12.02.2014

Wilmer picking fresh papaya

The last two days buzzed by and I am sitting in the airport quite sad that I am leaving, but happy to be already plotting my next trip to my home in Nicaragua.  It’s hard to put to words how I have grown to feel about this incredibly small speck on the map. When I realize that something has impacted me so much it makes me laugh at how I came to this place, how the winding roads have led me to find something that will forever be imprinted on my soul.  

This closes the chapter on my Global Health Fellowship with UMass and turns the page in how I will let this world we exist in mold me further.  I look forward to seeing you one day in El Tololar.... I’m thinking this July!

10.02.2014

I'm sitting under the lime tree watching the puppies play in the grass. I'm starting to feel sad that there are only 2 more nights left here. Last year, my trip to Lake Asososca was the highlight, but yesterday's trip to the beach wins the prize this year.

Visiting the beach in the States is such a battle. It's so crowded that you can barely make it to the water.  I went to the beach with Reynaldo who works in the pharmacy at the Health Post. The rest of the people that intended on coming enjoyed last night's Fiesta of the patron saint of Los Leches too much!  Basically this was similar to the fiesta at Telica, but in a smaller space, with more friends from El Tololar and a better disco!



Nevertheless, I took the 7am bus into Leon, met Rey after his church service (no sleep btw) and walked through Sutiaba, a merchant section of Leon, instead of doing the only thing I know which is taking a taxi!

The bus to the beach is also much longer and more packed than taking a taxi and I received a history lesson of the neighboring areas. Rey has been so great in telling me so much about Nicaragua and El Tololar. I'm hoping that I can help him a little too in learning how to swim with lesson number two.

 Despite crowded company on the bus, there were only a handful of people actually on the beach. That is the plus side of having a friend that knows the ins and outs of Nicaragua.

El Tololar staff
 (Top, from left) Carlos, Miriam, Pamela, myself, Griselda
(Bottom, from left) Reynaldo, Dra Urrutia, Paula

We swam for about three hours and he definitely has gotten a hang of the movements of swimming, only problem is we did not reapply sunblock, ouch!

 Next stop, joining other sunbathers for a nap on the rocks with a cool gentle breeze and the soothing sounds of the ocean. 

Trying to walk the length of the beach took more than three hours during which we discussed the health and social problems in El Tololar and Nicaragua in general. There is the ever-challenging issue of availability of potable water, or even water for the daily operations in the village. Many people I have spoken to here are increasingly disappointed with the government for this and other health issues.

06.02.2014

Today, we are doing home visits to all of the houses in the Los Pocitos sector of El Tololar.  One of our patients with chronic kidney disease is not well and requires an IV infusion with vitamin supplementation for concurrent anemia.  We are also distributing antiparasitics and educating on Diarrheal illnesses today.  It is one of the hotter days without any wind. 

Paula and I stop at a store to cool off and have a snack.  I also could have afforded more sunblock yesterday at the pool and am suffering!  At night, the power and water are both out.  At least the moon is half full to help guide us through the night.  Cheers erupt from all of the neighbors when the lights go on.  We have to wait for morning for water, at least there is enough stored for a few days if needed.  Living in the dark is one thing, but lack of potable water is not something we are used to in the States.

Sick patient receiving IV fluids during home visit

05.02.2014

It's Noah's last day in Leon, so we are going to going to a pool at a Hotel in Leon in the afternoon after work.  It is a gorgeous day and the pool is amazing.  After a long morning in the heat, it is amazing to cool off and relax.  Reynaldo and I get dinner in Leon before taking the workers' bus at night back to El Tololar. 

Pool in Leon 

05.02.2014

Dr. Urrutia has asked a favor of me this morning.  She would like that I see the patients so that she can prepare all of the necessary paperwork for the health deparment at MINSA.  I joke with her that she doesn't need to ask me because I will do whatever she needs me to do.  I am realizing that there are only a few more days of work here at the health post and I am already starting to feel a little sad about leaving.  Then again, I know I will come back here because this isn't just a place that I have worked, this is also an important part of my life's story, my family and just like Adilza said when I first arrive, you always have a home here...

Dr. Urrutia seeing a patient at the clinic 

04.02.2014

Adilza's surgery was perfect, uncomplicated and she barely has any pain right now.  The only thing she did not like was how exhausted the anesthesia has made her.  They have told her that the mass in her thyroid appears to be benign along with the pathology report from the previous biopsy, which is such a relief.  The bright side of her surgery is that family from all over have dropped by to see her, talking about life and telling me stories.  They like that I have enjoyed playing pool on several occasions and decide that we must go play in another sector.  We all pile into a truck and head off to a regular billiard with four tables.  Everyone is sharp at their game, making it hard to keep up.  Growing up playing pool with my Dad helps a lot around here, and they love it that a women also grew up playing pool.  Another “best night” to add to the list!

03.02.2014

I have awoken extra early this morning, 4:15 because Adilza has to have a surgery to remove a mass from her thyroid.  She is quite calm about things unlike myself and clearly her daughter who did not sleep much last night.  She never ceases to amaze me and how calm and bright her personality is, not really phased by what she has to go through right now.  I will await the phone call after working at the Health Post to hear that she is doing great!

31.01.2014

Last day at Heodra, unfortunately. It was too fast where I was just getting into the swing. At least I have achieved my goal of understanding the systems within OB in Nicaragua and observing resource management. I watched my first classic Cesarean section, which is a lot easier to perform than the Finnenstein. They do both, but reserve the classic for emergencies and large babies. I

I also understand now why they do more Cesareans in Nicaragua (45%) because they have an overwhelming adolescent population along with high diabetes rate with many infants being large respective to the mother's pelvis. They do not have fancy monitoring equipment to trial labor as we do, so instead of risking poor outcomes, they section the patients. Despite resources, infection rate is reported to be <0.004%. What a great group, wish I had more time to spend with them!

Additionally, Magda, from CIDS, came by to conduct a key informant interview with one of the lactation consultants who I rounded with in the morning. It looks like we will have a lot of pieces of the puzzle to try to improve women's knowledge of exclusive breast-feeding in El Tololar. 

UNAN residents hard at work

30.01.2014

These days have been loooonnnggg. At the hospital all day and then 3 hours of Spanish class with homework is very fun, but tiring. I can't remember a time at home were I regularly went to bed at 8pm. Yrela, my Spanish teacher,  is very sweet and my grammar is picking up. She asks for a topic of interest to discuss with each class. We have gone through the geography and culture of Nicaragua, some newspapers, the destruction of Leon and other things in just a few short days, She is such a vibrant and delightful person who I will miss when I leave here.

 Yrela and me at Dariana Spanish school 

Day 2 and 3 of Heodra were very interesting in postpartum and high risk inpatient. Rotating through a different group of residents in a different area has been very challenging with breaking through a familiarity, language and cultural barrier compounded by the amount of work they have every day. I have made very good friends with the lactation nurses, who are actually part of the pediatric department. They are amazing with the patients, patient and spend a lot of time with the family as well.

Giant breast feeding poster at Heodora hospital

28.01.2014

The results session from yesterday was very good in some aspects from gaining the women's point of view in light of the results that there is much room for improvement. It was disappointing that no men came to the meeting after all of the hard work. There will have to be another strategy if were are to seek the men's opinions.

I started working at Heodra in labor and delivery, which was quite interesting. Culturally, patient care is more paternalistic here, which conflicts greatly with my Family Medicine roots. The women labor by themselves, which with the first baby can be quite long. Then, at the last minute, a family member is whisked in the room for support. The residents are very skilled and have mountains of paperwork for each patient. Tomorrow, I move on the the postpartum area. But now, I have Spanish class to run to.

Central Park, Leon, in the early morning

27.01.2014

I pressed snooze a few times this morning before peeling myself from bed. By the time I got to the kitchen across the yard, Adilza had a cup of coffee waiting for me. I hurry off to the Health Post and see many of the people of El Tololar on my way. Workers are collecting left over peanuts from the harvest meticulously combing through hay and debris on the fields. Men are tediously cutting grass with machetes.

As I round the corner to the Health Post, I see Rey running a horse across the yard to pull water from the well for the crops and animals, which takes three people and two hours to complete. I will see him shortly running the pharmacy before he goes home to continue working with his family. Sadly, it has me thinking, have I ever actually had a hard days work?

I know I flex my brain a lot at our health center and hospital, especially on a difficult overnight call. It's so easy to feel grounded here in the country where your ties are more with the earth than with machines. Even now sitting in the morning light waiting the the rest of the staff to show up at the Health Post, It is so peaceful, the soft chatter of the People, a few dogs, birds chirping and an occasional bicycle whirring by...

On the other hand, its kind of a big day with the the focus groups and meeting with the people of El Tololar to discuss the results of the breast-feeding project.

Moms and babies at breast-feeding presentation

26.01.2014

It's 9am on my birthday, the latest I have slept since arriving in El Tololar. Last night's celebration at Telica was incredibly fun! People had come over from the neighboring towns to celebrate. It was basically like a carnival in the central square, with rides and food and merchant vendors. Fireworks were lighting the sky continuously while we were visiting the different vendors.

Then, some brilliant blue and white fireworks started just across the street. I was admiring this and then everyone started to run frantically away. Someone grabbed my arm and said "don't touch anything!"  It was an electric wire exploding! No one got hurt, but we lost power for quite a while, not affecting the carnival in any way. The rest of the night was spent drinking some beer and dancing. Paula's birthday ended at midnight and mine began.

I spent the rest of the day making posters of results to report breastfeeding results to the people of El Tololar on Monday afternoon. I am very nervous about the turnout that we would like to have.after spending so many hours going house to house to invite them.

Adilza took me to celebrate at the Pulperia on the corner in the evening.

Birthday celebration with Adilza

24.01.2014

After seeing many patients in the morning at the Health Post, Reynauldo and I have set out to invite the rest of the Ermita #2 Sector for Monday's presentation. At the end of our tour, I asked him how far we needed to walk if we wanted to invite some more families that we interviewed in November to the meeting. I was thinking about how to get them invited without a vehicle. His response: "We can't go, it is 3km just to get there!”

It's amazing, because that is the distance they need to traverse to get to the Health Post if sick. For men, that means missing a day's pay and then actually getting there. That is always in the back of my mind when I see a sick male present at the clinic after something terrible brought him there, such as last year when a young male in his 30s presented with renal failure.

Calibri or hummingbird in the early morning light 

23.01.2014

We had a very busy day doing home visits, checking on some of the pregnant and chronic patients. We invited all of the women and the fathers of the babies in the Ermita sector to a results presentation and more focus groups for the exclusive breast-feeding project, for which we have found that there is an overall deficiency in exclusive breast-feeding before six months of age.

Hopefully, a more detailed explanation of this will be presented at the CUGH meeting in the Spring!  Now the aim is to get input from men through focus groups, to look for an additional avenue of intervention. The women were quite positive about coming, but for the men it may be difficult as many are still working at the time of the presentation. By the end of the morning, we are all ready for a siesta as it is very hot. We post-poned the other sector for the next day in the afternoon.

22.01.2014

There is something special about the early morning light in El Tololar. I have a goal of getting to the Health Post in time to begin the day's activities, but I find my self under the spell of the golden rays of the sun. At the end of rainy season, there are morning glories lining the peanut fields. Golden yellow flowers fill a field with the picturesque San Cristobol volcano smoking gently in the background. On the opposite field, Telica is contributing a burst of clouds to the early morning sky. I have snapped a dozen or so photos of these same frames, but I never get tired of them. I am ten minutes late today due to this enchantment.

San Cristobol

I did survive running the health post yesterday for which Dra. Urrutia was grateful. Luckily, the pharmacists helped me tremendously in finding the medications that the patients needed. Today was another whirlwind of patients with Dra. Urrutia trying to complete consults with a splinted dominant hand due to severe carpal tunnel and we finished just in time to catch the bus to Leon!

Golden flowers

21.01.14

Spanish class yesterday afternoon was fun. It is amazing how much grammar I am missing out on. However, I was able to get the respect of a taxi driver after all of the taxis I asked to take me to the class were trying to charge me double. They even tried to tell me that I was going to a more remote part of Leon. Even the price I got was more than it should be, but I was in a rush and could not argue further.

En route, we compared travels in Nicaragua, culture, history and whatever came up. After getting out of the taxi, I looked at my change to find that he charged me the correct price. It made me feel like less of an outsider for once. After getting up with the roosters, I am off to take over the clinic for a day while Dra. Urrutia is away!

"Stop dilly-dallying - clinic is that way!" 

20.01.2014

Notice, I have written the date in reverse, just trying to emphasize that I still have not gotten used to that!

Today was the first day working at the health post this year. It was a very busy day, just made the bus to Leon. This is where Dra. Urrutia informs me that I am in charge of the consultations tomorrow!!! She has to have her injured hand attended to and she is entrusting her patients to me. This may seem like no major task, but the medications in Nicaragua are completely different. We shall see. I know that the rest of the staff will be there to help, no worries, off to Spanish class!

Departure

I can never seem to sleep the night before a trip. Anxious about so many things, did I pack everything? Will my patients be ok? Will my husband, cat and the rest of the family be ok? Well, probably!!!

It's been a difficult year that moved too fast, now that I think about it. I have felt very inspired being in Nicaragua the past two years and I can sure use some of that inspiration right now and definitely some warmth after the bitter cold of the New England winter.

I am ready and I have a lot planned for these weeks (maybe too much). Nica, are you ready for me?