Last Day

  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

  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

  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

     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!

   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

   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

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.