"Army Ants" Invade Clinic

During an examination yesterday morning, Sebastian pointed out that ants were flooding into the room under the door. An area for a foot or so in front of the door was swarming with tiny black ants about 1.5 cm long. 

Behind the door on the wall was an "army" of ants, moving in formation,down to the floor underneath the door. The rearmost portion of the army went up and over the wall. 

In the pharmacy on the other side of the wall, the ants marched up a corner in the room.

The start of the invasion was one of the ventilation holes in an opposite wall. Why the ants chose the direction they took is not evident.

The forward most ants were brushed away and the leaders of this formation acknowledged defeat and the army quickly dispersed, presumably outside the clinic. They seemed to appear and then disappear within a half an hour or so!

TAT for Fever Assessment in Gigante

Fever is one of the most common presenting complaints in any paediatric setting. Nicaraguan 

parents generally know when their child has fever, based on touch, and in Canada, the majority of families have a thermometer or an electronic device to measure temperature. 

The days of the traditional mercury thermometer are long gone. Whenever a thermometer broke, tiny beads of toxic mercury spread out along the floor and entered our environment. In our digital era, there are a variety of non-toxic electronic options.

Annie using TAT to assess for fever. 

The newest electronic method to assess temperatures is the Temporal Artery Thermometer (TAT). Dave Bateman RN, Nurse Manager at the Prostate Cancer Centre in Calgary, Alberta, Canada, donated a TAT for the Gigante clinic. Thank you Dave!!

Over my career I have witnessed a variety of "new" methods and devices to measure temperature. Some have come, not stood the test of time, and disappeared. TAT is new to me. As such, I reviewed the medical literature on the subject.

The TAT has only been around for a few years. I identified seven citations published since 2010 that compare TAT to oral, rectal, or "core" temperatures. The TAT compared favourably in each article.  

A December 2012 article in the Journal of Clinical Anaesthesia compared TAT to oral temperatures in sixty children under anaesthesia at 15, 30, 45, 60, 90 and 120 minutes. There was no statistical difference.

An April 2010 article in the Journal of PeriAnesthesia Nursing compared TAT with esophageal (core) temperature in 23 children. TAT was only 0.074 degrees centigrade higher than the core temperature, and well within the 4% margin considered acceptable in the modern clinical world. 

The data to date suggest TAT is reliable. The device is certainly simple and non-invasive. I requested that every temperature be measured at least twice to confirm within-individual reliability and so far the results have been good.

Thank you Dave Bateman at the Prostate Cancer Centre in Calgary. Much appreciated!!!! 

References

Sahin SH et al. Comparison of temporal artery, nasopharyngeal, and axillary temperature measurement during anesthesia in children. J Clin Anesthesia 2012;24:647-51.

Calonder EM et al. Temperature Measurement in Patients Undergoing Colorectal and Gynecology Surgery: A Comparison of Esophageal Core, Temporal Artery, and Oral Methods. J PeriAnesthesia Nursing. 2010;25:71-8.

"Too Successful!"

The clinic is "too successful." We were swamped during the first two days with many more children than we could assess.  

Fifty-three children arrived but we were only able to assess nineteen. We saw all the acutely ill children and requested that the remaining mothers return over the next few days.

The clinic has limited hours of operation and until a few days ago, none of the team had met one another. Any lack of medical experience has been more than compensated by genuine compassion, a wonderful spirit of giving, and a "can do" attitude. Congrats to Project Woo who made this clinic possible. 

The volunteer workers come from the United States, Canada, and Spain - a true international effort.

We were not prepared for so many families. Our expectations were that the community might be slow to support the new clinic. Several weeks ago I was cautioned not to expect to be busy!!

Many of the families were disappointed not to be assessed. Good health care takes time. An important principle is not to sacrifice quality for quantity. 

With so many children, one of the biggest concerns was to identify the acutely ill children from those who were only at the clinic for a routine well child check up. Triage is the medical word that describes the process necessary to separate patients by acuity. Triage is a challenge for every health care facility and for experienced health care providers. We talked a lot about this and my sense is that we did a great job.  

The Clinic is Designed to be a "Cool" Place

Average daytime temperatures in Nicaragua on the Pacific side are in the low 30's C. So, hot!  

The clinic is designed with a variety of "cooling" features. 

The orientation of the clinic is such that the morning sun comes in through windows in the pharmacy and one of the examination rooms and the afternoon sun settles more to the front of the clinic. The veranda serves as a waiting area and is shaded with a corrugated roof that is about three meters deep.

The windows are smaller and shuttered to minimize sun but allow a breeze-way. The wind has been blustery and fierce, so with the windows open, within an hour so, there is a fine layer of red earth dust on all the surfaces.

There are tiny "port holes" about a foot above the floor to allow cooler air to enter the clinic and fenestrated bricks at ceiling level to allow the hot air to leave. 

There are ceiling fans in every room, but until the electricity is operational, these traditional tropical chilling devices only offer the illusion of coolness.

Notwithstanding all the above, the clinic was very hot on the first day, and I was a puddle from the first hour. The few times I stepped outside the wind felt great as my perspiration started to evaporate. Glad I wore a loose shirt.


  

Opening Day!

Open!!!! Loads of Gigante citizens and a cadre of Project Woo workers worked hard over the last few months to prepare the clinic for opening day on Monday February 17, 2014.

Lisa, Christian, Pili, and a local resident,
talking over procedures before the clinic opened. 

We arrived over the prior weekend, and met with Lisa Bisceglia, Volunteer Coordinator for Project Woo, who led the cadre and who arranged for the final touches before opening day. Between Project Woo and the community, the clinic is well served. Based on the enthusiasm shown around the opening, the clinic will be a terrific success.  

Dr. Mariana Jarquin, a local physician who currently works for MINSA at the Coyol clinic, was present for her twice monthly community outreach clinic in Gigante. In April, after the completion of her two years of post graduation community service, she will join the clinic as the Health Program Coordinator. 

Lynne, Sebastian, Lisa, Sarah, and Lane,
just before the first family arrived. 

Lynne Maher, an American Nurse Practitioner with tremendous local experience coordinated the clinical efforts.

Pili and Sebastian, a Spanish couple from the Canary Islands, made a big difference on opening day. Pili served as a clinical assistant and took the presenting complaint information.  Sebastian served as interpreter in the office with me. He was terrific. I might not speak Spanish well, but I knew enough to know that he did a wonderful job. Caring, patient, and precise. What a great guy.

Christian, another Project Woo volunteer, was the intake person who signed in all the mothers and children at the reception are.

Sarah, a Project Woo volunteer, who is an American EMT, worked in the clinic with me to help with the assessments.   

The first morning. Dr. Jarquin is on the right talking to Lynne. 

We were all hard at work cleaning away the construction dust at 8 AM and the first patient arrived at about 9:30. Six hours later, after a blur of children, our first day was over. I saw ten children with a variety of minor complaints and was pleased to have all the necessary medications on hand for the problems.   

The clinic door was designed by a local artisan.
The leaves of the tree will eventually honour the donors
who supplied the funding for the clinic.