The Pediatrician

My 6am run

FMRC Clinic

Exam room

 

FIMRC has hired a pediatric surgeon to come a few days a week to our clinic.  She comes from Rivas and FIMRC pays her $50 for a half day, then she sees all of the children for free. This is less than she would get in Rivas as she is a private doctor which is.a highly sought after position because they get paid more. For every consult she sees in her private clinic she makes $20, plus however much she makes for her surgeries. Here, pediatric surgery is different than the states in that they go through a pediatric residency and then surgery, which is why she can have a clinic where she sees normal pediatric complaints. In the states, pediatric surgeons go through a surgery residency and then specialize with pediatric surgery.

 On pediatrician days, we take the vitals of the kids and do developmental assessments.  Many are delayed and we can work with them in therapy. While the mothers are waiting we give a health talk on a prevalent topic.  Some of the ones we have done include respiratory illnesses, parasites and urinary tract infections.             Giving a talk

Weighing a baby

The pediatrician does a great job with the kids for many reasons. She listens to every mother (I've seen 3 dad's at the clinic since being here) with the same level of respect and without rushing them - even though she knows within 2 minutes what the child has. She then does a very thorough physical exam (here there are no labs to help aid the diagnostic process). She also goes over development since the majority of kids are malnourished.  As I've mentioned, the most common issue is parasites - from the water, salads,  cuts in kids feet that step in animal feces (this may sound gross but I also step in animal feces a lot because there are lots of pigs, cows, horses, chickens,  and dogs that roam around in the dirt road and on people's dirt yards so in blends in with the dirt).  She gives out antiparasite meds every 3 months or if a child has symptoms (weight loss, night cough, diarrhea, stomach pains). If a child does not get better she will send them to Rivas to get a stool sample.  The medication she normally gives evict the parasites (usually through the stool but can also happen through the nose/mouth).  However,  sometimes a child will come in with a huge belly and diarrhea which means the parasites have grown so much that there are a lot and are large so she can't give that medication or the parasites will try to burrow through the colon causing more peoblems.  In this case she gives are medication to kill the parasites instead.  Some of the rare complications with parasites include them adhering to the colon wall and having to remove them surgically,  certain  parasites can enter the blood stream and replicate In the lungs causing respiratory problems.  We have not seen any of these rare complications.  Another common childhood problem is urinary tract infections.  Diapers aren't changed as frequency and little girls don't wipe well.  With boys, they also get them from poor hygiene.  None of the boys get circumcised here but the moms don't do the exercises so their foreskin gets stuck causes issues down the line such as needing a circumcision at the age of 9. Also, because they all play in the mud they get dirt stuck causing inflammation and infection.  There is a major difference between health problems her and in the US so I like seeing how it is handled                                          
                              The doctor writing a prescription

Little boys getting examed.  One difference is the resource difference.  Here, only one sheet is used on the exam table the entire day.  The other day one of the patients had scabies so she exposed all of the other kids to it.  They just don't have throw away sheets here to change after every child.  Also, for looking the ears we use an otoscope with throw away covers after each kid...here they have one to reuse.

Adios!

Ometepe Volcano

Ferry Ride

Over the weekend we went to the volcanic island of Ometepe.  It is located in the middle of Lake Nicaragua and contains 2 volcanoes, one active and one inactive.  We took a ferry over which was an hour ride (only one of my friends got sick on it)!  When we got there we had to find a ride to the base of the volcano where the hostel was.  We found a taxi guy to take us.  He was talking to a friend so we got some glass bottle sodas to go, then he told us we have to finish them before we go.  This is because here, they reuse all bottles and they can't buy new ones unless they bring back the old ones (without huge inflation prices).  So we finished and then piled in.  We drove about 3 minutes and he stopped to pick up a pizza for his family.  We continue on 5 more minutes and he stops to chat with his friends and pick up an empty gasoline container.  Then he fills it up at the gas station down the road.  We drive on, thinking that's the last of it when he stops at a house to drop off the full gasoline container.  This all happened along the main road so we never even went off track.  At this point he asked us where we were from then turned off his music and put in his American CD which consisted of Celine Dion titantic songs and other slow jams.  We also had him make a stop for us to do  sunset hike.

After this we made it to our hostel which was called Finca Magdelena, a co-op which has they own farm of vegetables, herbs and coffee beans.  It is the best coffee I have had since being here!

The next day, we got up early to hike the inactive volcano.  We started off on a nice path and our guide pointed out the different types of monkeys, trees, and flowers.  We made a few water stops and then things changed.  The path ended, it started sprinkling, and the real hike began.  At the first viewpoint 2 of my friends turned around because of the rough terrain so only 2 of us remained.  We had to hike up boulders and at one point we were hike through clay mud puddles!  Our shoes and legs were completely mud covered.  We made it to the top but no great view because of the clouds.  We then hiked into the crater which was the most difficult part and ended at a lagoon where we ate lunch.  The way down was different than up but so slippery we kept falling into mud puddles.  We were cracking up because you could always hear when someone fell because of the mud sucking you in...then the guide would laugh at us too.  Also, my legs were like jelly on the way down which made it hard.  After such a hike I felt accomplished after making it and it brought me back to my swimming days of intense physical workouts, it also made me remember how much I love these activities!  Since the hike took all day that's all we had time for before leaving Sunday morning because the last ferry is at 11 am.   We made it back to Las Salinas just in time for a surf competition.

Monkey!

This is our path

And our shoes!

Made it to the lagoon in the crater with our guide!

Therapy Clean Up and Festival Fun Limon

At the Therapy center, the mothers are in charge of keeping it clean and raising money to keep it open. One of their fundraisers is to make piñatas to sell.  Since Rachel's birthday is this upcoming weekend, we have decided to purchase a piñata from the Therapy group. Also, earlier this week we helped the mothers clean up the therapy center.  The therapy floors are tile so we helped mop the floors but I'm not sure how much it helped because there is so much wind that kicks up all of the dust you almost have to do it hourly to keep it clean.  We also helped rake the leaves and trash into piles and then burnt it all.  Trash collection is a new concept here.  A trash collection service began this year and they are supposed to come every Monday to pick up all of the trash however, it is unreliable and has not been around once in the last 3 months, maybe even longer.   Therefore, people need a different way to get rid of the trash. Here, they collect it into piles and then light it on fire to burn it up.  It works well to get rid of the trash and compost and I am surprised the fires don't spread, there is so much wind and it is so dry now.  The ash piles are left but they are a sign the place is clean.   The big issue is that there are so many burnings and people are always inhaling this smoke, and many times they are burning plastic so that smell is always lingering.  Hopefully the trash collection service will come more frequently in the years to come! 

Weedwacking with the machete

Burn piles.                      Catie with machete and Tomanei looking                                             on!

This week therapy was fun as always (and now clean)!  Here we all are sitting at the table.  The day always begins with coloring to warm up the kids.

This is Tomanei.  He is in therapy because he does not know his colors or how to count. The colors could possibly be from being color blind, I don't think he has been tested.  He also has severe ADHD for which he is now on medication (the only kid in the community on medication for this).  One contributor of this is the large amounts of sugar and coffee the kids here eat/drink.  Every morning, the kids have a cup of coffee with sugar and no one seems to think it's a problem.  Also, fruit drinks are delicious and made with fresh fruit but there is always a lot of sugar added.    

This is Julian, he had some sort of vascular accident during birth and will bolt use his left hand a lot of the time so we work on getting him to use this hand.  With him is his 11 year old sister who bring him to therapy every week.  Their mother works in Costa Rica, she will work for 3-6 months and then come home for a few months and then leave again.   While she is gone the kids stay with relatives and much of the responsibility falls on this girl.  Julian gets really nervous at the beginning of group and always wants to be by his sister, he seems to have some abandonment issues and for good reason.  

At the end of each session we play a  game.  This week we played musical chairs.  The red van is one of our transportation vehicles and the driver, Hilton, plays music for us.  The kids always beat us out!

Fun Limon also had a festival on Friday.  Fun Limon was created by the Ford Foundation about 7 years ago.  The Ford's are a family who moved into a community within Limon, Nicaragua.  The community is Rancho Santana.  The family wanted to give back to the community and started a community development program.  The program has adult literacy classes, English classes for kids and adults, sports leagues for kids, a farm to provide school lunches for kids, and a scholarship program.  The scholarship program is for kids in the community who are on track for college.  It pays for their college, transportation, supplies, and clothing needed.  The students must maintain an 80% average, if they are close to falling below that then the foundation tries to find out why.  The high school is in Rivas, an hour and a half by bus so many kids stop before then.  The university is in Rivas or Managua (3 hours) and for many majors, classes are held on Saturdays only.  Medical school, nursing, and engineering  are more time intensive ands are 5 days a week.

The festival was a kick off to the sports camp.  3 retired MLB players came in for the weekend to teach thee camp.  Baseball is the biggest sport around here.  We had a booth with a jeporady game.  We made up health questions but many didn't transfer to rural Nicaraguan culture.  For example, we asked what to do before crossing the street but since cars are new within the last 5 years no one is taught about street safety.  Also, many people don't have toothbrushes or toothpaste so kids don't brush their teeth often or at all.  Health education is an area that people are not as aware of here.  The festival was fun and we gave out toothbrushes, toothpaste, shampoo, lotions and notebooks with pens for school.

The line at our booth!

Floppy the clown!

MLB players

MLB players

The kids had a blast and it was a great day!

Hasta manana!

  

Prenatal Visits and Micro-insurance Program

One great aspect of FIMRC is their community outreach.  This is especially apparent in their prenatal home visits and their micro insurance program.  At any given time, there are 50 pregnant women in the community and many of them are young and still children themselves.  The prenatal home visits began to emphasize health during pregnancy. The program is lead by a Nicaraguan woman who is well respected within the community, and who just recently gave birth so is able to relate well to the pregnant women.  Every month of pregnancy and then after the baby is born she goes house to house with a different talk each time.  I have been accompanying her once a week. Here, advanced notice does not really exist.  We walk from house to house and just seee who is home.  Then, once there, a family member will bring out plastic lawn chairs for us to sit in either outside our on their porch.  We go to the house and first she gives a pretest to determine how much the participant knows about a given topic.  Then we give a talk on topics such as fetal development, complications and when it's necessary to see a doctor, nutrtion, exercise, the importance of breastfeeding and many other topics.  Then the participant is given a post test to determine if the talk was helpful.  After this we take her blood pressure and record her weight.  Then,  a baby shower is set up once a few women reach around 7 months and they are given diapers, baby clothes and blankets.  I hope to be able to go to one while here!  This past week we went to a few different homes.  One was of a 15 year old,  another an 18 year old, and a 22 year old.  It is amazing to see how much they learn through the talk and encouraging as well.  It's different than in the states because there are no baby books available and as I mentioned the hospital is an hour and a half away and since most people don't have cars they are sitting on a hot, crowded bus.  Therefore, prevention and education are extremely important.  This includes exercise, healthy eating habits and general knowledge of what is appropriate during pregnancy and what is not.  The concept of prevention is also prevalent in the clinic.  The young doctor, Domingo, puts every pregnant woman on aspirin because there have been studies showing it reduces the risk of pre eclampsia and here it's worth it to prevent rather than treat.  As I mentioned before, all of the pregnant women go to the hospital to wait for their delivery 2 weeks before their due date.  Also, if they need a c - section it is performed at 37 weeks.  They will not perform vaginal birth after a c - section so all of those women get sectioned.   I have more to say about the hospital in another blog!

To the left is Roxana who runs the program, and she is teaching a woman how to use a thermometer.  The thermometer is mercury so it's old and should be used with caution but it's the best they have.

Another program being implemented is the micro insurance program.  As I mentioned, a pediatrician comes twice a week and has appointments for the kids and then we keep all of the files at FIMRC.  The new program involves going to the homes of the children who are constantly sick coming to the clinic with the same illnesses. During the home visits we observe different issues that may be causing illnesses.  Some of the issues here include coal burning stoves indoors, food left out uncovered all day, drinking water straight from the well, uncovered water sources including wells and latrines, children running around without shoes on, and many other issues.  The common illnesses include respiratory tract infections, urinary tract infections, parasites, ameobas, and bacterial GI infections.  We then will enroll the families in an educational program about how to prevent their children from getting these illnesses and then if they come to the educational sessions and are making a sincere effort we will buy them something to enhance their home to prevent illness.  So for kids with respiratory infections buying a gas stove, kids with parasites buying a water purifier and shoes and other household items.

The house I went to was actually right across from where I live.   A 3 year old boy consistently has parasites and now he is extremely behind in growth and weight for his age.   This is his house, the well is to the right and uncovered.

This is the indoor stove, which is coal burning and can cause respiratory infections, including pneumonia.  The room it is in is open to the outside so its not quite as bad.  However, it should be outside altogether.

Hopefully, with education and an emphasis on preventative medicine we can help prevent some common childhood illnesses!

Adios!

San Juan Del Sur

Last weekend we took a trip to San Juan del Sur which is south of where I am on the Pacific coast.  It is a big surf area and they have world surf competitions there.  The actual city is in a cove and then you have to drive about 30 min (6 km)  to get to the beautiful swimming beaches.

                              Some guys playing futbol at sunset

We stayed in a hostel and met a lot of tourists from all over.  A lot of them were surfers from all over and then there were also some European travelers who were going through all of Central and South America.  Also, wealthy Nicaraguans vacation here as well.

The first night we went to a local bar and that's where we saw the doctor from the clinic we work at.  All of the bars are right along the ocean as are all of the restaurants which gives it that beach feel.  In the morning we hiked up to the Jesus statue which overlooks the cove.  It was not a long hike but it was steep.

                                           View from the beach

View from the top

We then went to playa Hermosa which is a beautiful beach!  It's very secluded so in one direction see the ocean, then you look behind you and it's nothing but trees and hills.  The waves were also huge!  I was surprised that they weren't strong waves for how large they were.  

At night we went to a reggaton bar with live music.  Overall, it was a great trip!

                              real coconut water and yes it is much better                                       than anything store bought!

Adios!

Hot springs, natural healers,and therapy oh my!

                       Morning wake up call (Howler Monkeys)

Last week we spent an afternoon at the hot springs.  Driving up, the sulfer smell got really strong.  There are quite a few hot springs around because of all of the volcanoes.  It was really beautiful with all of the trees around yet also different than I expected.  There were three hot spring pools with cement surrounding them.  The one pool was the filler which used its water to fill the other two...with the other 2 being lower than the first.  Someone from the community has been designated to clean it and maintain the pools therefore it costs a few dollars. Its really interesting because with the hotmsprinmgs and many other activities in the area they have a discounted price for those who can't afford much, then the local price, then the local foreigner price, then the foreigner price. Mmany of the locals take their showers there and there is a washing station for laundry so they don't have to use their own water.  There were a few families swimming, people sshampooing their hair, and then women doing laundry which takes about three hours for a medium size load because its all by hand.  The Nicaraguans also have a different idea of modesty than we do.  They all wore their clothes in the hot springs because bathing suits are too revealing.  Also, many wear jeans in this hot weather but with more form fitting tank tops\shirts.  However, breastfeeding in public is extremely prevalent with no cloth covering as would happen in the states.  But then when the pediatric surgeon comes in she is always wearing heels and tight fitting clothing that no US doctor would ever wear.  I am still trying to figure out cultural dress.

                                Us at the hot springs

Laundry day

 Later that day we went to see the highly respected natural healer in the community.  Nicaragua is moving mainly towards western medicine and the natural healer works with the the community doctors.  For example, if there is a non compliant patient who wants to see the natural healer instead, the doctor will talk to the healer and even give medications that the patient won't take from the doctor.  Also, she has anti parasitic medications along with natural herbs and a sauna (hand made).  Luckily, I did not need the sauna.  She uses her hands to detect energy through your body and then snaps her fingers ifsomething is "bad".  For me, she said I had two vertebrae out in my back so she gave me a really nice massage.  I also had no ovarian cysts and a great immune system.  Another friend had a bad liver and parasites.  I should mention that besides the clinic, there are so specific stores or shops, everyone sells things out of their home.  So the local barber works from home, little stores are in front of a persons house, the bakery only makes goods by request from her home, and the natural healer works out of her home.  So at the natural healers I had to use the bathroom, she had me climb over a fence where the pigs were and that's where her latrine was.  She then walked away and one of the pigs started chasing me so i had to run into the latrine!  It then lost interest but I also ran out of there!  Overall, it was a great experience and i was able to learn about natural healing!

                              Natural Healer

One really nice aspect of this community is that everyone has a role.  For example, kids with Down Syndrome don't go to a different school but instead become productive members of society and no one looks at them differently.  Every Friday, there is therapy for all of the kids in need of physical therapy or therapy for cognitive delay.  Many infants are slow to start talking and walking because their mother's never put them down long enough to start using their own strength.  Also, the concept of talking to infants is lost here therefore, many babies aren't saying any words at 2/2.5 years.  The kids I saw in therapy had different types of issues.  One girl has cerebral palsy so we performed exercises with her.  Another girl was born with myelomeningocele (spina bifida).  She has surgery and now has subsequent paralysis.  That can get better with therapy and time, she is only 3 months now.  She also has hydrocephalus which is when there is too much fluid in the brain.  She is having surgery (a shunt) to fix it.  Her mother didn't take any prenatal vitamins and so this was a product of not enough folic acid because as I said earlier, parasites love leafy greens so people can't eat them.

Hasta Pronto!

Diabetic Home Visit

                              Mi Casa

Today I performed diabetic home visits, the person who runs it is an older Nicaraguan lady.  We went from house to house checking blood glucose (sugar) levels and blood pressure as well as asking about symptoms and medication compliance.  Many blood sugars were in the 400-500 levels with normal being less than 126.  Surprisingly, no one even had symptoms.  It is also difficult to find compliance here due to their diet.  Rice, tortillas, and fruit are staple foods so when we say to cut back on these foods people then ask well then what do we eat??  And honestly, there is no good answer because its difficult to buy different foods.  Also, insulin is extremely difficult to get here so metformin is the only medication given out.  For these reasons most people have poorly controlled diabetes with many complications.

The visit also gave me the opportunity to see many different houses.  The houses range from those with front doors, ceramic floors and a kitchen table to those with diet floors and no table.  Most houses are made of cement but there are some of wood and others of tarp.  Every home also has a latrine which is a hole dug deep into the ground used as a toilet, surrounded by tin walls.  Sometimes, homes will have an outdoor clay oven and many have a washing station for clothes.  An interesting sign off status is having these portraits superimposed onto some sort of background.  For example,  a baby in a queen sized bed, our two people with the background of a nyc apartment.  It looks slightly odd but people here love it.

                               Very nice home

 This is a well that many homes have in order to get water. They are working on purifying the water so many homes how have filtered water.  The tropical climate is perfect for parasite growth so those who don't have a filter (and even those with one) get parasites.  Here, everyone is advised to take anti parasites every 3 months, and the medication is cheap because its so common.  Many of the kids who come into the clinic are malnourished,not hungry, and have a night cough... All of which are signs of parasites.

The cows are coming!! Animals and humans share the roads around here.

Below is a latrine

Hasta luego!