urinalysis.

Children with abnormal screening tests will be referred forfollow up to the Clinic.

Paediatric Health Education

Essentials of good nutrition

How to disinfect water with SODIS

How to prevent worm disease

How to use oral rehydration solution

How to treat fever

Provide Basic Medications for Every Child

1. Multi-vitamin - two month supply

2. Acetaminophen with Spanish instructions on dosage

3. Oral rehydration solution packets sufficient to make two literswith Spanish instructions on how to prepare and use

With the approval of the mother, every child could betreated for worms with mebendazole
and for parasites withmetronidazole.

Gaby Organized the Toys for the Children - Thank You!

2012-01-08T04:00:00.000-07:00

Gaby is a 10 year old girl who visits my office. She is a terrific gal. The acorn doesn't fall far from the oak, and her Mom is wonderful as well. When Gaby and Mom found out I was on my way back to Nicaragua, Gaby purchased some toys for the children. The photos show children enjoying her generous gifts.

Thank you Gaby.

The boys loved the small flashlight!

The girls favoured the skipping rope!

Snakes, Scorpions, and Spiders

2012-01-07T12:30:00.000-07:00

Theseanimals are all Scary and the first letter of each name starts with an“S.” A Silly coincidence.

Over thelast week I have had two of these creatures in my casita. I don’t walkbarefoot!

White-fronted Parrots in Flight.

I havenot seen a snake in Nicaragua. Every morning I start my bird watching at 5:30,before the dawn breaks over the horizon. I walk briskly for about 30 minutes toan area along a stream (a deep and wide river in the rainy season). I spend anhour looking at the birds and then I walk back to the casita to get ready forthe clinic. Most of the hour is spent on paths in the jungle. I am constantlyon the look out for snakes. Every hanging vine and piece of wood on the groundis suspect.

About aweek before I left for Nicaragua I listened to a very funny TED talk by DouglasAdams, the famous author of “Hitchhiker’s Guide to the Galaxy.” He also wrote, “LastChance to See,” a book about endangered species. Adams visited the locales ofall the endangered species he wrote about and since he was going to Madagascar,a place filled with deadly snakes, he consulted a world authority on snakebite.Adams’ anecdote about meeting with the Australian Herpetologist (snake expert)was hilarious. Adams asked the expert what to expect if he were to be bitten bya deadly snake.

“You die of course," the expert replied, "that’s what deadly means.”

Theaudience roared with this comment and so did I. However, the grim reality isthat some snakebites are deadly and Nicaragua is home to a dozen or so the mostdeadly snakes in the world. There are 10,000 to 100,000 reported snakebites inCentral America every year and of course most bites in underdeveloped countriesare not reported.

So, I’vedecided that it is not a matter of IF I come across a snake, but rather WHEN and HOW OFTEN. My desire is to minimize encounters.

I do alot of stomping when I walk in the jungle to send vibrations ahead to let the snakes know I’m around. I make noise. Stomping and noise doesn't help with bird watching. I do not move fast. I want to give the snakes lots oftime to move. The same rules hold for preventing grizzly attacks back home. There should be Snake Spray.

Theconventional acute care for snake bite is to immobilize the extremity, usually aleg or hand, to apply a pressure bandage with sufficient pressure to stop thereturn of the venous blood to the heart but to allow the arterial flow into theextremity, and to elevate the leg or arm.

Orange-fronted Parakeet Eating Flowers

I getasked a lot about snake anti-venom. Years ago, when I was backpacking inThailand, I visited an anti-venom center. Handlers milked the venom from thevarious vipers and the liquid was sent to labs to prepare anti-venom. Therecould theoretically be an anti-venom for every snake and there are a number ofproducts available, but none are approved by the US FDA and all are consideredexperimental because there are no good studies to prove if, or how well, thepreparations work. To be effective at all, the anti-venom should beadministered within 4 to 6 hours. Of course the anti-venom must be availablelocally and you must be able to identify the snake to choose the correctanti-venom.

Imagine a bird watcher person like me who is bitten by asnake on his leg in the jungle. The medical books suggest that the snake shouldbe identified with a photograph. How many people bitten by a snake hang aroundto take a photo? The snake would likely slither away. Do you think that someonewho was bitten would chase after the snake to take a photo? I don’t think too manysnakes are identified by photograph.

The nextquestion is how would this person immobilize and elevated the leg? That is not possible unless there is a convenient stretcher and four able-boded men to carry the person. So, this means that the only acute intervention wouldbe a pressure bandage above the lesion, and a speedy retreat to the nearestanti-venom place.

The nearest anti-venom location is likely in the US. How fast do you think a person in Nicaragua could get from the jungle to the US? Could this be accomplished in less than 4 to 6 hours? Hmm. Not likely.

This all means that prevention is the key to survival.

White-fronted Parrot

Poverty, Child Labor, Child Prostitution

2012-01-06T19:10:00.000-07:00

Poverty in Nicaragua is a serious obstacle to social progress.

During 2002 to 2007, only half of the children who started grade one finished primary school. Children did not finish school because of school fees the family could not pay or because the child quit to work and help support the family. Farms and mines regularly use child labor. Since Ortega was re-elected in 2006, the school fees have been free, so hopefully this will improve.

About half of the adult households in Nicaragua do not have an adult male present. Marriage is not an expected outcome for relationships.

During my first trip to Nicaragua in October 2010 I rented a residence and the owner provided a woman to cook and a man to care for the grounds.

The woman was in her mid-twenties, good looking, spoke much better English than I spoke Spanish, and her cooking was terrific. I was interested to learn about the country and asked her a lot of questions. She was not married but she had three children, each with a different father. One father was Nicaraguan, one was German, and one was American. The German had stayed in Nicaragua for a year or so. The American was a GI who had visited the country. The mother was not embarrassed to explain about three fathers and three children. She was pleased about the two foreign fathers because both sent money to provide support for their illegitimate child. The youngest child was a 13 month old infant and the mother was planning to send the child on an airplane to the US to spend a month with the single father who was still living in the home of his parents. Presumably the paternal Grandma was the designated care person. A non-related Nicaraguan who was traveling to the US accepted the responsibility to care for the in-transit infant. I was appalled, but the mother didn't blink an eye as she told me this story. I wondered if perhaps she expected, or perhaps hoped that the baby might remain in the US? The German and American fathers provided dollars and Euros and this was what was important. After the first few days in Nicaragua, I realized that the woman was flirting a bit with me and I wondered if I had been identified as potential father and supporter number four?

This mother's values were very different than mine, but I realized I should not judge her by my standards. She was part of an emerging Nicaragua middle class. She was bilingual. She was self supporting. Her children were well fed and clothed and the oldest attended school. Perhaps the baby will be raised up in the US? I am fairly sure her children will be more successful for her efforts.

Other mothers sell their children into prostitution to earn money. Which is better? Should the mother prostitute herself for her children, or should the mother sell her children into prostitution?

Daniel Ortega, the President of Nicaragua, is a known philanderer, apparently with the full knowledge of Rosario Murillo, his partner of four decades. Worse, he has been accused of sexual abuse by his wife's daughter, who in 1998 accused Ortega of molestation and rape from the time she was 11 years old. Amazingly, her mother supported Ortega and she continues to support him notwithstanding these allegations. The support implies tacit approval of Ortega's actions, which no one apparently doubts. In Nicaragua, men sometimes claim sexual rights over a daughter from a previous relationship. When the leader of the country models this behaviour, what can we reasonably expect from the men of the country?

Ringed Kingfisher
MUCH larger than the similar Belted Kingfishers in Canada.
Vocally and very indignant when I invaded his fishing space.

Very Young Mothers

2012-01-05T14:09:00.002-07:00

Today themost worrisome child was the last child. Grandma brought in a seven day-oldinfant. The Mom was in the next room with an OB GYN Physician Assistant fromSan Jose, who helps out at the clinic several times a year.

Grandmareported that the tummy of the baby felt hollow when she tapped on the abdomen.She advised that the baby had not gained weight in the first week, which is notunusual, but the baby looked tiny and tired. Grandma could not answer all thequestions and so I waited until Mom was available. When Mom walked in shewas about 15 years of age. This was her first baby, and she wasfloundering with breastfeeding. She explained that the baby only fed twiceduring the daytime, or about every 6 hours, and was otherwise asleep, and thenshe fed every hour or two over night. The baby only fed about two minutes at atime. Babies need to feed often or their blood sugar falls, which can lead totiredness and worse. I asked Mom to show me how she breastfed and then wereviewed the importance of latch and good positions. I asked Mom to show me howshe burped the baby and I corrected her approach. I explained the basics of thefrequency and duration of breastfeeding to Mom and Grandma. We arranged for thebaby and Mom to be reassessed and weighed in a week at Las Salinas. This babyis a very high risk for failure to thrive.

I saw twoinfants who were brought in for well baby checks by their pregnant Moms. The Momswere at the clinic to see the OB GYN Physician Assistant. One baby was 4 months old and the other was 5months old. These Mother were pregnant within several months of delivery andthey will deliver two babies in less than a year! Ouch! I’m glad the OB GYNPhysician Assistant is available to help them with birth control.

Today wasmostly a well child check up clinic. There were some coughs and colds. We saw13 children including one follow up.

Red-billed Pigeon - Very common and very skittish.
They perch at the tops of trees.
As soon as you come into sight, they fly away.
They also fly away as soon as a Vulture arrives in the nearby airspace.

Bedwetting in Nicaragua

2012-01-04T18:01:00.000-07:00

A nine year-old girl was brought in by her Aunt because she wet her underwear by day and her bed at night. Seventy-five percent of my Calgary practice is day and night wetting, so this was a terrific opportunity to compare the cultures. There was no difference. The girl only pooped once a week and she drank only 500 ml a day. This is so predictable back home and great for me to confirm in Nicaragua.

This weekI saw two toddlers with Herpangina, a throat infection caused by Coxsackievirus. Coxsackie virus is common in Canada and is more often seen in the summermonths. Now is the Nicaraguan summer. The virus causes a fever and sore throatand the there are tiny sores in the back of the throat on the palate that arediagnostic of the infection. The tiny sores are white circles surrounded by ared area. When only the throat is involved the infection is referred to asHerpangina. Sometimes there is a rash on the soles of the feet and the palms ofthe hand and in this situation the infection is called Hand Foot and MouthDisease. Antibiotics will not help and fever control and hydration are themainstays of treatment.

I cannot believe my two weeks is almost over.Seems like I arrived yesterday. Time flies when you’re having fun.

Brown Pelican at Sunset

Tic Toc - Waiting on the Tick

2012-01-04T15:01:00.000-07:00

When I showered I felt something in my groinand flicked it off. Looked to me like a green seed pod but when I stepped on thepod a lot of blood spurted out. Myblood. Ouch.

It was a tick. Specifically,the tick was Amblyomma cajennense. Thistick is found mostly in the jungle and likes to prey on animals.

Amblyomma cajennense

There was a small black central puncture wound with an areaof redness around the bite that was about half a centimeter wide.

I had showered for dinner the night before and surely wouldhave noticed the tick then, so my thoughts are that the tick arrivedovernight, perhaps picked up in my clothes earlier that day. As this thought settled, I recollected an itch in the same area overnight. The itch was likely the bite. I didn’t check the time, I just rolled over and went back to sleep. I only sleptfor six hours that night, so the tick was attached for a maximum of six hoursand this detail is important because the duration is correlated with the riskof infection with Rickettsiae rickettsia, which causes Rocky Mountain SpottedFever, or just Spotted Fever in Latin America.

I immediately took some clarithromycin, which I had on hand, and the next day I obtained Doxycycline, which is the recommendedtreatment.

The incubation period for Rocky Mountain Spotted Fever ranges from 3 to 12 days. The tick needs to be attached for 2 to 10 hours forthe Rickettsiae to be released from the tick salivary gland and an earlier onset of symptoms occurs when there is a large volume of the inoculum. I likely have alow risk for infection, but there is a risk. I will just have to wait and see.

Tic Toc - waiting on the Tick.

Fisherman Walking Home at Sunset

Interpreter Success

2012-01-03T03:55:00.000-07:00

Mydecision to hire interpreters for this trip to Nicaragua was a good one. I feelmore confident that the mothers understand my recommendations.

Theinterpreter this week is Jessica Southern. Jessica is not only bilingual, butshe is an American paediatric nurse. Wow! What a great combination for my work!Jessica works for FIMRC, a US charity, at the Las Salinas community clinic, butthe clinic is closed this week, so she kindly agreed to help me. Jessica isterrific.

Wesaw 9 patients today and we saw them in 5 hours, which is fast compared to pastvisits. I typed out the basics of the treatment plan and Jessica communicatedthe recommendations to the mothers. After two days, we are a good team. Thiswas my best clinic day yet!

Thesickest child was a boy with a history that suggested urinary retention. He hadpast history of treatment for urine infection and kidney stone. I hear thesediagnoses a lot and the histories do not usually fit with these diagnoses. Mysense is that any urine problem in Nicaragua is diagnosed as infection or stoneor both. The boy was 12 years old and had pain severe enough to make him cry. Duringthe episodes of pain he felt as if he needed to pee but he could only passsmall amounts. His urine today did not show infection or blood, and he had anepisode last night, which makes infection and stone unlikely. He had a verynarrow pee hole at the end of his penis. Jessica arranged for him to have anultrasound at the Las Salinas clinic and to see the pediatric surgeon who comesup from Rivas once a week.

Afourteen-month old boy was brought in for recurrent hives, which Mom wasconvinced was due to beans, beef, and shrimp. From the age of 8 months he has experienceditchy bumps. He had typical papular urticaria, which is usually an allergic or immunologicalresponse to insect bites and not usually to food. The clinic pharmacy had an anti-histamine,which I asked Mom to give him at bedtime on the real itchy days.

A12 year-old boy came in with typical migraine. He told me the headaches weremuch worse when he was walking on really sunny days. The sunlight in Nicaraguais very bright and I have no doubt this would aggravate the headache in anyperson with migraine. Poor hydration likely also plays a role in his headaches.I treated him with Naproxen and Jessica reviewed the migraine- teaching handoutI prepared with Mom.

Thedays whiz by in the clinic. This is no different than at home. One child afteranother until the waiting room is empty.

Mostof the children today did not have a chart at the clinic, which means this wastheir first visit. They came to see the Canadian Doctor.

This immature Tri-colored Heron was fishing in the late afternoon.
The sun was very bright and the bird opened up the wings
to create a shadow so the fish in the small pools would be easier to see.

Prevention. Prevention. Prevention.

2012-01-02T17:25:00.000-07:00

Dad brought in his five year-old son with fever and sore throat.
He had the typical vesicles of coxsackie virus. The throat is very red and sore, and the neck glands are enlarged. Unless the typical vesicles are noted on the tonsillar pillars, many children are treated with an antibiotic as per strep throat, but this is a virus, lasts a week,
and fever control and hydration are all that is necessary.

It is never too soon to start planning for the next visit. With the next visit I will try to plan some community based preventative care clinics. Preventative care is essential everywhere in the world, whether in developed Canada or in underdeveloped Nicaragua. The key to health is preventative care.

I now have contacts in the region. Bo Fox, who I met on the last trip, and Sheyla and Jessica, who help as interpreters with this visit, live in different

communities in the region. Within an hour of the clinic, there are seven communities along the dirt road to the north or south. At the next visit I will try to organize community teaching sessions on a variety of common paediatric topics.

Back in Canada I will develop a PowerPoint presentation in Spanish and on the next trip we will find community locations with electrical power, hopefully a fan, and enough room and chairs for local mothers to come. We will advertise the sessions locally for several weeks before the event. I will plan a two-hour session and cover four basic topics. After each thirty minute session, I will answer questions. We will provide water, juice, and nutritious snacks for the families. Sounds good. Hope we can do this.

The basic topics I will present will include:

1. how to disinfect well water with SODIS.

2. how to prevent worm disease.

3. the principles of good nutrition.

4. the principles of good hydration.
5. how to use oral rehydration solution for diarrhea.
6. how to treat fever.

Every Mother will be asked to bring the immunization cards for her children and we will check the immunization status and advise the mother if she needs to get caught up at the next public immunization day in her community.

Every mother who attends will be provided with:

1. Mebendazole, three day course, for worms

2. Metronidazole, three day course for parasites

3. Multivitamin for two months

4. Acetaminophen to have on hand for fever
5. Enough Oral Rehydration Solution powder to make two litres.

5. Spanish teaching handouts on worms, parasites, nutrition, hydration, fever, and diarrhea.

Howler Monkey who watched me very carefully this morning.
The loud roars of the males at dawn and dusk
can be heard for miles and serve to delineate territories.

Foot Wounds on the Beach

2012-01-01T12:18:00.001-07:00

Many Nicaraguans walk barefoot, which seems impossible to me, but I see this all the time. The pathways, the beach, and the dirt roads are definitely not foot-friendly for Gringos like me. Nicaraguan soles must be like leather.

Over the last two days I was asked to assess two Americans with foot injuries.

A middle-aged man was stung by a sting ray as he was walking in the surf. He felt severe pain and pulled out the stinger from the side of his foot. His fingers started to tingle from the venom and he dropped the stinger. He described the pain as the worst he ever experienced. The puncture wound at the side of his foot was surrounded by a black area about 2 cm by 1 cm. I did an Internet search on sting ray wounds and venom and learned that for foot injuries the most serious common complication is if the stinger penetrates the bone which can lead to osteomyelitis (bone infection) or if the stinger breaks off and leaves a foreign body which invariably gets infected. The worst aspect of the acute injury is the severe pain, which is ameliorated by intense heat. I checked with the fellow the next day and he was feeling great, so infectious complications are not a concern.

The second person was a high school senior who stepped on something sharp on the beach. He had a very painful, hot, swollen area below his third toe and when he moved the toe, the pain was intense, which implied the tendons or muscles that controlled the toe were inflamed. I treated him with ciprofloxin, anti-inflammatory medications, hot soaks, and elevation. I checked on him earlier today and he is improved with less tenderness and swelling. All good.

Snowy Egrets must have tough, no slip toes
because they land on the beach and rocks with no problem.

Sexual Predators in Nicaragua

2012-01-01T10:17:00.000-07:00

Tim Rogers is the Editor of Nicaragua Dispatch, an excellent online daily that provides news in English. I met Tim during my April 2011 trip to Nicaragua. Recently he featured an article on child sexual abuse in Nicaragua.

http://www.nicaraguadispatch.com/features/sex-predators-find-easy-prey-in-nicaragua/1498

The article featured a photo of an arrested sexual predator and I realized immediately that I had seen this man during a trip to Granada.

Granada, the fourth largest city in Nicaragua, was founded in 1524 by the Spanish, and the history, architecture, and location on the shores of Lake Nicaragua make the city an important tourist destination. The central square is bounded by a beautiful cathedral and several prominent hotels. The plaza is busy with lots of vendors who sell leather goods, jewelry, pottery, nuts, t-shirts, and other tourist stuff.

In October 2010, I spent a tourist afternoon in Granada. I noticed a middle-aged white man and suspected immediately that he was a predator. He was sitting with a ten or so year-old Nicaraguan boy on a park bench. The boy looked self-conscious and held his head down without making eye contact with the man. Everything about this scene was wrong. I wandered in and out of the central plaza over the course of an hour or two and I saw the man again with another child.

The plaza was filled with adults and there were lots of children who were selling merchandise on behalf of these adults. No one seemed interested at all in either the man or the child, which seemed so strange. Don't the Nica adults see what is going on?

On the one hand I felt as if the rest of the adults in the plaza must be blind. There were numerous security people outside the hotels that ringed the plaza, and the Granada Police were routinely present in the square, and they all cast blind eyes on the situation.

Then I wondered, Oh my gosh, is this just the way it is in Nicaragua?

In the article, Tim Rogers reports, sadly, that this is how it is in Nicaragua.

This Variegated Squirrel chattered at me
during my morning walk.

Book Review - Unfinished Revolution by Kenneth Morris

2011-12-31T14:36:00.000-07:00

Unfinished Revolution - Daniel Ortega and Nicaragua’s Struggle for Liberation.

Kenneth E. Morris. 2010. Lawrence Hill Books. Chicago.

The points below include the ideas and information from this book that I considered interesting. These are points that Morris makes and I do not have sufficient experience to confirm or refute the information.

According to Morris, in Nicaragua, the words "to succeed" are interpreted as "to conquer." Nicaragua has been conquered on so many occasions (initially by Spain and then by the US) that success and conquer are interchangeable words.

United States hegemony over Nicaragua
My generation likely only relates to the Iran Contra - Oliver North debacle, but the US has an almost two century record of intervention. The Monroe Doctrine, a US policy introduced in 1823, "legalized" US hegemony over all of Latin America. In 1856, William Walker, a US soldier of fortune, invaded Nicaragua and proclaimed himself President. American troops have since occupied Nicaragua in 1865 to 1877, 1894, 1896, 1898, 1899, 1907, 1910, and 1912 to 1932. The Contra War in the '80's is only the most recent armed intervention by the US. Any paranoia in Nicaragua about American intervention is therefore well justified.

Daniel Ortega, the current President, is 66 years old, and he joined the Sandinista Youth at age 15 years. He killed his first National Guardsman at age 22 years. He served 7 years in prison and was tortured by the Somoza jailers.

The Sandanista revolution was successful but resulted in 45,000 deaths. The Contra War that followed resulted in an additional 40,000 deaths. Nicaraguans of my generation have mostly known war in their youth and middle age, and almost all have had a family member killed, injured, or who fled the country.

After the first elections in 1984, the Sandinista government made freedom of religion a right, abolished the death penalty, and extended formal rights to women.

Ortega lost in the 1990 election, in part because of fear of American invasion if he was re-elected. According to Morris, the US invasion of Panama was not only designed to oust Noriega, but also to threaten Nicaragua to shape up or to suffer a similar fate.

Presidents Chamorro (1990), Aleman (1996) and Bolanos (2001) did not improve the welfare of the average Nicaraguan. They were either corrupt or inept.

Ortega, who was re-elected in 2006 and again in 2011, is viewed as authoritarian and corrupt, but according to Morris, his corruptness is directed to achieve the power to help the people rather than to achieve personal gain, and in this sense his actions are considered by some to be altruistic.

Nicaraguan citizens expect corruption. In a 2001 poll, 73% of those polled desired an authoritarian president and 57% considered bribery of a public official as acceptable conduct.

After his re-election in 2006, Ortega eliminated fees in public schools, worked out an energy deal with Venezuela that eliminated the habitual power blackouts in the capital, provided subsidies to lower the price of food staples, and provided free access to medical care. He initiated Zero Usury, a small business incentive loan program, and Zero Hunger, a program to provide each mother (women are the head of the household) with a chicken and cow to provide eggs and milk for the family.

Nicaragua is still the second poorest country in the Western Hemisphere.

This morning at 5:45 AM, this Crab-eating Raccoon & I crossed paths.
He looked real surprised to see me in the forest.
The light was very poor but iPhoto allowed a pretty good image.

Planning Pays Off

2011-12-30T12:58:00.000-07:00

The first week has gone very well.

For this trip I arranged an interpreter and Sheyla was terrific. She quickly learned the routines and she improved each day. For a person without any medical training whatsoever, she did fabulous. Thank you Sheyla.

I decided that I wanted to bring the medications that I would likely need so that I had my drug of choice for treatment and also so that I would not need to deplete the clinic pharmacy. I have only accessed the clinic pharmacy on one occasion, which is amazing.

I prepared Spanish teaching handouts on sixteen common problems and this week I used 11 of them, many of them multiple times. Not every Mother can read, but the family will have access to someone who can. I consider this a solid success.

None of the children today were real sick. Most had colds or diarrhea. A baby had an infected insect bite, likely a spider. One girl had high fever, delirium, diarrhea, vomiting and abdominal pain. She looked great but her fever was down because Mom gave her both acetaminophen and ibuprofen, which was the right intervention for high fever and delirium. I treated her for Typhoid Fever. I remember that our Med School Infectious Disease Prof, Dr. Ken Buchan, told us that delirium is common with Typhoid. Ken Buchan was an absolutely fabulous teacher. His teaching decades ago, made a difference today!

Rainbow at Dawn

Surf Spray Rainbow

I think all the children have worms and parasites.

2011-12-29T14:23:00.001-07:00

When I arrived at the clinic this morning there was a five year-old girl with abdominal pain and vomiting in the exam room and Dr. Flores was talking to her Mom. For three days she had experienced episodes of acute central abdominal pain. The episodes lasted up to an hour, sometimes she cried, she was doubled over with the pain, and occasionally she vomited during the episodes. She had up to seven episodes a day. Between the episodes she wasn’t eating as well but she otherwise felt fine. Her last poop was three days ago and described as stickly black. Her exam was normal.

The pattern of the pain and the vomiting was suspicious for intestinal obstruction. I could feel a lump on the right lower side of her abdomen. I obtained a poop specimen. The clinic can test for parasite cysts, worm eggs, and blood. She had all three. The child developed an episode of abdominal pain while she was at the clinic and I examined her again. She was not distressed and the lump as no longer palpable. I treated her for parasites and for worms. I did a quick Google Scholar search of worms and intestinal obstruction and learned that this is possible. I’m not sure she had obstruction due to worms, but that is how I treated her. The 3 day mebendazole treatment will get rid of the worms and Mom knows she must come back if the pain and vomiting continue.

The two week-old baby came in with the results of the ultrasound. Amazing! Mom obtained an ultrasound in Rivas for $20 and the films with the report were available to me in 48 hours. Wow! Outpatient results that fast would be difficult to obtain in most Canadian centers. The Mom and Dr. Flores made this happen and this shows that the system can function.

I checked poop for parasites and worms twice today and both tests came back positive for both. Both families used well water. I'm sure most of the children are "colonized" or infected with worms and parasites. I reviewed how to disinfect water with the SODIS system and the need to wash hands and fresh produce to minimize ingestion of worm eggs. My Spanish teaching handouts on these preventative measures came in real handy.

A Dad brought in a three year-old boy with typical nephrotic syndrome. These children develop generalized edema (swelling) after common colds. An abnormality in the immune system is the likely cause. The Dad was told (or he understood) that the edema was due to infection and that antibiotics were the treatment for nephrotic syndrome. I had a hard time clearing up this misconception, but the distinction is important. Nephrotic syndrome requires treatment with a steroid medication and the problem is usually recurrent. I was not convinced that the Dad really understood but Sheyla felt confident that he did.

White-throated Magpie Jay,
which acts like a Magpie and looks like a Blue Jay.
Note the cute black feathers on the top of the head.

The Interpreter is Making a Difference

2011-12-28T16:57:00.000-07:00

Another kidney clinic day. When Dr. Flores found out that I was a paediatric kidney specialist he asked if I would see the chronic kidney patients in the community.

"Of course," I replied. I asked that he designate kidney patient days and general paediatric patient days. My reasoning was that chronic kidney patients would take more time than general paediatric patients. I asked to spend an hour with a kidney patient and to see 6 children a day, and to spend half an hour with a general paediatric patient and to see 12 children a day.

Yesterday and today I saw only kidney patients and all but one had recurrent urinary tract infection, which is a very common problem, but when I asked Dr. Flores if there were other kidney problem patients, such as nephrotic syndrome, nephritis, kidney failure, high blood pressure, etc, he replied, "No, all urinary tract infection." This sounded strange to me.

The solitary patient that did not have recurrent urinary tract infection had hemolytic anemia with dark urine during infectious events. The mother was told the dark urine was infection but the dark colour is really due to the chemicals in urine from broken down red blood cells.

I have learned this is a common situation. On prior visits I realized that "dark urine" was interpreted as urinary tract infection. Dark urine can mean dehydration, kidney stone, nephritis, hemolysis, and other problems, but is not usually a sign of urinary tract infection, except it appears, in Nicaragua. In Nicaragua, dark urine or blood in the urine is interpreted to mean urinary tract infection and the child is treated with antibiotics. My sense is that every kidney problem is urinary tract infection. Gosh, I wish it were that simple.

Sheyla, the interpreter, is getting better at explaining the ins and outs of how to prevent urinary tract infection and I can see that mothers are happy with her explanations, so I presume the patient teaching is happening. How can I know for sure? I can't. Only time and experience with Sheyla, and follow up visits with the same child, will clarify if we are connecting properly. I really need to learn Spanish.

Today I learned that Dr. Flores and Marta, the clinic nurse, were informed that I only wanted to see kidney patients. This is not true. There is a communication problem with the Director of the Clinic. I definitely asked to see both kidney and general paediatric patients. Sadly, this sort of communication problem is routine. The Executive Director of the clinic speaks English, is originally from Rivas, now lives in the US, and he helps manage and raise money for the clinic, and he means well, but communication problems like this are the rule. Today I asked Marta to cancel some kidney patient days and to arrange general paediatric patient days.

Communication. Communication. Communication.

Whimbrel with Crab, Dawn, Surfside.

Great First Clinic Day!!!

2011-12-27T16:58:00.000-07:00

What a great day!

Sheyla, the Nicaraguan interpreter, met me at the clinic and we saw five moderately complicated nephrology patients. By the end of the day Sheyla and I were coming together as a team. She will be with me for four days this week and next week a new interpreter will take over. Sheyla is a pre-school teacher. She did a great job. Thank you Sheyla.

In addition to treating the presenting problem, I gave each mother a vitamin supply for two months and some acetaminophen to have at home to use as necessary. The vitamins were courtesy of Health Partners International Canada. Thank you HPI Canada.

The Spanish teaching handouts on common problems worked great. Most of the children had a non-urinary problem as well. Constipation is just as common in Nicaragua as in Calgary. One child came in because of urine infection but had an ear infection and pneumonia. This child also had intestinal worms and as losing weight.

This boy had recurrent foreskin infections, epilepsy, and he smelled like he lived beside a campfire. Many of the children live in poorly ventilated homes with an open fire for cooking. Mom reports he has asthma but his lungs were clear today.

The sickest child was a 15 day-old baby boy. On the third day of life, the day he went home from hospital, he developed fever, fresh blood in the urine, and he cried every time he peed. The blood and fever continued for two days and then stopped but he continued to cry with voiding. Mom reported that he "really" cried with voiding and the voiding took a long time. Mom noted some orange powder in the diaper, likely uric acid, and this lasted two days. Then when he continued to cry she took him to Rivas and he was treated with IV Gentamycin for five days. He improved. His urine was clearer. He was crying less with voiding but still crying. The Rivas doctors sent him home on Clavulin but while in hospital they did not do a blood test or ultrasound. I’ve heard this story before. The standard intervention is to treat the acute issue (infection) and not look for the cause. This was the way things were done in Canada before I graduated in the ‘70’s. Mom also reported that he was tired with feeding and breathing a bit fast. I asked Mom whether she had seen him pee and if so, whether his stream was weak or strong. “Slow and weak,” she reported. He did not look septic but he was breathing a bit fast. His abdomen was softly distended. I put a urine bag on at just the right time (my luck has definitely turned) and he peed within two minutes. I dipped the urine and there was no infection.

This is a classic story of posterior urethral valves, which is a congenital blockage in the urethra, the tube that carries the urine from the bladder through the penis. Male infant, infection in the neonatal period, blood in the urine, discomfort voiding, and a weak urinary stream. We don’t see children present like this anymore in Canada. Prenatal ultrasounds pick this congenital problem up and intervention is planned after delivery. Infection is prevented from birth.

In Canada, if this child presented without any prenatal care, the child would have been referred to a Pediatric Urologist when admitted to hospital, blood work, an ultrasound, and either a catheter x-ray study or a cystoscopy would have been performed as soon as the infection was under control and the valves (blockage) would have been removed to relieve the obstruction.

I asked Dr. Flores how to arrange a good ultrasound and blood work on short notice so that I can review the results during my stay. Getting things done fast is sometimes a concern in Canada so I wasn’t optimistic. However, this might happen. The next challenge was who would pay. The state does not pay for ultrasound. This is only offered by private facilities. The cost is about $25.00. Marta, the clinic nurse, and Sheyla looked at me as if to say, “Will you pay.” I did not offer. If I offer to pay for this ultrasound, I will need to pay for all the ultrasounds. There are limits to how much I can afford. Twenty-five dollars does not seem like much, but in a country where the average wage is $100 a month, where over half the families make less than $500 a year, and where public health clinic doctors make $500 a month, this is a lot of money. The clinic is working hard to raise money to purchase an ultrasound.

So the first day went well, and I am now sitting in a covered area, enjoying the sunset and a cold Tona, the local beer. Time for a Tona.

Brown Pelican Flying South; Just Passed Through the Setting Sun

Midnight Motorcycle Madness

2011-12-27T06:41:00.003-07:00

Planes, Automobiles, and Motorcycles.

There is a great John Candy and Steve Martin movie
with a similar name,
and I am starting to feel like Steve Martin.

Last night I left the restaurant after a great dinner.

I'm about half way back to the casa

and I smell gas.

Then I realize that I can feel gas
spraying on my left leg.

So I pull over.

The bike stops,

the lights go out.

I put my hand down by the left side of the engine
and there is gas spurting out.

My leg, shoe, and hand are covered in gas.

Didn't think it was a good thing
to try and restart the bike.

Pitch dark.

Of course I am exactly
in the darkest portion of a dirt country road,

not a casa or light in sight.

The moon was only a sliver.

The stars however were magnificent.

No flashlight,

but my cell phone allowed me
to illuminate the bike a bit

and I found and toggled off the gas supply.

The gas stopped spurting,

which by now had covered a lot of my lower body.
If this were a classic Roadrunner Coyote story,
that would be the time when someone
would strike a match. Boom!

I moved the bike as close to curb as I dare,

without the bike toppling into the ditch
and walked back to the casa.

The cell phone was sufficient with the stars

and the walk back was pleasant.

Too bad.
I was just getting my motorcycle legs back.

I WILL get to the clinic today.

Arrived

2011-12-26T14:29:00.000-07:00

Little Blue Heron Surfside

This morning I did manage to confirm that the rental car was not available. I actually spoke to a Hertz employee who turned up at the hotel. No car for me.
So, I took a taxi, a 2.5 hour taxi, to Limon, and around noon, I arrived. Whew. Seemed like longer but really only 3 days compared to the usual 1.5.

The next problem is how to get back and forth to the clinic. Well, Matt, an especially helpful person who manages the casa where I stay, has offered to lend me his motorcycle. Ok by me. I enjoyed my motorcycle days as a young man. I even raced motorcycles for a season. So, the motorcycle works for me.

Matt's Honda

I unpacked and placed all the medications and supplies in one bag. I had mixed them all up with my clothes and equipment because there was a last minute snafu with the permit for customs. This time the meds were co-mingled and I chose the correct time to put the bags on the conveyer belt that takes the bags through the scanner. I was watching the scanner operator and he was periodically pre-occupied with a young woman. I put the bags on during one of his pre-occupied moments. Hey no problema! So, now the meds are ready to take the clinic.

All in all, the sky is clear, the sun is shining, the bags and medications all arrived intact, and tomorrow is another day.

Pacific Ocean, about 5 km from Clinic

Peace, Goodwill, and Complicated Travel

2011-12-25T16:24:00.000-07:00

A trip to Nicaragua would not seem right unless something went wrong with the outgoing travel. Major glitches in the past include luggage that did not arrive, and officious customs officials who confiscated supplies.

The problem started on the 23rd when my flight from Calgary to Houston didn't happen. The pilot advised that the repair crews swapped out multiple computers and the plane was repeatedly powered up and down,
but all to no avail. The fuel tank, definitely full of fuel, did not say full. Safety is important and rules are meant to be followed in the interest of public safety. So, after several hours on the tarmac, without any hope of making my connecting flight to Managua, I re-booked for the next day. Sounds simple, but that was not my karma.

Christmas travel is generally complicated. Everybody is traveling. Seats are in short supply. Patience is thin. Even so, I did manage a flight to Houston on the 24th, but there was simply no possibility of a connection to Managua the same day. So, last night I enjoyed the Houston Marriott. Nice hotel with a revolving restaurant at the top.

The good news is that I am now in Nicaragua, with my luggage, and the supplies were not confiscated.

The bad news is that I arrived two days late, and I am still in Managua.

The 4 Wheel Drive Toyota Land Cruiser that I rented with Hertz was not waiting for me. I had phoned to make sure they would hold my car, and I had offered and was happy to pay for the two missed-use days before I arrived. I arranged a very early morning flight from Houston so that I could pick up the vehicle and drive the same day to Limon, the nearest community to the clinic. Not only was the car not waiting for me, but the Hertz booth at the airport was not even open. A confirmation number is worthless when there is no one to discuss this with. All the other car rental agencies were open. Of course none had vehicles.

So, I took a taxi to the Hotel Intercontinental. I had been scheduled to stay there on the 23rd, and ended up paying for the room because by the time the airplane computer thing ended, I had passed the cancel-before deadline. Not that I hoped that the hotel would offer me a free room. That doesn't happen. But, I did want to check the Hertz counter at the Hotel and I hoped to enlist the concierge in my quest for a car.

The Hertz counter at the hotel was also closed, of course.

I checked in. The Hotel Intercontinental is definitely the best hotel in Managua. I'm lucky there was accommodation. In fact, the availability of the room lifted my spirits and I thought, surely fortune is now smiling on me.

I enlisted the help of the concierge and thanked him with a large monetary encouragement. He phoned the person who was on local-Hertz-Christmas-duty, and this person apparently agreed to contact the Manager, or more likely, to try and contact the Manager on Christmas Day. They are to call back. Hmm.

The rainy season ended in Nicaragua a month ago, but you could have fooled me. The palm trees are swaying very briskly, the sky is grey, and there is rain falling. But, I am on the Hotel veranda, which is very dry, and somehow I know that tomorrow will be sunny.
"Into every life, some rain must fall."

That's Longfellow quoted by a Shortfellow.

"Wake Up"

2011-12-20T07:19:00.000-07:00

The lyrics of the song, "Wake Up,"

by Arcade Fire,

certainly my favorite group from the last decade,

should be read by my generation.

Win Butler, the lead singer songwriter,

alternates between sadness and screaming,

in this anthem for his generation.

Somethin' filled up

my heart with nothin'

someone told me not to cry.

But now that I'm older

my heart's colder,

and I can see that it's a lie.

Children wake up,

hold your mistake up,

before they turn the summer into dust.

If the children don't grow up,

our bodies get bigger but our hearts get torn up.

We're just a million little god's causin' rain storms

turnin' every thing to rust.

I guess we'll just have to adjust.

With my lightin' bolds a glowin'

I can see where I am goin' to be

when the reaper he reaches and touches my hand.

With my lightnin' bolts a glowin'

I can see where I am goin'

With my lightnin' bolts a glowin'

I can see where I am goin'

You better look out below.

The song is not merely about children waking up,

but also about the need for their parents

and their grandparents (my generation) to wake up.

Change waits on nothing,

and change now happens on a logarithmic scale.

This song helped me realize

that my eyes have not stayed wide open

to the changes in the world around me.

The Internet is woven into the lives of

the youth in Nicaragua,

and they must be restless.

Daniel Ortega,

a young revolutionary of my generation,

started a successful revolution

in a relative communication vacuum.

Arab Spring
proves what is possible
with restless revolutionaries
in the digital age.

I do not know whether Ortega

has the pulse of the Nica youth.

Are his eyes wide open? If not,

the poverty and the discrepancy

between what Nica youth live at home

and what they see on the Internet,

might herald spring in Nicaragua.

Worms in Nicaragua

2011-12-19T06:32:00.001-07:00

Intestinal worms are common in Nicaragua.

Children Without Worms (CWW), an organization dedicated to the worldwide control of worm disease, performed a survey in five Nicaragua communities in 2005, and documented a prevalence rate for worms of 49%!

Worms are soil-transmitted helminths (STH). Eggs are ingested by individuals through food that is not carefully washed or on dirty hands. Larvae penetrate the skin directly. The eggs or larvae develop into adult worms, which produce eggs. Infected individuals contaminate the soil with their feces. Eggs develop in the soil. The cycle continues.

Once infected the child can develop abdominal pain and distension, intestinal obstruction, iron-deficiency anemia, malnutrition and poor growth, allergic reactions, and lung disease.

CWW in partnership with Johnson & Johnson and local government, targets school-aged children to receive a 500 mg dose of mebendazole and the families to be educated on hygiene. In Nicaragua the drug is administered by the Ministry of Immunization.

CWW advocates four key components to break the cycle of worm disease.

1. Water - access to potable water for handwashing and cleaning of foodstuffs.
2. Sanitation - latrines to keep infected feces away from individuals.
3. Hygiene Education - personal and environmental hygiene (handwashing).
4. Deworming.

I emailed Ms. Kim Koporc, Director of Children Without Worms. to inquire if there is a way for me to help in the clinic where I will work.

At the very least, I will prepare my own handout on how to disinfect water and on the need to wash all fruits and vegetables prior to food preparation, and the importance of regular hand washing.

While in Nicaragua, I will find out if the Ministry of Immunization campaign in 2010 included the clinic region where I work and how often the dosing is administered. Without intervention to prevent re-infestation, the worms will return. I will bring enough 500 mg tablets of mebendazole for every child I see and handouts in Spanish on hygiene and how to prevent re-infestation.

I've traveled extensively in my life and I only developed a gastrointestinal problem once. While on a family vacation to snorkel in the Cayman Islands, I developed shellfish toxin poisoning after eating at a fancy restaurant, which could just as easily have happened in Calgary. I've never been ill, touch wood, with any of my trips into rougher country. I've visited Haiti once and Nicaragua three times in the last twenty months and stool tests performed on my return from each trip have been negative. I set high standards and my compulsive nature helps. I was very strict about hand washing and all the fruits and vegetables were carefully washed in a dilute bleach solution before use.

Malaria in Nicaragua

2011-12-17T11:08:00.000-07:00

Malaria is present in Nicaragua. The Center for Disease Control reports malaria is present in only 6 of the 17 Departments (sort of provinces). The six reported Departments are located on both the Pacific and Atlantic coasts and in the interior. The absence of reports in the other 9 departments must be a reporting anomaly. Mosquitos do not acknowledge borders.

Malaria in Nicaragua is due to Plasmodium vivax in 95% of cases and P. falciparum in the remaining 5%. This is good news because P. vivax is still chloroquine sensitive and has a good prognosis for full recovery, compared to P. falciparum, which is a much more serious infection.

The anopheles mosquito transmits malaria. The bite transfers asexual parasite forms into the bloodstream and these parasites undergo a liver and then a red blood cell stage. About a week or two after entering the red blood cells, the blood cells burst and release thousands of parasites and inflammatory chemicals into the blood. The inflammatory chemicals include pyrogens, which cause the fever. The fever in P vivax develops every 48 hours days, which is referred to as tertian malaria. The red blood cell destruction results in anemia.

Children suffer the most severe disease; especially children aged 6 months to 5 years. In parts of the world where malaria is endemic, malaria might cause as many as 10% of all deaths in children. Survivors develop partial immunity.

Older children might present with the classic periodic fever with chills and shivering. However, this is uncommon in young children. After the mosquito bite, younger children are asymptomatic for one or two weeks. The fever is usually continuous and might be very high (40°C) from the first day. The symptoms are non-specific. Children become restless, drowsy, apathetic, and anorexic. Older children might report generalized ache, headache, and nausea. Many children have only flu-like respiratory symptoms, with mild cough and cold. Vomiting is very common. Mild diarrhea is also common, with dark green mucoid stools. Seizures might occur at the onset of the disease. Differentiating a febrile seizure from cerebral malaria is often difficult. The liver might be slightly tender. Splenomegaly takes many days, especially in the first attack in nonimmune children. Children with partial immunity might develop only a low-grade fever, anemia, poor appetite, and malaise. The diagnosis is established when parasites are noted on a thick blood smear, but only 50% of children with malaria have a positive smear, even on repeated examination. P vivax malaria might relapse for up to 3 years.

Since the symptoms are often non-specific, high fever in a susceptible young child requires a high index of suspicion, and in the absence of a recognized cause for the fever, empirical treatment might be necessary.

The treatment of P vivax is a 3-day course of chloroquine, followed by a 14-day course of primaquine. The primaquine is necessary to eliminate the dormant stage of the parasite in the liver.

An Ounce of Prevention is Worth a Pound of Cure

2011-12-17T07:39:00.000-07:00

I believe in immunizations.

There are serious infectious illnesses that were common when I started medical school but are no longer a concern in Canada. Polio was still around when I started my training, and this scourge has been "officially" eradicated worldwide. One of the first children I resuscitated as a medical student in the ER died later that day of measles. I saw literally hundreds of children with invasive H flu infections. I know how deadly infections can be and I know that immunizations work.

I've travelled a lot and I've always made sure to keep my immunizations up to date. In preparation to travel around the world in 1974 I was inoculated for smallpox, typhoid (3 shots), cholera (2 shots), typhus, yellow fever, and the plague. These immunizations are either no longer offered or are administered as different and improved vaccines. The latest preventative therapy for cholera is Dukoral, a liquid ingested weekly for two weeks prior to travel and which offers protection for about six months.

Like almost every Canadian of my generation I have a smallpox scar on my upper left arm. The scar implies immunity. However, on a trip to Kenya in 1979, my immunization permit did not include a record of immunization with Smallpox. They refused to let me into the country unless I submitted to an immunization at the airport in Nairobi. My scar on the arm was not proof enough. Since then I have traveled with documentation, although these records no longer seems to be checked.

For my trip to Haiti in 2010 I updated my status for diphtheria, pertussis, tetanus, typhoid, measles, mumps, rubella, H1N1, and cholera. All I need for this trip is more Dukoral for cholera. Cholera is not currently a concern in Nicaragua, but, I believe in immunizations, and an ounce of prevention is worth a pound of cure.

Doomed to Develop Dengue?

2011-12-16T13:35:00.004-07:00

As part of my preparation to return to Nicaragua I recently spent several hours reading about Dengue Fever. I'm glad I did.

Dengue fever is common in Nicaragua. Fortunately up to 50% of infections are not symptomatic. However, for those who do develop Dengue Fever, the symptoms are severe. The infection is sometimes called Breakbone Fever because of the severe bone pain with the infections. The bone pain is thought to be due to destruction of white blood cells and platelet precursors in the bone marrow.

The infection is caused by one of four serotypes of the Dengue virus and individuals who live in endemic regions will be infected by multiple strains over their lifetime.

The mosquito that transmits the virus bites by day so mosquito nets are of limited use. Only takes one bite. I have been bitten by lots of mosquitos in dengue endemic areas of the world, so the chances are good that I have had an asymptomatic infection.

The really bad news about dengue is that a small percent develop Dengue Hemorrhagic Fever and Shock Syndrome. This happens when an individual is infected with a new strain. The risk of Dengue Hemorrhagic Fever increases as the duration of time between infections increases. So, if I experienced an asymptomatic infection in the past, perhaps in Asia, Africa, South America, or the Middle East, and I am infected with a different strain on a trip to Nicaragua, I could be in trouble.

An immunization has not been developed. There is no anti-viral medication available. The only treatment is supportive care with hydration, blood pressure support with pressors, platelets and plasma for bleeding, and so on. All modern (read not available in Nicaragua) ICU therapies.

So, prevention is important. I will be much more careful with DEET application with this trip.

For the medical professionals who would like to learn more, I made notes on Dengue Fever from my reading, and the notes follow below.

The WHO ranks Dengue Fever as the most common mosquito-borne viral disease in the world. In the last 50 years, the incidence of dengue has increased 30-fold. In 2007, the Pan American Health Organization (PAHO) reported the highest number of dengue fever and dengue hemorrhagic fever cases (918,495) in the Americas since 1985. Each year Dengue results in an estimated 22,000 deaths, mainly in children.

Dengue is caused by infection with 1 of 4 serotypes of dengue virus. Genetic studies suggest that the serotypes evolved from a common ancestor in primate populations approximately 1000 years ago and emerged into a human urban transmission cycle 500 years ago in either Asia or Africa.

Infection with one dengue serotype confers lifelong immunity only to that serotype. Antibody prevalence increases with age, and most adults are immune.

Dengue is transmitted by mosquitoes of the genus Aedes, which breed around dwellings in small amounts of stagnant water such as those found in old tires or other small containers.

In the Americas, dengue epidemics were rare post World War II because mosquitoes were eradicated with coordinated vector-control efforts. Systematic spraying was halted in the early 1970s because of environmental concerns. By the 1990s, A aegypti mosquitoes repopulated Central and South America.

Female Aedes mosquitoes are daytime feeders. Humans are their preferred hosts, with ankles and the back of the neck being the preferred sites. The mosquito inflicts an innocuous bite and is easily disturbed during a blood meal, causing them to move on to finish a meal on another individual, making them efficient vectors. Not uncommonly, entire families develop infection within a 24- to 36-hour period, presumably from the bites of a single infected mosquito.

Mosquitoes acquire the virus when they feed on a carrier of the virus. Persons with dengue viruses in their blood can transmit the viruses to the mosquito 1 day before the onset of the febrile period. The patient can remain infectious for the next 6-7 days. The mosquito can transmit dengue if it immediately bites another host. In addition, transmission occurs after 8-12 days of viral replication in the mosquito's salivary glands (extrinsic incubation period). The mosquito remains infected for the remainder of its life. The life span of A aegypti is usually 21 days but ranges from 15

to 65 days. The virus does not adversely affect the mosquito.

Once inoculated into a human host, dengue has an incubation period of 3-14 days (average 4-7 days) during which viral replication takes place in target dendritic cells of the reticuloendothelial system, such as dendritic cells, hepatocytes, and endothelial cells, and the process results in the production of immune mediators.

Infection with the virus is asymptomatic in 50 to 90% of individuals.

Data from the 1997 Cuban epidemic suggest that for every clinically apparent case of dengue fever, 13.9 cases of dengue infection went unrecognized because of absent or minimal symptoms of a non-specific febrile illness.

Classic dengue fever is defined by the Pan American Health Organization (PAHO) as an acute febrile illness of 2-7 days duration associated with 2 or more of the following - severe headache, pain behind the eyes, severe muscle pain, joint pain, characteristic rash, hemorrhagic manifestations, low white blood cell count.

Many patients experience a prodrome of chills, red mottling of the skin, and facial flushing (a sensitive and specific indicator of dengue fever). The prodrome might last for 2-3 days. The illness presents with the rapid onset of high fever. The fever lasts 2-7 days and might reach 41°C. In addition to the symptoms and signs above, the patient might have weakness, vomiting, sore throat, or altered taste sensation. The severity of the pain led to the term breakbone fever. The rash is a centrifugal, maculopapular or macular confluent rash over the face, thorax, and flexor surfaces, with islands of skin sparing. The rash typically begins on day 3 and persists 2-3 days. Fever typically resolves with the cessation of viremia.

Leukopenia and thrombocytopenia are common findings in dengue fever and might be caused by direct destructive actions of the virus on bone marrow precursor cells. The resulting active viral replication and cellular destruction in the bone marrow might be the cause the severe bone pain. Approximately one third of patients with dengue fever have mild hemorrhagic symptoms, including petechiae, gingival bleeding, and a positive tourniquet test.

Dengue fever is typically a self-limiting disease with a mortality rate of less then 1%. Supportive care with analgesics, fluid replacement, and bed rest is usually sufficient. Acetaminophen can be used to treat fever and relieve other symptoms. Aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), and corticosteroids should not be used.

A small percentage of persons who were previously infected by a dengue serotype develop bleeding and endothelial leakage after infection with another serotype. The severity of secondary dengue infections appears to intensify with longer intervals between infections. When an individual is infected with another serotype, non-neutralizing antibodies recognize the dengue virus but do not neutralize or inhibit virus replication. Instead, the virus and antibody form an antigen-antibody complex. This complex is recognized by receptors on macrophages, which then internalize the immune complex and allow the virus to replicate unchecked. This phenomenon is called antibody-dependent enhancement. The affected macrophages release vasoactive mediators that increase vascular permeability.

Patients with dengue fever are at risk for development of dengue hemorrhagic fever or dengue shock syndrome at approximately the time of defervescence. Abdominal pain in conjunction with restlessness, change in mental status, hypothermia, and a drop in the platelet count presages the development of dengue hemorrhagic fever. Of patients with dengue hemorrhagic fever, 90% are younger than 15 years. In persons with dengue hemorrhagic fever, the fever reappears, as a biphasic or "saddleback" fever curve. Along with this biphasic fever, patients with dengue hemorrhagic fever have more obvious hemorrhagic manifestations and plasma leakage. The critical feature of dengue hemorrhagic fever is plasma leakage. Plasma leakage is caused by increased capillary permeability. Bleeding is caused by capillary fragility and thrombocytopenia. Dengue shock syndrome is essentially dengue hemorrhagic fever with progression into circulatory failure, with ensuing hypotension, and, ultimately, shock and death. Death can occur within 8-24 hours after onset of signs of circulatory failure. The most common clinical findings with impending shock include hypothermia, abdominal pain, vomiting, and restlessness. Dengue hemorrhagic fever has a mortality rate of 2-5% when treated and up to 50% when not treated. Worldwide, children younger than 15 years constitute 90% of dengue hemorrhagic patients

No specific antiviral medication is available to treat dengue infections. Single-dose methylprednisolone showed no mortality benefit in the treatment of dengue shock syndrome in a prospective, randomized, double-blind, placebo-controlled trial.

The only way to prevent dengue virus acquisition is to avoid being bitten

by a mosquito. Susceptible individuals should wear N,N-diethyl-3-methylbenzamide (DEET)–containing mosquito repellant and protective clothing, preferably impregnated with permethrin insecticide. They should choose well-screened or air-conditioned places. Mosquito netting is of limited benefit, since the mosquitos bite by day. Larval habitats (stagnant water) should be eliminated or treated with larvacides. Indoor sprays should be considered to eliminate mosquitos. Community-based vector control programs include vectoricidal agents and biological control agents.

Immunizations in Nicaragua

2011-12-11T07:20:00.002-07:00

Nicaragua has a great immunization program. The immunization rate was very poor until the Sandinista government came to power in 1979. The graph below shows the substantial improvement in immunization rates for the first and third doses of diptheria, tetanus, and pertussis and for the third dose of polio. Polio has not been reported since 1990! Tetanus and pertussis continue to be reported, as they are in Canada, most likely due to lack of immunity in adults.

After the revolution, the People's Health Councils organized Jornadas Populares de Salud (People's Health Days). In 1980, an estimated 30,000 volunteers carried out a series of Jornadas and immunized children for polio and measles. Since then the government holds immunization clinics, usually on Sundays, a traditional family day.

The immunization schedule for Nicaragua is better than Canada in some respects. Nicaragua offers the new rotavirus vaccine. Rotavirus is the most common virus that causes diarrhea in infancy.

Nicaragua has done better than the majority of other Central and South American countries. The 2010 data below is from UNICEF and shows the immunization rate for the first and third immunizations for diptheria, pertussis and tetanus. Most worldwide immunization data shows a fall off from the first to the third vaccine. Only very well organized heath programs have high percentages for both. Canada doesn't look good on this graph. Is the data wrong? Is immunization over-estimated in many countries? Not sure how to interpret this discrepancy?

I reviewed this data so that I would understand more about what infectious diseases to expect in Nicaragua. I will inquire about the comprehensiveness of immunization in the region and I will start to evaluate the immunization records that the mothers bring in with visits. If the immunization program is working well in the region then I will not expect to see diptheria, polio, measles, rotavirus, or German measles, but I might still see chicken pox, whooping cough, and mumps.

Thank you Colleagues

2011-12-09T09:30:00.000-07:00

We reached out to the physicians who refer children to my clinic and they reached back to help out. On Wednesday, Michele Holtsbaum, my office manager, drove around on a snowy day to collect donated medical supplies for the trip to Nicaragua. Thank you Michele.

The donated medications will augment the pharmacy in the clinic in Nicaragua and are very welcome and needed. I will use some of the medications personally during my visit.

A big thank you to the colleagues who donated supplies.

Dr. Patricia Bryden

Dr. Michael Guiffre

Dr. Sandra Foss

Sunnyhill Pediatrics

With these donations, I will be able to offer every family some acetaminophen drops or tablets to have on hand for future fevers or discomfort. I doubt there are many family homes in Canada that do not have acetaminophen or ibuprofen on hand. This certainly isn't the case in Nicaragua, and in the region where the clinic is located, there is no such thing as a pharmacy. The nearest pharmacy, gas station, and grocery is in Rivas, which is about an hour away on a very bumpy, rutted, dusty, dirt road, with more cattle, chickens, pigs and horse-drawn wagons than cars. I imagine the mothers have a network in their community and they might be able to find someone who has fever drops or tablets available, and perhaps even with a current expiry date. I've prepared a Spanish teaching handout on fever and I will offer this and a modest supply of acetaminophen to every mother who I see.

Thank you Pendopharm

2011-12-07T06:08:00.001-07:00

Pendopharm, a Canadian pharmaceutical company, produces electrolyte gastro, an oral rehydration solution (ORS). This ORS will make a difference for the diarrhea that I will see in Nicaragua. The powder in one sachet can be mixed in 200 ml of clean water to produce a replacement solution for the watery small bowel diarrhea common with viral gastroenteritis.

Pendopharm donated 150 boxes of electrolyte gastro, and this donation will make a difference not only for the children I see, but for children in the region for months afterwards.

The physiological rational for ORS was discovered in the 60's and early solutions were effective to treat cholera. ORS was popularized by the World Health Organization (WHO). ORS has saved millions of lives.

So long as the Mother uses clean water and is taught to mix the powder in the correct amount of water, the sachets are ideal. They can be stored and used as necessary, the concentrations of sodium and glucose promote good absorption of sodium, and the
fruit taste is pleasant for the child.

In Haiti, clean water was not readily available and the families were so poor that they could not afford bottled water. I pre-mixed the solution personally for the children in bottles of water we purchased every morning. If I can find a ready source of bottled water I will consider the same practice in Nicaragua.

Julia Keshen, Associate Brand Manager, Consumer Products, for Pendopharm, made this donation possible.

Thank you Julia Keshen!
Thank you Pendopharm!

Thank you Health Partners International of Canada

2011-12-06T07:07:00.002-07:00

Last Friday I was networking online, trying to find medical supplies to take to Nicaragua, and I discovered Health Partners International of Canada.

HPI Canada was established as a not-for-profit relief and development organization in 1990. During 2010, HPI Canada provided over a million treatments in 75 countries.

HPI Canada prepares a container of common medications and supplies that are useful for medical trips to countries where physicians and medications are in short supply. The generic container is not focused on paediatric care and is therefore not useful for my purposes, but there was a form for "Special Physician Requests." Supplied medications are donated by pharmaceutical companies who partner with HPI Canada. Physicians are requested to donate a modest percent of the wholesale cost. Definitely a win-win solution all around!

Paperwork, I thought. Probably take forever. Rather than just fill out a form and send the information into cyberspace, I phoned and was put through to Ms. Martha Florez, Manager of Physician Programs for HPI Canada. Ms. Florez was incredibly helpful. She acknowledged that approving a special request in time for my trip in three weeks was a long shot, but she advised that if I got the paperwork to her, she would do her best.

I spent the next three hours working on the paper. The time consuming part was estimating medication needs for the trip. I had the data about expected diseases (see my November 29, 2011 blog) but I needed to determine how many bottles of the pediatric formulation of each medication would be needed. I looked up each formulation online, calculated dosages based on the age (weight) of the children I will see, prepared a spreadsheet, inserted my data from previous visits, and estimated the number of children I would see. I'm sure a less compulsive person would just have made a good estimate, but I decided that the time invested would help insure any HPI Canada resources would be utilized. I've seen bags, closets, and even store rooms of expired medications around the world and this is a preventable and sad waste of resources. I do not want to become part of the problem. I need to be part of the solution.

I was working through this methodically when Ms. Florez phoned to advise that she had talked to individuals at her end and that she needed the documents by about 2 PM. HPI Canada is headquartered in Quebec with a time zone two hours ahead of Alberta and the clock was ticking. I managed to send the completed application, my medical documents, and the important list of medications just in time.

Yesterday Ms. Florez phoned with the terrific news that she had expedited my application and obtained some of the medications on short notice.

Thank You Health Partners International Canada and Thank You Ms. Martha Florez. Wow!

Intestinal Parasites and Solar Water Disinfection (SODIS)

2011-12-03T07:39:00.000-07:00

Intestinal parasites in Nicaragua are endemic and the water is the most common source.

In one recent study, 53% of tested wells contained amoeboflagellates. A study of 480 apparently healthy individuals in Leon reported that Entamoeba histolytica or Entamoeba dispar was present in 12% of stool specimens. A 2001 survey found that 13.1% of children under 5 years of age suffered from diarrhea as a result of unpotable water.

While in Limon I will find out if there is support for community programs to disinfect the well water. If this can be arranged, perhaps the problem might not recur after treatment for abdominal parasites.

Solar water disinfection, SODIS is a method to disinfect water that works and that is commonly employed in poor rural areas around the world.

SODIS can be used to disinfect water using sunlight and plastic polyethylene terephthalate (PET) bottles. The World Health Organization (WHO) recommends SODIS.

The PET recycling mark is widely recognized and confirms the suitability of a plastic bottle for SODIS.

Large 2 litre colourless, transparent PET water or pop bottles are needed. The labels are removed and the bottles are washed. Older scratched bottles should not be used. The bottles are filled three quarters full with well water, shaken for 20 seconds with the cap on, then filled completely and recapped. Very cloudy water should be filtered prior to exposure to the sunlight. The filled bottles should be exposed to the sun for 6 hours and will heat faster and to higher temperatures if placed on a piece of corrugated metal that is sloped and faces the sun.

Perhaps I should stockpile 2 litre PET bottles and small sheets of corrugated metal and give these out with instructions every time I prescribe an anti-parasitic medication.

Using Data to Plan Trip Four

2011-11-29T06:01:00.000-07:00

During past trips I kept an electronic copy of the written summary of patient visits. I typed out a short summary with the name, age, gender, symptoms, physical exam, assessment, and recommendations. I used Google Translate to convert the text to Spanish, and the printed version was placed in the clinic chart and a copy was given to the mother. Until I got into the routine I did not save every patient, and when the clinic was hectic, I forgot to save some patients, but I managed to save all but one or two a day, so my records are pretty good.

I reconverted the files one by one to English, and then made a spreadsheet of age, presenting complaints, diagnoses, and medications prescribed.

The children ranged from 1 month to 11 years of age and I saw 12 to 24 children a day.

The graph below shows the most common diagnoses and the percent of patients with these diagnoses.

I expect to see about a hundred patients during the next trip and based on this data I can predict how many of each diagnoses I will likely see and I will bring enough medications in each class to cover the common problems without dipping into the clinic pharmacy stores. As well, I will bring my preferred medication for each problem, which obviates the need to choose a second or third line medication from the clinic stores.

The most common prescribed medication was an anti-pyretic followed by an antibiotic.

I'm sure that I did not diagnose all the cases of scabies, ringworm, and tinea versicolor. Many children had these skin infestations but the mother often didn't point the rash out as a problem. As well, the clinic did not have supplies of medications for these skin infestations. With the next visit I will bring enough medications to treat these problems.

I am also sure that I did not diagnose all the cases of abdominal parasites. A case might be made that any child who drinks well water, that is to say probably every child, likely has an abdominal parasite. Perhaps I should bring enough to treat every child. But, if they continue to drink the well water, the parasites will return.

Over the next month I will prepare a teaching handout in Spanish for the common problems such as fever, cold, ear infection, rehydration with gastro, nutrition, abdominal parasites, scabies, ringworm, tinea, and impetigo. Having the handouts will save me time when I see children with these problems.

Planning the Fourth Trip in 14 Months

2011-11-25T07:36:00.001-07:00

Orange-fronted Parakeets

During the last week of December I will fly to Nicaragua for my fourth visit in fourteen months.

Illness doesn't take a holiday, and my presence, I hope, will allow clinic staff in Limon to spend more family time during the Christmas festivities. All good.

Daniel Ortega, the president of Nicaragua, recently re-elected for another five year term, stated that he expected to continue to govern on a path that is "Christian, Socialist, and in Solidarity." The church figures prominently in his government and in the country generally. Christmas is an important religious holiday in Nicaragua. The predominantly Catholic population celebrates the birth of Jesus with festivals, pageants, and traditional church activities.

My goals for this trip are to provide Spanish teaching sheets for the common problems that I will see, to bring along the majority of the medications that I expect to personally use, and to establish a long term relationship with an interpreter.

On prior visits I kept a computer file on almost all of the children that I assessed. I prepared the files as a permanent record for the clinic chart and the recommendations portion was given to the mother as a written reminder of the instructions. I am tabulating these records and in due course I should be able to estimate the medication needs.

I am hopeful that some of my Calgary colleagues will again donate medical supplies for me to take to Nicaragua, and I will purchase the deficiencies between my estimate and the donations.

The records will also serve to identify the basic problems for which Spanish teaching sheets need to be prepared.

Finding an excellent translator is an important project. I will pay the translator very well by Nicaraguan standards but a modest amount by ours. An excellent physician translator relationship can make a huge difference with quality of care.

I expect to post a blog every week or so until I leave and then daily while in Nicaragua so that the friends of Help Nicaragua Children can keep in touch.

Gigante, "Foot of the Giant"

2011-04-23T11:34:00.006-06:00

Depending on who you talk to, or what you read, the foot of the giant is either this peninsula that forms one arm of the bay, or the foot is the entire bay.
When we arrived in Gigante, just before noon, the town was in full Samana Sanata swing. The restaurants and bars were alive with music and people were spilling into the streets with cervezas.

One table had three local fellows, a bottle of rum that was almost empty, and they looked like their sobriety was fading fast. Bo Fox reports that the combination of alcohol and breaking waves with undertow is a fatal formula on holiday weekends.
Gigante is a fishing village and we learned that the local fisherman are hard workers and hard drinkers. They smoke and drink much more than the average Nicaraguan, perhaps because they earn more. The fish they catch is packed on ice and has a good market in Managua.

   The population of the town had swollen with the holiday festivities and we were very fortunate to bump into Bo Fox as soon as we drove into Gigante. He was literally the first person we saw. This was fortuitous because we brought along the remainder of the toys that we had brought for the clinic patients.
   As we walked to a beach restaurant, Bo said hi to at least ten local fellows. He has only lived in Gigante since January, and by now he seems to know most everyone. What a congenial guy! We enjoyed a soda with Bo and then he had to leave to do a Skype conference with a volunteer for Project Wave of Opportunity, the charity he works for.
   We walked along the beach and enjoyed lunch in a Gringo cafe at one end of the beach. There were hundreds of families on the beach. Children built sand castles, adolescents played soccer, and parents sat under tarps or umbrellas. The beach was a sea of smiles.
   Later that evening, back in Limon, we hosted a party for the clinic staff. Everyone was in Samana Santa holiday mode, and we had a great time. What a great finish to a week of work in Nicaragua!

Three-day Work Week

2011-04-21T10:12:00.001-06:00

When I arranged this trip I was advised I could work through the entire week before the Easter holiday weekend, but today we were informed the clinic is closed on Thursday and Friday. Samana Santa is a big holiday in Catholic Nicaragua and there will be lots of family-oriented religious festivals from Friday to Monday. The crucifixion and the resurrection will be played out as pageants on the streets.

The last day was a busy day with more complicated and sicker patients than we cared for over the last few days.
An eleven-year old boy arrived with a cold, headache and a history of fainting during running. The latter complaint drew my attention. He had fainted twice during exercise and on one occasion he was unconscious for ten minutes and his lips were blue during that time. Ouch! He was overweight, which is uncommon in Nicaraguan children, but otherwise his exam was normal. I arranged an ECG, which was also normal. No evidence of QT prolongation, ischemia, or ventricular hypertrophy. In Canada, a paediatric cardiologist would likely due an echocardiogram, a 24 hour holter monitor, and a treadmill test. After reviewing this with Dr. Flores, I am hopeful that a cardiology consult and echocardiogram can be arranged in either Rivas or Managua.

   A 33 month-old boy had an open fontanel. The soft spot should close by about 20 months of age. His head circumference was at the 85 percentile. I asked Marta, the clinic nurse, to inquire about seizures and the mother described "absence" spells. Likely this boy has hydrocephalus. In Canada, he would have a CT or MRI and EEG, a pediatric neurosurgical consultation for the hydrocephalus, and a pediatric neurology consultation for seizure control. His neurological exam was otherwise normal without any evidence of increased intracranial pressure, but this will develop without surgical intervention. After discussion with Dr. Flores, I am hopeful that a surgical consult in Managua can be arranged.
   Kate and Sian came by and presented a cake to the clinic staff to thank them for their hospitality during their stay.
   While they were in the clinic they presented an information session on anemia with a poster they designed for the class.

In lieu of working at the clinic today, we decided on a road trip to Gigante, the fishing village where all the children we saw on Monday and Tuesday live.

Another Truckload from Gigante

2011-04-20T07:24:00.002-06:00

Another truckload of children arrived from Gigante today. Bo Fox reports that this fishing village is home to about 500 individuals of which 31% are children, according to a recent census conducted by Project Wave of Opportunity. Over the last two days, we therefore saw about a quarter of the children.

None of the children were sick today and I mostly did well child checkups and answered the same kind of questions that many Canadian Mom’s might ask. Many asked for a vitamin or tonic to stimulate appetite and I responded with nutrition advice.
Most of the children were "dressed up" for the visit to the Canadian doctor. Bo reports that they are mostly shoeless and wear only shorts and a T-shirt at home, but for the trip to the doctor they had pants or dresses, and shoes and socks.

Bo reports that today I saw the poorest families in the community. Apparently about twenty individuals live together in a communal arrangement in a home made of large pieces of plastic. The children were all well cared for, their teeth were not full of cavities, and they were happy and playful with their peers. By and large the Nicaraguan children were all very well behaved in the clinic. Karen reports that when they were playing outside they were more rambunctious and mischievous. Karen made sure the children had fun while they waited.

The team of Kate and Sian from Bristol, England, Bo Fox from the US, and Karen and I from Canada moved faster today. Kate and Sian took the histories, I did the exams, Karen distracted the children, and Kate and Bo interpreted the treatment recommendations. Bo and Kate

Bo and Sian

   Kate with a happy little girl
   We enjoyed dinner with Kate and Sian, to celebrate their last night in the area. Tomorrow the will travel to Leon to enjoy the Samanta Sana festivities. We had dinner at Yolanda's a local restaurant. Yolanda greeted us like family when we walked in. She had a big smile and hug and we felt very welcome. We had plantain chips, which were salted, and seem to be a local equivalent of the potato chip. Large portion meals with fish or chicken, beans, rice, salad, and four Tona, the local beer, all for only $28.
   Bo Fox is an amazing fellow. He was full of energy, enthusiasm, and ideas. I'm not sure how long he has been in Gigante, but he has clearly woven himself into the fabric of the community. His relationship with the mothers and children looked like family. He sure made a difference for us. Thank you Bo!

Great Day in the Clinic

2011-04-19T07:24:00.002-06:00

A truckload of children were at the clinic when we arrived at 9:30 AM. The families were all from Gigante, a small community about 20 km away. Bo Fox, who is a worker with Project Wave of Optimism, an organization with a mission to foster community development, was advised that a pediatrician would be available at the clinic, and he went door-to-door to identify families who might benefit. Eighteen mothers and their children arrived and 7 hours later, after we saw the last patient at 4:30 PM, they left together. Incredible to think that 18 mothers each spent an entire day away from their homes to spend about half an hour with a pediatrician.

Imagine 35 people in this truck!!!

Two final-year medical students from Bristol, England were at the clinic. Their university arranged for them to volunteer at the clinic and also in the hospital in Rivas for two weeks. Both of the students were fluent in Spanish and for the first time, I obtained a precise history from each mother. The students translated for me and in return I served as a pediatric professor as well as a clinician.

I designed a history and examination form, a two-page checklist, and I used this for the first time. The form definitely improved the data record and saved time. I used Google Translate only to document the diagnoses and the treatment recommendations. The checklist and the Google Translate document, together with a growth chart, were stapled together at the end of the assessment and will become part of the permanent medical record for that child.

Karen assisted with record keeping, gave out toys, took photos, and arranged play activities for the children who patiently waited their turn.

The first patient of the day was the sickest. A 6 year-old boy presented with a two-day history of high fever. A week prior, he had a runny nose and cough without fever and someone had treated him with six days of amoxicillin. The day after he finished the antibiotic he developed the high fever. Today was the second day of fever and in the clinic his temperature was 39 degrees. He looked a bit toxic. He had very very red throat and he only coughed once but there was mild inspiratory stridor. He had a small lymph node in the neck. The trachea did not feel tender. His air entry was normal. His exam was otherwise normal. I worried that this might be the start of a bacterial tracheitis or even epiglottitis. I do not think these children are immunized for H flu. I had clavulinic acid available and I treated him with this antibiotic and with acetomenophen for fever. I made sure Mom knew to bring him back the next day if he was not improved and for Mom to take him straight to the hospital in Rivas, about 30 km away, if he developed difficult breathing or drooling. I will inquire about the boy today.

Hummingbirds

2011-04-18T18:17:00.002-06:00

Hummingbird identification is a challenge. The birds are tiny and usually don’t sit still long enough to even focus the binoculars, much less get a good look. I learned years go to take a picture first. With modern digital photography and a fast shutter speed, a sequence of photos can often provide enough information for later identification.

Yesterday morning I was standing along a stream under a forest canopy and waiting to see what might fly by. I spotted two hummers by the edge of the stream. They hovered about a foot over some green algae-like growth in the shallowest part of the stream. There were no flowers. Hummingbirds eat insects and I wondered if this hummer ate insects that lived in the aquatic plants. I started to take photos right away. More hummingbirds arrived and I realized this was better than average photo opportunity. I moved to put the sun behind me, which startled the hummers and they disappeared. I stood still and waited, and they returned a few minutes later. Over the course of the next fifteen minutes I took about a hundred photos of the hummers as they descended to bathe in the stream. The hummingbirds usually arrived as a pair but sometimes there were three at a time. They hovered looking down into the water and then they descended into the water and splashed around until their feathers were soaked, and then they flew off.

Back at the casa I downloaded the photos and hoped there were enough images in focus to make identify the humminbird. I hit the hummingbird jackpot! The photos allowed a precise identification of four different species! I had presumed I was only looking at one species.

A distinctive white band in the tail allowed identification of a Band-tailed Barbthroat.

The tail shape and the purple breast and head separated by a green neck allowed identification of a Violet-crowned Woodynmph. The distinctive central green breast stripe allowed identification of a Green-breasted Mango. A great image of a thick coral-red bill with a black tip allowed identification of a Blue-throated Goldentail.

There might well have been more species present. I have not done an internet search about hummingbird bathing behavior to know whether communal bathing is common. Perhaps once a safe location is identified by one species others learn to tag along.

Fires in the Mountains

2011-04-17T11:36:00.001-06:00

   Yesterday morning at dawn, I saw two columns of smoke in the distance. Within an hour the smoke turned into a cloud that moved with the wind. The amount of smoke looked larger than I would have expected from a small rubbish fire.
   The smell of smoke was fairly strong in the air and both the smell and the amount of smoke grew over the day. The winds are generally brisk and by midday the smoke from one of the fires extended for about five kilometres down a valley and towards the ocean. As the sun set the smoke was replaced by flames that crept down the valley. I was up at about 1 AM and the flames were still visible but less intense. By dawn the flames were gone and there was no visible smoke.
   The area engulfed by the largest fire and the spread down the valley with the prevailing wind suggested to me that the fire was out of control. Accidental fires are likely common. There is no garbage service and refuse is burned on the property. Yesterday I drove by a large bonfire on the side of the road and there was no one attending the fire. This is the dry season and I imagine that some of these fires get out of control. Intentional fires are a common method to clear land in preparation for planting. There is no fire department and when either a refuse fire or a crop-clearing fire get out of control, the fires are obliged to burn out.
   I shuddered to think about people who might have lived in the valley the flames engulfed. Presumably they would move out of harms way, but their possessions, some of their livestock, and the indigenous fauna might not escape.
   I checked for any news reports of fires in the region and of course there were no reports. What occurred to me is that a small community could disappear in the mountains and that these incidents might escape the attention of the local authorities.

One Step Forward, Two Steps Backward

2011-04-16T09:15:00.002-06:00

I had arranged to meet with Rob, the local FIMRC organizer, to give him the customs receipt to retrieve the medications at the airport. I was advised that Rob would be at the Las Salinas clinic on Friday afternoon and on Saturday morning. Thereafter, the FIMRC group were scheduled to close down operations for the Easter Semana Santa week. I was scheduled to work at the Roberto Clemente clinic on Friday, so I advised FIMRC that I would drive to Las Salinas later on Friday afternoon. When I arrived at the clinic, there was no sign of Rob and after waiting for half an hour, I left. I emailed the FIMRC folks and I had hoped to hear back with a revised time to meet Rob, but I haven't heard back. This morning (Saturday) I will drive back to the clinic and I hope Rob or someone is there. Otherwise, I guess that means the medications will not be used. Perhaps if the medications are still at the airport when I return to Canada, I can take them back home. This feels like a step backward.
   The second step backward is the lack of power and internet at the casa where we are staying. Lack of power means no ceiling fans and this means a very sticky sleep. Lack of power means flashlights and candles after 7 PM. Lack of power means no coffee in the morning. Amazing what we take for granted.
   The step forward yesterday was the work at the clinic. We saw over ten families, most with more than one child, and courtesy of the portable printer, each mother was presented with treatment recommendations written in Spanish. Another copy was signed and became part of the permanent medical record for the child. On this visit we started plotting weights on CDC growth charts.
   There were no seriously ill children yesterday. The common presenting complaints were poor appetite, poor weight gain, headaches, fever, and nosebleeds.
   There were three children with headaches. One child had classic migraine, another child likely had migraine, and the cause in the third child was not clear to me. This last child had headaches that had routinely awakened him in the middle of the night for over a year! When headaches wake a child, this is considered a "red flag" for a potentially serious neurological problem. His neurological exam was normal. He was only five years old but he cooperated well and he allowed me to visualize his discs with the ophthalmoscope and the margins were crisp, which was reassuring. In Canada this child would justify referral to a paediatric neurologist and he would likely have a CT scan. I discussed this with Dr. Flore, the clinic doctor, and if the boy does not improve, perhaps this can be arranged. I otherwise offered a variety of analgesia options for the mother to try.
   One 11 year-old boy was overweight. Overweight children are not common in Nicaragua. Most are shorter and thinner than the average Canadian child. His blood pressure was borderline. Diabetes and hypertension are apparently very common in the adult population. I explained to Mom that her son was 9 kg overweight. I outlined an exercise program with fast walking or jogging every day in the cooler hour immediately after dawn. I made specific nutrition recommendations. I advised Mom that if he didn't loose weight his risk for diabetes and hypertension was likely high. I know the Mom took these recommendations to heart because she has adult family members with diabetes.
   This first clinic day on the second trip felt like progress, and progress is good.
   We didn't manage any clinic photos so another gorgeous sunrise will have to suffice.

Trouble with the Law

2011-04-15T16:09:00.002-06:00

After passport control, we picked up our bags from the carousel, and this time, to our relief, our bags made the journey with us. After piling the bags on a cart we proceeded to the customs area where we placed our bags on a conveyer belt that moved everything through a scanner.

"Is this your bag," the customs officer asked as soon as the bag emerged from the scanner.

"Yes," I replied.

He pointed to a security area and implied that I needed to take the bags to be checked by hand. A pleasant young woman opened the bags and as soon as she saw the medications, her look advised me that we were in trouble. I gave her the letter, in Spanish, that FIMRC provided to vouch for the charitable reason for the medical supplies.

The woman asked one superior, and then he asked another superior, and then I was advised that without the proper official documentation, I could not bring the meds into the country.

I brought out my laptop, found a wireless link in the airport, and with Google Translator, I explained that I was a Canadian paediatrician, and that I needed to leave for Las Salinas in the morning, and that the medications were needed for the clinic.

No go. Rules are rules. No ticket, no entry.

So, we left without the medications, but with a receipt, signed and stamped, that advised that if we can arrange the necessary documentation, we can retrieve the supplies.

The next morning, at the Hotel Intercontinental Managua, I emailed Anna, my FIMRC contact, and advised her about the problem. She promptly responded that she would do what she could.

We picked up our Toyota Prado (Land Cruiser in Canada) at the hotel, and again with the help of Google Translate, I learned why the expensive maximal insurance coverage on the last trip did not cover me for the $375.00 scrape on the fender I unknowingly suffered in the "secure" parking lot at the Hotel Colon in Granada on the last day of our March trip. Nothing is covered without an official police report. I'm not sure I would have tried to report a scrape to the police, even if I had known about the damage.

Well, I checked the Toyota very carefully this morning, and it occurs to me that I should have taken pictures with my digital camera to document the condition when I accepted the car. Next time.

We left the hotel for La Union, a supermercado, the Safeway or Sobeys, in Managua. We stocked up on produce, water, juice, and cooking supplies for the next 10 days, and packed everything in the Toyota.

Leaving the supermercado, I watched a white car turn left in a gap in a divided road and I presumed that I could make the turn as well. Bad move. Two policeman watched the white car drive by and then they pulled me over. I had made an illegal left turn. They saw me coming.

Neither of the two policemen spoke any English; why should they? I understood I had made a mistake and presumed the problem was an illegal left turn. There was a policeman at my window and another policeman at Karen's window. Karen's Spanish is much better than mine. Neither of us could follow the dialogue well, but when the policeman at my window, now holding my drivers license, demonstrated how he intended to put my license into an envelope and seal the envelope, I realized my license was going to be confiscated.

Ouch!

My heart rate picked up a few beats and I noticed that the air conditioning was not keeping my armpits dry.

I pulled out the FIMRC letter, written in Spanish, that described my work as a doctor, and which stated that I was delivering supplies to a clinic in Las Salinas. The policeman at my window visibly softened.

However, by then, the other policeman, at Karen's window, had pointed to a paper with $100.00 written on a line, an amount that was presumably the fine for our infraction.

"I think he wants money Dad."

I showed the other policeman the FIMRC paper but his demeanor did not soften.

I took out some bills and gave each of the policemen $10.00 US, and they sent us on our way with directions to Rivas. I'm old enough to remember when speeding tickets in Canada were about $25.00.

I am confident that both those young policemen will submit the money to the necessary authority as honest individuals who are interested to prosecute the law in an honest and ethical fashion. Well, maybe not.

The rest of our journey was much less exciting.

I was more relaxed on the crazy Nicaragua roads. Nothing like experience.

What went right and what needs to be improved for the next visit?

2011-04-06T07:07:00.005-06:00

What went very right was that we provided care to over 100 children in a rural area of Nicaragua. The families appreciated our care and their smiles as they left were affirmation of a positive and helpful impact on their lives. Most had traveled for one or two hours and then were obliged to wait for up to four hours to see us, and afterwards they traveled for another one to two hours to return home. Can you imagine the average Canadian family doing this to obtain routine health care? Maybe you can. There are some that say charity begins at home and that the Canadian Health Care system is in trouble, but that is another issue. Compared to Nicaragua, our health care is excellent.

   What went right was that notwithstanding communication challenges, we connected satisfactorily with the mothers. I didn't say very good, I certainly didn't say excellent; I said, satisfactory. This was positive but my Spanish skills need a lot of work and this will take time and practice.
   What went right was that we provided much needed medications that will help families for many month to come. The two bags of medications we brought were the equivalent of about 20% of their available pharmaceutical stores!
   The toys we brought for the children were a big hit. We brought just enough and next time we will bring more.
   Google Translate was a great help with communication. With the next visit we will bring a portable printer so that we can print out individualized treatment instructions for the mothers. Last weekend I purchased a Canon Pixma IP100 portable inkjet printer. The printer weighs only 4.4 pounds and is faster than the printer I have at home.
   There are other clinics in the region that also deserve help and in the future I would like to work in a variety of situations and perhaps help to improve communication and cooperation between the clinics. You would think that in such a medically impoverished country that everyone would cooperate for the greater good, but politics, competition, and egos intervene everywhere.
   I learned about an American charity, FIMRC, that has a mission to provide health care to children in poor countries. They are working to establish a medical clinic for children in the region. I contacted them and there is a good possibility that I will collaborate with FIMRC during future visits. The photo below shows the clinic in Las Salinas where FIMRC is working to establish a clinic for children.

   From a logistical perspective, our Garmin NAVI GPS was very helpful to navigate from Managua to the remote area in southwestern Nicaragua. Kudos to Louise who was the navigator. We never got lost.
   Some parents in my practice and some physicians who refer to me have asked to donate money to this project. Thank you! I need to set up a Canadian Charity before I can accept money. Spending my own money and accepting donations of medical supplies is one thing. Spending the money of another person is quite another thing. I am a do-it-by-the-book kind of guy. I like to cross the "t's" and dot the "i's." I cannot accept money without legal and financial accountability. I will keep you posted.
   We will visit again during the last two weeks of April. We will spend another week to gain experience and to determine if this is the correct venue to channel our efforts. Karen, my daughter, will accompany me on this trip. She has time off courtesy of Spring Break.
   There was nothing that really went wrong.
   Yes, our luggage didn't arrive with us and we had to wait a half a day the next morning in Managua, but we still arrived at the clinic before sunset.
   Yes, the left rear view mirror on the Toyota Land Cruiser was broken and limited my visibility on those crazy roads.
   Yes, my Spanish was poor, but between the modest English of the clinic staff and my mediocre Spanish, and courtesy of Google Translate, the communication with mothers was satisfactory.
   Yes, we did develop a flat tire on the second last day, but this was fixed and we made it back to the airport over those rough and tumble roads without a second flat tire, which really would have been a problem.
   Yes, someone did ding the Toyota, which somehow cost me $384 notwithstanding the maximum insurance coverage available. This happened in the "security lot" at the Hotel Colon in the center of Granada. The high wire fence and security guard protected the Toyota from thieves, but the close quarters allowed another "secured" car to hit mine. They didn't report it.
   Yes, there were strange bugs and one snake was spotted, but apart from some itchy bites, this was no different than the risks of a walk in the Alberta mountains when the bugs are biting.
   So yes, there were lots of minor frustrations. But, there were more than enough smiles and successes to make the troubles all seem inconsequential.

This is the local trucking industry. Carts like this, towed by an ox or horse, transport bricks, bananas, wood or whatever.

Lots of homes had a beehive kiln in the front yard.

This old wooden dugout was likely used on the rivers and lagoons that fed the Pacific.

Water wells were common.

Last Day

2011-03-26T07:39:00.001-06:00

  The final day started with the sickest patient for the entire week and ironically the patient was an American woman. They clinic physician asked if I would talk to her mostly because I could speak to her in English, but also because she was frightened. Her anxiety was well founded. She had been sick for two weeks with fever and shortness of breath. She had received two courses of antibiotic, oral then IV, had been treated in both Managua and at the clinic, and she looked very tired. I examined her and thought she had an effusion in the right base. Turns out she has a past history of three episodes of pleurisy, which implies there is likely an underlying predisposition.
   They treated her with IV aminophylline, which I have not seen used since I was a young resident at sick kids. While she was at the clinic she developed all the signs of aminophylline toxicity. She became agitated and talkative, her heart rate increased and eventually she vomited. Her lungs did open up, so the intervention was successful.
   Notwithstanding two weeks of illness with multiple visits to various physicians and clinics, she had not had a chest x-ray. After two weeks of shortness of breath and with no improvement, I suggested she seek out a more comprehensive care situation, at least in Managua, and preferably back home in Texas. She was reluctant to return to Texas because she no longer has medical insurance in the states.
   We saw over a dozen children, only one of whom was moderately ill with pneumonia. The homes are very poorly ventilated, some without a single window, and they sometimes cook outside the home over an open fire. The floors are often earthen and there are animals all around the home. The air quality in the homes must be pretty awful. On a positive note the parent do not usually smoke; they cannot afford to.
   At the end of the clinic we hugged and shook hands and then gathered for a group photo. From left to right in the photo are Manuel, the clinic administrator, Dr. Flore the general physician, Martina, the lady who cleaned up in the clinic, an obstetrical nurse who arrived that morning, Marta the clinic nurse, the pharmacist and me. Louise took the photo.

Politics Politics Politics

2011-03-25T08:24:00.002-06:00

We talked with an American physician and his para-medic wife yesterday afternoon. They have been in Nicaragua since November 2010. They came down to offer care in churches. They have enjoyed their mission and they had some incredible tales to tell.

The night prior we ate at a local restaurant and there were some pre-med students in the restaurant. By amazing coincidence they were all from Clemson University in South Carolina. I lived in SC during the nineties. I was recruited to help develop a new children's hospital and I had an academic appointment at both the University of SC and at Clemson. Clemson was my first full professorship. I introduced myself and talked with the students for awhile and they reported that they were in Nicaragua to help set up a new children's clinic in a rural village. Based on this I tracked down the clinic the next afternoon and that was how we came to meet Bill and Christie.

One incredible-to-believe story is that an individual cannot get free health care without a birth certificate. On the surface this sounds like a reasonable request. The government would like to keep records on the health of individuals. However, the clinics are obliged to actually refuse care if you do not have a birth certificate, or at least the clinic staff cannot be seen to be helping people who are not registered.

Obtaining a birth certificate might be straightforward in Managua, Rivas, or Leon, but in the rural hills there are huge obstacles. During the rainy season, from May to November, the roads are often not passable even if there were buses available. Mothers birth on their own in the villages. There are no officials present to register the birth. When a child is not registered within a few weeks of birth, the paperwork to obtain a birth certificate apparently costs $300, or half the average yearly wage of a worker! So, lots of rural families do not have birth certificates.

Bill and Christie had lots of other stories that will percolate in my mind as I consider how best to help out in this country.

I made contact with Rob, the American administrator of the new children's clinic and perhaps I can help out at this clinic in the future as well as at the Roberto Clemente clinic.

We have settled in well at the clinic. Our routine is to see 15 to 20 patients over 5 hours from 10 AM to 3 PM. In the mornings I'm up at dawn to watch birds. In the afternoon we enjoy incredible sunsets.

Montezuma Oropendola. This bird rips off the bark and eats the insects that live underneath. The bird was dropping two inch chunks of bark all around me as I took the picture.

Below are Howler Monkeys. There is a baby riding on Mom.

The Toy Lady Nurse

2011-03-24T07:38:00.002-06:00

Louise purchased a lot of small toys in Calgary and about a quarter of one of our large bags was filled with these small gifts. Most were purchased at the Dollar Store, and were therefore inexpensive.
She purchased soft rubber balls that were covered with a map of the world and she could show the children Nicaragua and Canada. Toddlers love to squeeze these balls during the exam. Bead bracelets were bright-coloured fun for the toddler girls. Dora pens were a big hit with little girls. Small plastic animals and dinosaurs were fun for the little boys. Louise found some cute teething rings and every baby left sucking on a pink or blue ring. There are also wooden trains, small kaleidoscopes, and flashlights with a pen at the other end that she has yet to give out. We are running out fast because siblings need to have a gift too
Louise searched a lot of stores to find the various toys. Linda MacNaughton, one of her co-workers at the Prostate Cancer Centre, gave Louise some great ideas and she also purchased some of the toys. Thank you Linda!

The toys make a big difference to lessen the anxiety about coming to see the doctor, especially one with white skin and a different language. The majority of children have been very cooperative and the toys have helped with the transition from the mother's arms or her hand to the examination table.

Coming together as a team

2011-03-23T08:15:00.002-06:00

Notwithstanding an hour a day on the Rosetta Spanish software, my linguistic skills are still much too rudimentary.

Dr. Flores, a family physician at the clinic, has English skills about as good as my Spanish skills and between us we managed a satisfactory history for my examinations.

The saving grace was Google Translate, a feature that allows text in English to be simultaneously translated into Spanish. After listening to the history and examining the child, I typed out a brief history, exam, assessment, and plan in English and the Spanish appeared like magic. Either the nurse or Dr. Flores read the instructions to the mother and this worked very well on the first day.

On the second day, my history and exam portions were shorter and the assessment and plan sections were longer.

I did not bring a portable printer and this would have been a great benefit because the instructions could be written out for the mother. All translation efforts, whether verbal or written suffer the vagaries of the skill of the translator. I have always preferred mothers to have a written record of my recommendations.

Literacy in Nicaragua is very good, courtesy of the Sandinista social revolution and emphasis the government placed on schools. In the early 1980’s, within a year or two after the Sandinista forces successfully defeated the Somoza National Guard, the government held a “Literacy Crusade,” that improved the literacy from about 20% to over 50% during one year. UNESCO recognized Nicaragua for this outstanding social achievement. Since that time, the government has established schools in most of the accessible communities and literacy has been sustained at a higher rate than many other Central and South American countries.

We only saw 14 patients the second day. I was able to intervene for a heart murmur, possible pulmonary stenosis and a strabismus. We otherwise assessed pneumonia, otitis media, impetigo, parasitic infestation, fungal skin infection, and chronic serous otitis media with hearing loss. Most of the children were four to six years old.

We improved our routines today. We moved the computer into the exam room, I wiped down the stethoscope with alcohol more often, the exam equipment was within easy reach, I brought my iPhone to use as a calculator, we stored some of the common meds in the exam room, and I arranged a brighter exam light by the table.

Marta, the clinic nurse and Dr. Flore worked better as a team with Louise and I. Today both teams were better prepared for each other. We are starting to understand how to work together more efficiently.

Almost all the patients are waiting when we arrive. There are buses and the children arrive together. The children continue to be well cared for and the mothers all seem very devoted to their families.

Lots of mental images!

2011-03-22T08:02:00.001-06:00

Departure morning. I have some walking shoes from MEC. Lightweight. Breathable. Waterproof. Good traction. I wore then in Haiti and last October in Nicaragua. When I arrived back in Calgary last fall I left the shoes on my outside porch to let the winter “disinfect” the shoes. I was very worried about bed bugs because the place we stayed in had lots. On the day we left I retrieved the shoes from the porch and routinely put my hand in the shoe to check for whatever. This is a practice I have done for years hiking in the bush. I pulled out the desiccated exoskeleton remains of a one-inch scorpion!!!! Ouch. I must have carried that scorpion back from Nicaragua last October. Glad he didn’t sting me. Generally, the venom is inversely related to the size of the scorpion.

Arrival in Nicaragua. After everyone else on our flight had retrieved their luggage, the absence of our bags was very noticeable. Ouch. The luggage arrived the next day and we left in the afternoon for the clinic.

Arrival at the Roberto Clemente Clinic. We arrived just in time for an incredible sunset. Wow!

Sunday. Their day of rest and ours too.

Monday. The first clinic day. The first patient was a severely handicapped five-year-old girl. She was obviously blind, spastic quadriplegia, athetoid movements, and malnourished with tiny arms and legs and no muscle mass. “Oh Oh,” I thought! “What if the entire day is like this? I hope they don’t expect Canadian doctors to cure this sort of thing.” They didn’t. Child had intrauterine Toxoplasmosis, diagnosed in Managua, and all the family desired was information on nutrition. Whew! I supplemented her oral liquid feedings with oil and carbohydrate. Thereafter we saw a total of 18 children, almost all infants, with a variety of complaints. Asthma, pneumonia, gastro, cystitis, otitis media, common cold, lymphadenopathy, scabies, and some well baby checks. I picked up a hip click and the clinic can arrange an ultrasound in Rivas or Managua. I also diagnosed probable rheumatic fever and this child and a another ill-looking child with pneumonia were the sickest children. A lab bus arrives every Thursday to do blood tests and other lab work.

All in all, our first day was very positive. The Nicaraguan health system is basic but pretty well organized. The children were very well cared for. Nutrition was not a major issue. I have a sense I saw the ‘middle class’ of the community today and only a few of the really poor.

Tomorrow is another day.

Laundered Money

2011-03-14T05:54:00.001-06:00

I went to the bank over the weekend to withdraw some US currency. Credit cards are ok for major centers and gas stations but I've found that cash is more flexible in poor countries.
   After I returned home, I recollected that I had some left over cash from the 2010 trip to Nicaragua. The money was stored in a small safe in my basement.
   When I opened the safe, the locker room smell was an immediate clue that there was a problem. The inside of the safe and the contents were covered in hundreds of colonies of red fuzzy mould. The US currency was the source. The bills, mostly ones and twos, which are great for a range of small thank you gifts, were stacked up, and the mould was tracking down the sides of the piles. Everything else in the safe was either covered in mould or most certainly colonized.
   I gathered everything up and and went directly to a sink and disinfected the non paper contents and the cash. I threw out the papers and file folders that were not essential and I put the important paper documents outside in the cold, dry Calgary air. After rinsing everything and setting the contents in the window to enjoy the benefits of solar irradiation, I disinfected the sink with bleach. I disinfected the entire inside surface of the safe. The inside surface was not conveniently smooth but I insured that every surface was wiped. I left the safe open. I transferred the soggy cash to the clothes drier and then I showered.

   Afterwards I thought of a variety of missed opportunities. The bills could have been examined to determine the source of the mould within the pile of currency. I imagined the source was a well used wrinkled small denomination bill. I could have photographed the mould with a macro lens and saved a specimen to look at under my microscope at the office. A specimen could have been sent to the university for identification.
   However, the moment I discovered the mould my overwhelming thought was contagion control. I did not want the Central American mould to spread out in my home.
   So, now we know why Central American drug dealers launder their money. The humid climate causes mouldy money.

Thank You

2011-03-05T05:29:00.001-07:00

Thank You the Calgary physicians who generously donated pharmaceutical and other medical supplies.

The list of physicians continues to grow and now includes

Dr. Susan Aitken

Dr. George Barr

Bonavista Medical Clinic

Dr Patricia Bryden

Dr. Sandra Foss

Dr. Michael Giuffre

Dr. Barry Hardin

Dr. Ashref Jeeva

Dr. Susan Kinnie

Dr. Marilyn Lee

Dr. Peter Nieman

Sr. Aravind Subramanian

Sunnyhill Pediatric Clinic

Last week Michele, Darlene, and I sorted all the medications. To conserve weight and space we took all the medications out of the packing boxes and we recycled the cardboard and package inserts. The savings in space and weight was amazing. The remaining medications are less than a third of the space and half the weight.

Several weeks ago I sent a preliminary list to the family physician at the clinic in Nicaragua and he prioritized which medications were in greatest demand. Antibiotics ranked very high. I ordered 1000 dose quantities of generic amoxicilin, cephalexin, nitrofurantoin, and sulfatrimethoprim. I also ordered similar quantities of dilantin, phenobarb, and hydrochlorothiazide. Andy Chiew, the pharmacist, has generously agreed to pay half the cost. Thank you Andy.

The medications were sorted by class, by drug, by dose, and by expiry date and placed in large zip lock bags. Darlene made computer printed labels with the generic name, trade name, dosage, expiry date, and quantity for each zip lock bag.

All the medications have an expiry date that is beyond September 2011, which will help insure they are used.

I sent a spreadsheet with precise quantities of the medications to the clinic last week and they will obtain the necessary custom permit so that no duty is necessary.

We leave two weeks from today.

Medical Supplies

2011-02-25T06:14:00.001-07:00

The file room at my clinic is starting to look like a small pharmacy. Andy Chiew, the pharmacist in the building, dropped by and he was impressed at our growing stock of pharmaceuticals.

I have not obtained enough antibiotic supplies. I asked Andy to find out the least expensive generic source for an antibiotic in each of the basic classes and I will purchase a 1000 dose container of a half a dozen antibiotics. Andy arranged for me to purchase these medications at cost, which is most appreciated, and then he generously offered to split the cost! I was overwhelmed. Thank you Andy!
Many physicians have generously donated supplies and others have been setting aside pharmaceuticals for us to pick up. Michele Holtsbaum, my office manager, will visit half a dozen offices later today to pick up some of these supplies and she will do this again in March.

I purchased two very large duffel bags with wheels from MEC and expect to fill them both. These versatile bags have shoulder straps on the back and can be carried as a pack on the shoulders, they have wheels on the bottom and can be rolled along the ground, and there are grips on three sides so they can be carried by hand. I used one of these bags for Haiti last year and although very heavy when full, the bags were otherwise great.

Learning Spanish

2011-02-10T05:41:00.002-07:00

I know enough Spanish to roughly follow a simple conversation and even to slowly read basic passages but my spoken Spanish is inadequate, especially for a professional medical intervention. During my visit to Nicaragua last October I had a driver who served as my interpreter.

I have used interpreters in the United Arab Emirates and Haiti.

   In the Emirates I was the Head of Pediatrics at the Royal Tawam Hospital and my position came with a full-time interpreter. I was exposed to a number of well-meaning male interpreters and I learned that most translate what they thought I should say rather than what I said. None of the available interpreters suited my needs. Many presented as very chauvinistic and condescending in their attitudes to the mothers and this was not acceptable. During the first month in Al Ain I met a nursing assistant from Palestine who was working on an adult service. He was a good interpreter who understood my need for a literal translation, for patience, and for a professional attitude. He was happy to interpret for me but this took quite a bit of haggling because he was not a designated interpreter. You would have thought that re-assigning him to my department should have been a very straightforward matter but the nursing department would not release him to my service unless I arranged to have his salary paid through my department and to incorporate a new salary without going though the conventional budget process and at the wrong time of the year turned out to be a major problem. However, I eventually succeeded and my clinical efforts were definitely better for my trouble.

   In Haiti the need for a good interpreter was painfully clear. On my third day a new interpreter arrived and he turned a difficult morning into an impossible morning. I might not speak Creole, but I can certainly read people. I would ask a question and the interpreter would provide an answer to another question. This happened so repeatedly that I started to speak very slowly and purposefully with him, the kindest and most preliminary way for me to let him know that I would try my best if he would try his; he was clearly impatient with the mothers and increasingly with me; I guess he felt that the failure to translate, his job, was either the mother’s problem or mine. After an hour or so, and with an increasing sense that he was just not interested in trying to connect with the mothers, I started to get impatient with him. “Is anything wrong,” I asked? “No,” he replied, but he laughed at me when he said this. His mind was clearly somewhere else and finally, when another translator became available, I asked him to leave. The new interpreter turned my morning around. The histories took a quarter of the time, the mother’s had the light of understanding in their eyes, and I was confident that I was offering good care.

   The clinic in Nicaragua does not have an interpreter who will routinely be available. I have offered to hire a local person with fluency in both languages but there are none available in this rural community. So, I need to learn Spanish.

   I researched the various methods to learn Spanish and I decided on The Rosetta Stone, a computer-learning program that incorporates audio with visual images. Last week I ordered the Spanish, Latin America version, Levels 1 to 5. I also ordered a well-known Medical Spanish textbook. For the last two mornings I set my alarm for an hour earlier and I spent the time working on my Spanish.

   My goal is to arrive in Nicaragua with rudimentary Spanish.

More Donations!

2011-01-28T07:45:00.005-07:00

Every day I see 2 new children and 6 children who have returned for follow up. I send a consultative note to the referring physician for each visit and every day 8 letters are faxed back to these doctors within 24 hours of the child's visit.

   Two weeks ago I started to send a request for donations of medical supplies with each of these letters. Almost every physician receives samples of various medications from pharmaceutical companies. Many of these samples are used and many are thrown away on the expiry date. My letter requested that my colleagues consider setting aside desirable medications for me to take to Nicaragua.

   I did this before I left for Haiti last spring, but this time I started earlier and I will reach out farther into the Calgary medical community. Michele Holstbaum, my assistant, will pick up the medications on specified days, once in February, and a second time in early March.

   We will take all the medications out of the packages, sort them into categories (antibiotic, pain, asthma, etc), sort them again by specific medication, and sort them again by expiry date. When the medications arrive in Nicaragua they will be ready to use in the most efficient way possible. This is considerably better than the jumble of meds I took to Haiti in two duffle bags.

   Last week we received donations or promises of donations from

Dr. Susan Kinnie,

Dr. Michael Guiffre,

Dr. Ashref Jeeva,

Dr. Patricia Bryden,

Dr. Marilyn Lee, and

Dr. Aravind Subramanian.

Many thanks to these colleagues for their help and for their gift to the children of Nicaragua.

Thank you Pharmascience!

2011-01-22T10:25:00.001-07:00

Pharmascience donated 150 boxes of Electrolyte Gastro, which is ideal to rehydrate children with diarrhea. Many thanks to Julia Keshen,

Product Manager for Pharmascience, and to Cathy Chan their local representative, for arranging this helpful donation. Pharmascience is a Canadian Company founded by two pharmacists in 1983 and which now employs over 1300 people.

Diarrhea is common in Nicaragua. Diarrhea is one of the leading causes of death in children. The cause of death is usually dehydration and oral or intravenous fluids can be a lifesaver. Thank you Pharmascience for a donation that might well save lives.

Contaminated drinking water is often the source of the germs that cause diarrhea and access to safe drinking water is a big problem in Nicaragua.

One major lesson I learned in Haiti was to make the treatment very simple for the family. Giving a family some packets of rehydration powder and expecting them to mix the powder in water at home would not work. The family either did not have access to safe water or could not afford bottled water, and even if they had water, they often could not read the instructions on the packets, and even if they could read the instructions, many would not mix the powder in the correct amount of water. The solution was to purchase 1 liter bottles of water, mix the packets in the water, and to write simple directions in French about how much the child should drink, and to tape the instructions onto the bottle. We never had enough water or powder so we were never able to give a family more than one day of rehydration solution. Courtesy of Pharmascience and the water we will purchase in Managua, this should not be a problem for our Nicaragua trip.

This donation started me thinking about the water situation in Nicaragua.

A five year-old child needs about 1.5 liters of water a day. Where would a 5 year-old Nicaraguan child who lives in a rural area obtain 1.5 liters of fresh water that was safe to drink?

There are community wells with variable quality and sanitation and family members often need to walk long distances for this water. World Health Organization (WHO) data indicates that access to improved water supply in rural areas of Nicaragua increased from 46% in 1990 to 63% in 2004. Access to improved sanitation in rural areas or Nicaragua increased from 24% in 1990 to 34% in 2004. Going in the right direction.

Rainwater is collected in cisterns during the 7-month May-to-November rainy season, but these sources are often not chlorinated or filtered and stagnant water that sits out in the heat is soon not safe. In Haiti last spring I had a shower from a rooftop cistern and tadpoles came out of the pipe!

Lake Managua and Lake Nicaragua are large fresh water lakes but Lake Managua is polluted and the country has a very limited water pipeline infrastructure. The country has salt water on both the Pacific and Caribbean coasts but desalination is not currently an option.

Bottled water is available in commercial centers, costs about 30 cordobas ($1.35) for five gallons (19 liters), or about 7 cents a liter. This doesn’t sound like much by Canadian standards, but to supply just the drinking needs for a family of two adults (2.5 liters per day per adult) and two children (1.5 liters per day per child), requires 8 liters of drinking water a day and this is more than 50 cents a day. Many Nicaraguan families subsist on a dollar a day and paying this much for water is not possible.

Many Canadians take water for granted. We shouldn’t. Nicaraguan families don’t. For them, living in a lush tropical rainforest, only 11 degrees north of the equator, there is water everywhere, but sometimes, like the Ancient Mariner, “Nor a drop to drink.”