Opening Day

Over two hundred people attended the opening of the Gigante Community Health Centre; about a third of the population in the community! 

A few hours before the scheduled opening, two horse drawn trailers rolled in from Tola, a larger community that is 18 km away. Presumably the drivers left at dawn.

The tents offered great shade but the structures also trapped the hot air. I found a spot just at the edge of the tents and enjoyed some air flow as well as shade. 

Local children were the highlight of the opening. Various age groups staged great choreographed dance routines. 

Various community and government dignitaries thanked Project Woo, the community, local businesses, and other local benefactors. Afterwards the guests enjoyed juice and pastries.

The children took turns at a pinata until the candy burst forth and the ground was filled with the children who scrambled around for the treats. 

Great Day. Congratulations Project Woo!!!!

Great Community - Great Community Spirit

Sweet Water Fund is a local charity organized by several women who are committed to wellness and preventative health for the families in Gigante. 

The Starter's Gun

Today they held the first annual Sweet Water Fund 5K Run. The event started at the "town square" which is where the only road into town intersects with the commercial road that runs parallel to the ocean. The run started at 8 AM to avoid the oppressive mid day heat.

Steve (yellow jersey) off to a quick lead.

Local businesses supported the event and the about fifty runners participated, about half were local townspeople and the other half were gringos.  

Half-way hydration

Louise and I set up a hydration station at about the half way point.

Several women at the finish 

The winner finished the run in just under 18 minutes. 

Bo Fox and Sally, his Mom, at the finish

Team Sweet Water Fund

Charla

Charla means "chat."

Gigante plans a charla when there is a topic that affects the entire community. 

Nutrition is just the sort of topic that fits for a charla. 

Today Dr. Mariana will lead the charla at the Community Health Centre and the results of the nutrition survey will be part of the discussion.

Papaya - good source of Vitamin A

   

Fortified Foods - Great but Expensive

In Canada we take nutrition for granted because we are a wealthy country with diverse food options, but also because our diet includes a lot of processed foods, which are routinely fortified with essential nutrients. For instance, milk and orange juice are fortified with Vit D.

Nicaragua enacted legislation in 2006 to insure that all flour is enriched with iron and folic acid. Roberto, the owner of Party Wave, a popular breakfast and lunch WiFi restaurant in Gigante, showed me the label on a commercial bag of whole wheat flour. The label confirms the flour is enriched with iron, niacin, thiamine, riboflavin, and folic acid.  

Similarly, the milk is fortified. The label on this small child size milk carton confirms the drink is fortified with iron, vitamin A, and folic acid. 

Enriched foods are a terrific source of essential nutrients, but processed foods are often too expensive for a family in Gigante.

Nutrition Survey

Fourteen mothers completed a nutrition survey for their child. Six of the children were 1 to 3 years of age, four were 4 to 8 years of age, and 4 were 9 to 13 years of age. The age ranges were chosen based on the data for the Recommended Dietary Allowance (RDA) for children in the United States.

The mothers were interviewed by Maria, a local Gigante mother, and the data input was performed by Sarah, an EMT from the United States.

A program was designed based on data in Bowes and Church's book on the nutritional value of common foods. Portion sizes were determined by showing mothers common measurement tools for baking.

Data analysis was limited to calories, carbohydrate, protein, fat, fibre, sodium, calcium, iron, and the common vitamins. The result obtained for each nutrient was compared to the US RDA for age and a percentage calculated. The percentages within each age group were averaged. The data for those nutrients with an abnormal result is shown in the graph below.

The data is subject to a variety of limitations. None of the volunteers had prior experience. However, the dietary choices in Gigante are limited, the serving sizes were standardized, and the volunteers were patient and thorough with the protocol. My review of the raw data suggested that even for the small sample size, the trends were likely valid. There were few obvious "outliers" in the raw data.

The results of this survey will be presented to interested mothers in the community at an advertised "charla" on nutrition next week. Dr. Mariana will lead the discussion on nutrition and the data will serve as a talking point.

Coca Cola vendor in Masaya

Screening Summary

The Gigante Paediatric Brigade screened a total of 23 children.

The graph at the bottom of the blog shows that almost every child was screened through every station.

The nutrition survey took the longest amount of time (about 15 minutes) and when several children arrived at the same time, some mothers did not stay for the survey.

Precise age data is fundamental to interpretation of all the data, but was not obtained on every child because at the start we failed to confirm the birth date in the first four children, and the families left before we discovered this error.

Growth data was not assessed completely in three children, for unknown reasons.

Only one child who should have had a blood pressure measurement escaped without this screening procedure.

We obtained vision tests and urine tests on all children old enough to cooperate.
Six abnormal results were identified. One blood pressure was elevated and five urine tests were abnormal. Each of these children was assessed today at a special follow up clinic. The abnormal blood pressure was normal at follow up. Two of the children with an abnormal urine test had a normal test at follow up and the abnormalities were considered likely due to collection technique problems.

All of the children who returned for follow-up had a focused history and a complete physical examination. Nutrition counselling was offered to those who participated in the nutrition survey. 

Three of the abnormal urine tests were still abnormal at follow up and each was determined by history, examination, and repeat urine tests to have either cystitis (bladder infection) or vulvitis (inflammation and discharge) or both, and these children were treated with an antibiotic. One of the children also had blood in the urine and an ultrasound of her kidneys will be arranged for further follow-up.

All told, a very successful effort, especially for a team new to each other and to the procedures. 

Congratulations to the Gigante Paediatric Brigade. Well done!!!

Working With the Local Physician

Lumber delivery from local "Home Depot,"
that "drove" by the clinic. 

At the last visit I identified four children who I requested be seen by the local physician, Dr. Mariana Jarquin. Dr. Jarquin works at the MINSA clinic in El Coyol, about 20 minutes away. As of next week, she will be the designated physician for the Gigante Community Health Centre.

Today Dr. Mariana and I followed up on those four children and also several others who she identified in the interim to be assessed by me. Patient follow-up was better than I expected, and better than might have happened in Canada!!

During the last visit I saw an infant, who on routine exam had an inguinal hernia. I asked Dr. Mariana to direct the family to an appropriate surgeon, and this morning I learned that the child has already had the repair! Wow! The waiting list for a routine hernia repair in Calgary would have been much longer. Just to see the surgeon would likely have taken longer.

Also on the last visit, I saw a child with a complex cyanotic congenital heart problem. The problem was diagnosed by echocardiography in Managua. Sophisticated surgery is necessary for correction. The mother had missed an appointment to discuss whether the surgery could be done locally and she had no money to travel to Managua for reassessment. The frequent hypoxic cyanotic squatting spells the Mom described were a serious concern. I supported her travel costs and asked Dr. Mariana to help direct the mother to the appropriate place. This morning I was pleased to learn that the child was seen and will have the correction within a few months when an American Paediatric Heart Surgery Brigade arrives in Managua! I hope all goes well for her. 

Dr. Mariana asked me to assess several other children. One toddler had bilateral pneumonia and asthma and we sorted out the anti-inflammatory and bronchodilator medications for the child. Another had an abnormal urinalysis and the history and exam suggested vulvitis, which was treated with instructions on genital cleansing and an antibiotic to cover the usual organisms.

Good outcomes can happen when health care providers care enough to communicate and cooperate.  

Screening Clinic - Day Two

Gonzo checking families in at reception.

Another great day!

After two days, we have screened about ten percent of the children in the community and a problem was identified in a quarter of the children. Later this week we will see these children for a focused history and examination to assess the identified problem.

Mike and Lindsay at the Growth Station

The minor concerns with traffic flow and procedures that were identified at the first clinic were identified and corrected. There is nothing like experience to make things work well!

Maria and Sarah at the Nutrition Survey Station

  

Screening Clinic - First Day

A great start!

Twelve children attended the first ever paediatric screening clinic at the new Gigante Community Health Centre. 

Each child had a height and weight measured and the body mass index was calculated. 

For those children who were old enough to cooperate, the blood pressure and vision was assessed. 

If a child could void or if a mother brought in a fresh urine specimen, the urine was checked. 

Finally, the mothers were interviewed to determine a typical daily diet, and a nutritional assessment was completed. 

Michael Chmilar entering data at the Growth Station. 

Sarah and Maria entering data at the Nutrition Station.

Growth data was obtained on all children.  Eight children had a nutrition and blood pressure assessment. Five children had a urine test. Four children had a vision assessment.  

Only two abnormal results were obtained. One child had a borderline blood pressure result and one child had white blood cells in the urine. Both children will be asked to return for a full check up. 

The nutrition results will be assessed to determine trends for the community generally and the information for each individual child will be kept in their clinical record for discussion at the next clinic visit. 

Anemia in Nicaragua

Mural of Playa Gigante in the Community Health Centre

Anemia can affect the function of every organ because a reduction in red blood cells reduces the delivery of oxygen, which is necessary for the optimal function of every cell in the body.

The causes of anemia include anything that reduces the production of red blood cells, anything that increases the destruction of red blood cells, or blood loss.

The most common cause of anemia is iron deficiency anemia. If there is not enough iron, the body cannot produce enough red blood cells.

Blood smear in iron deficiency anemia. 
Note the RBCs have a pale centre.

Iron deficiency in Nicaragua is more common than in Canada. Poverty does that. The children are often not supplemented with iron after they are weaned from the breast, and thereafter, the diet of the average Nicaraguan child is not rich in many nutrients, including iron. In Nicaragua the iron is also low because of intestinal blood loss due to worms and parasites.

In 1993 the prevalence of anemia in Nicaraguan children aged 1 to 4 years was 29%. In response to this continuing concern, the Nicaraguan Ministry of Health initiated a National Micronutrient Plan (NMP) and an Integrated Anemia Control Strategy (IACS), which was implemented in 2004. The IACS included iron and iron/folic acid supplementation for children < 5 years of age, bi-annual treatment of children 2 to 10 years of age for intestinal worms, and fortification of wheat flour with iron. Although this initiative has reduced the prevalence of anemia in Nicaraguan children, the problem continues and is likely worse in rural communities such as Gigante.

Iron deficiency anemia due to poor nutritional intake can be prevented by starting supplemental iron when an infant is weaned off breast milk. About 1 to 2 mg/kg/day of elemental iron is necessary to prevent iron deficiency anemia. Treatment of iron deficiency anemia requires supplementation with 6 mg/kg/day of elemental iron for 3 months.

With this trip to Nicaragua I am fortunate to bring a donated supply of FeraMax, an iron supplement for children, courtesy of BioSyent Pharma Inc. Thank you BioSyent Pharma Inc.  

Screening Children in Gigante

Screening for common medical problems is a fundamental principle of good care and basic to preventative care. The Canadian and American Paediatric Societies recommend screening of children for a variety of problems.

Next week we will initiate screening for some of the common paediatric problems in Gigante children.

Our brigade of volunteers will divide into six teams to perform examinations for the following childhood concerns.

Growth
Nutrition
Immunization 
Vision
Blood Pressure
Urine

Growth will be assessed with height, weight, head circumference (infancy), and body mass index (BMI). The results will be plotted on standard charts provided by the Centre for Disease Control in Atlanta, Georgia. Measurements at future clinic visits will document the trajectory of growth for each child. When a child is not growing, there is a reason, and the cause needs to be determined and a solution found.

Nutrition will be assessed with a mini-program I developed based on data in Bowes and Church's book on the nutritional content of common foods. This book is the "bible" for North American nutrition analysis. Brigadistas will ask the mothers questions to determine the content of a typical daily diet (breakfast, lunch, dinner, snacks) and the program will provide data on calories, carbohydrate, protein, fat, sodium, calcium, iron, and the usual vitamins. The data will be compared to the Recommended Dietary Allowance (RDA) for age and gender for children in the United States. Based on this data, nutrition advice can be offered.

Nicaragua has a very good immunization program, but no country is perfect. The immunization status of every child will be checked against the schedule recommended by the Ministry of Health and any discrepancies will be followed up by Dr. Mariana, the local physician. 

Snellen charts will be used to screen vision from 20 feet away. Special childhood charts with common objects will be used for the younger children who do not yet know their letters. 

Blood pressure problems are not common in childhood, but when present, deserve attention. We will have a full range of blood pressure cuffs to assess children over the age of three years. 

Urine problems are likely common, especially infection, and urine dipsticks will be used to check a fresh urine specimen in each child. 

Children with poor growth, high blood pressure, or an abnormal urine test will be assessed by me later in the week at special clinics.

At future visits, I hope to bring technology to test hearing and hemoglobin.

If you reached the end of this blog and enjoy birds, please check out my Bird of the Day blog for this visit to Nicaragua. http://lanerobsonsblog.blogspot.com/ 

Brigadistas in Gigante

For the next two weeks the Gigante Community Health Centre will host a second International Paediatric Medical Brigade. Volunteers from the United States and Canada will provide care to local children.

A brigade is a military formation typically comprised of three to six divisions and of up to 5000 soldiers, under the command a Brigadier General.

Volunteers in a medical brigade are know as brigadistas.

The first time I recollect hearing of the use of this military metaphor for a humanitarian cause was during the Spanish Civil War when numerous international volunteer organizations supported the cause of independence. Norman Bethune, a Canadian surgeon, and one of my early heroes, served as a medic in this war. He is credited as the first individual to bring blood transfusions to the front line of a military conflict. His efforts saved many lives.

The second time I heard of this term was in the aftermath of the Sandinista revolution, when young men and women arrived from abroad to help war-torn Nicaragua with literacy, health, and agriculture campaigns.

Brigadistas continue to serve in Nicaragua, and our efforts over the next few weeks definitely qualify as a brigade. I am proud to serve as a brigadista in this worthy cause.

Driving in Nicaragua

No trip to Nicaragua is complete without a driving adventure story and this trip was a good example. 

We rented a Toyota Hilux at the airport and were pleased with the comfort and space for four individuals and a lot of gear.

Toyota Hilux - The Adventure Truck

Yesterday we were up before dawn for the trip back to the airport. The drive is about three hours, but I always add on a few more hours to compensate for Nicaragua. Glad I did. 

Just as we entered Rivas, smoke started to billow out of the engine of the truck. There was the smell of something burning. People on the road shouted for us to stop. However, I knew that I was only a short distance from a gas station on the Pan Am Highway and I decided to head straight there. Another good decision. Once I reached the gas station and turned off the engine, the truck was no longer operational. Had I stopped in the middle of one of the main Rivas streets, I might still be there!

After we opened the hood, there was oil everywhere. Something important was leaking. 

The gas station person suggest a "mechanico" and while that was the correct solution for the car, this was not the solution for us. We had a plane to catch. I paid the gas station to store the car and we hired a taxi to the airport. We made our flight. This morning I wrote a detailed email to the Manager of AVIS Nicaragua. Technically, I have not returned the car! We shall see how this works out. 

Tire Change - Cost 80 cents!!!! We paid more. 

That was not our only car adventure. We also had a flat tire during the first week. The spare tire is locked in place under the rear box of the truck. Tires are hot commodities in Nicaragua and subject to theft. The small key provided did not open the padlock! We were given the wrong key. So the lock had to be cut off. This sort of thing is par for the course in Nicaragua. Of course the key didn't fit. Why should we expect otherwise?

We drove on the spare for the rest of the trip and this was a concern, since the rural roads around Gigante are strewn with sharp, jagged rocks, which are definitely rough on tires. I thought about driving into Rivas to repair the spare, but this was a longer distance and I reasoned that waiting until we had to drive to Rivas for groceries was a better plan. Turns out we never did need to drive into Rivas except on the departure day and the spare lasted fine. 
  
Even without breakdowns and flat tires, driving in Nicaragua is always a challenge. The best roads in Nicaragua are only just ok. The Pan American Highway is a paved, two-lane, undivided highway with either a soft shoulder or no shoulder. The rural roads are very bumpy and filled with deep potholes that are much worse immediately after the rainy season. 

Pedestrians and bicycles are very common hazards on the roads. The Nicaraguan pedestrian perspective about the riskiness of standing on a busy road seems very casual to me. I am amazed that I do not see or hear about more pedestrian injuries. People seem oblivious to the cars. I drive very defensively.

Always need to keep a look out for the animals. 

Animals are common on rural roads and similar to the people, have a very casual attitude about cars. Dogs sleep on the roads, pigs routinely meander across roads, and chickens definitely scurry across the roads. I am told that if you kill an animal, the owner can claim compensation, which seems reasonable. You need to be very careful when there is both an adult and a young animal on the road. If the adult moves across it is best to wait until the youngster follows, because if you try to drive between them, this might precipitate a sudden untimely dash by the younger animal to catch up with the parent.  

There are oxen, horses, and donkeys, sometimes hooked up to a cart that seems to harken back to past times, but definitely still functional in Nicaragua.

Nutrition in Gigante Children

A common concern expressed by Gigante mothers is that their child has a poor appetite. Almost all of these children looked well nourished, but looks can be deceptive.

With this symptom, among other questions, I take a nutritional history and inquire what the child eats for breakfast, lunch, and supper, and how much water, milk, and juice the child drinks a day.

The typical story is rice and beans for breakfast, often with an egg or cheese, rice and beans for lunch, often with chicken or fish, and rice and beans for supper, sometimes with chicken or fish. There is usually a meat dish at least once a day. Plantains are another common carbohydrate. Water is the basic drink. Fruits and vegetables are not common and when I ask why, the response is usually because these food items are too expensive. There are trucks with loudspeakers that drive through Gigante every morning, and these trucks are the local vegetable suppliers.

So, the basic diet is rice and beans three times a day, one serving of egg, one serving of meat, and water or juice.   

I would like to plan a nutrition survey in Gigante. 

Bowes and Church's Food Values of Portions Commonly Used has been the standard reference for the nutritional content of foods in the United States and Canada for my entire career. I have several editions of this excellent reference book. Recently I sent the newest edition to both my adult daughters. So, I value this reference! 

Software is now available to assess the precise nutritional content down to essential amino acids and trace elements for the majority of foods. At the next visit I hope to host a growth and nutrition clinic. All children who attend will have a height, weight, head circumference (infants), calculated Body Mass Index, and nutritional survey based on a history of the child's typical diet and data from Bowes and Church's. 

The data collected will enable me to suggest changes for a child to achieve an optimal diet for growth and development. 

The survey will determine the "what goes in to the child" part of the nutrition equation. However, the "what goes out" part of the equation is also a consideration. 

Nutrition losses in the gut due to gastrointestinal illnesses are common in Nicaragua. Chronic or recurrent gastrointestinal infection with parasites, worms, bacteria, or viruses can undermine good nutritional intake. Parasitic and worm infestation should be considered in every child, even if they look well. Some medical authorities recommend routine treatment for parasites and worms annually, semi-annually, or even more frequently, even in the absence of symptoms. I treated about ten percent of the children for parasites based on history, exam, or maternal request. 

A Third of the Village Children

On Monday in the second week, I was advised that I have now assessed over a quarter of the children in the village. By the end of the second week I will have assessed about a third of the children in this rural fishing community. 

I have seen several of the children a second time, either for follow up, for a new problem, or in one case for an allergic reaction to a medication I prescribed. The faces of these children are now familiar, although their names are still a blur. The children are starting to wave at me when I am in town.  

I know the mothers better, because I have seen two, three, and even four children from the same mother on different days. Some of the mothers are therefore "regulars." The returning mothers are a good sign that I am doing ok. 

With the next two-week visit at the end of March, I will likely pass the half the children mark. I kept good notes, which will make every follow-up easier. 

Free Stuff

We brought small, colourful toys for the children, and the toys are popular. For apprehensive toddlers, the toys are a bridge to a happier examination.

Denai Webb and her classmates at the Before and After School Care Program at Alexander Ferguson Elementary School in Calgary, Alberta, Canada supplied the toys. Thank you Denai!

Little girl with toy and knit doll.

Dental care is a huge issue in the children. Almost every child has cavities and some have cavities in most of the lower teeth, and some in most of the lower and the upper teeth! Clarissa Waxmann with Sierra Dental, and her daughter Zoe, arranged for toothbrushes and dental floss for the older children. We found small tubes of toothpaste to complete this gift. Thank you Sierra Dental!

Nutrition is important everywhere, and many parents express concerns about the difficulties to achieve the correct balance of foods for their child. Courtesy of Health Partners International (HPI) Canada, we purchased a two-month supply of chewable multivitamins for every toddler and older child. HPI also donated some terrific knit dolls for the children, which the little girls really enjoy. Thank you HPI Canada!

Some pharmaceutical companies in Canada provide paediatricians with samples of the common fever medications (Tylenol, Tempra, Motrin). We collected these samples over the last six months and have enough to supply every family with enough medication to control the temperature for one febrile illness. Thank you to the manufacturers of these medications.

Irena Burns, a local pharmaceutical representative with Impres Pharma Inc. was especially helpful. She dropped off samples of Pediatric Electrolytes, an oral rehydration solution. Thank you Irena. 

Evil Eye - Mal de Ojo

During the first week I assessed at least one infant a day and almost every one had on a bracelet with several beads. Some had a bracelet on each hand. The beads in the photo above were the most common, but other beads were used as well. 

After I noticed this trend I inquired if the beads had any significance. I was advised that the beads are a talisman to ward off Mal de Ojo, the Evil Eye.

The concept of the Evil Eye is common to many cultures. When I worked in the Middle East there were mothers who spoke of this.

The person who casts the Evil Eye is considered to have powers to injure another person merely by looking at that person. An envious look at a good looking baby is enough to qualify, and according to folk lore, the look is enough to cause illness. The talisman is protection against this possibility. 

Pigging Out in Nicaragua

After working in the clinic, I took my gear to the Toyota Truck, which I park beside the clinic in a shady spot. Clearly this mother pig favoured the shady spot as well. Her six piglets were actively feeding. 

Fortunately the mother pig vocalized her presence before I started the car and drove off. The truck was on a bit of an incline down towards the pigs, so I put the parking brake on, started the engine, waited until the mother stood up, which upset the piglets, and then I backed away very slowly.

Meeting the Needs of the Community

Looking back at the first week, I am wondering if I met the needs of the families who came to the clinic. 

Only about 20% of the children were "sick" with a common paediatric problem. I saw otitis media (ear infection), bronchitis, urinary tract infection, bacterial gastroenteritis, parasitic gastroenteritis, impetigo, tinea corporis (ringworm), and facial abrasions. For these families, I likely met their needs.  

The other 80% all had numerous "complaints," but my sense was that these were mostly "well-child" visits for a routine check up. For these children, I am not sure that I met the needs of their family. I just do not know!

The "complaints" often did not make sense to me. 

Assessing a child for a problem is a kind of detective mystery. The clues are the symptoms and the physical examination findings. 

I was taught that the history (symptoms) is all important. I recollect a professor in first year medical school who taught us that by the time we started the examination we should know the diagnosis in about 75% of patients. Today, many physicians rely on laboratory and diagnostic imaging for a diagnosis and the history is often neglected. I am "old school" and still believe that the history "rules." In my clinic in Calgary, I have a microscope, a uroflowmeter, and an ultrasound. However, the history is still my main tool to sort out a problem, and I am able to predict the microscope, uroflow, and ultrasound findings based on the history with a high degree of confidence.

For the 80% of children with "complaints," the symptoms and my physical examination findings did not "add up" to an understandable problem. The clues did not make sense.

As the week evolved, when the clues did not make sense, I started to go back over the questions to confirm that the "complaints" really existed, and to my amazement and concern, I found that on repeat questioning, that many mothers admitted that the complaint was not really present.

My interpreter is excellent and this was not the reason for the confusion. Mothers everywhere can misunderstand, but the prevalence of misunderstanding is too high in Gigante for this to be the reason. Another possibility was that the symptoms were not temporally related, but I clarified this with precise questions. After ruling out the common and routine causes of this sort of confusion, I was left with a disquieting possibility. Perhaps the mothers told a story that was not true? 

Why would a mother do this? 

I asked the more experienced volunteers in the community and they responded that this was likely and that the reason is "cultural."  

"Perhaps the mothers thought that they needed an excuse to see you," some responded. 

"Perhaps the mothers thought you would be more likely to prescribe a medication if there were more complaints," others responded. 

I learned that some of the complaints were "surrogate" complaints. The child was the emissary for another family member (father) who actually had the symptom (headache, chest pain), and the mother presumed that if I prescribed something for the child, that the father could use the medication!

Medications are highly desired solutions to common problems that do not deserve any medication. Over treatment is a major problem in Nicaragua, and while this might be a "cultural" solution for Nicaraguan physicians, this has never been my solution to a problem.

Given all these "cultural" differences in perspective, I am left wondering whether I met the needs of many of the families. I did not offer medications without a reason and I refused to offer medications for a child that would be used in the father. Instead I relied on the provision of information in the hope that knowledge has power. 

This is the modern way, the Canadian way, and certainly my way, but this might not have been their way. If not, then I likely didn't meet the needs of some of the families, and as such, I need to learn how to meet their needs and still offer good medicine.   

"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!