Thursday, February 27, 2014

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. 

Wednesday, February 26, 2014

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. 

Tuesday, February 25, 2014

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.

Monday, February 24, 2014

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.   

Saturday, February 22, 2014

"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!

Thursday, February 20, 2014

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!!!! 

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.

Wednesday, February 19, 2014

"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.


Tuesday, February 18, 2014

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.