Thank you so much for taking time to look at our blog! We are a group of edical students who are passionate about training and in underserved areas. This January and February, we are in Peru, the Dominican Republic and Costa Rica internationally as well as locally in Flint and Lansing completing volunteer service, rotating in hospitals and clinics, and learning about international medicine and local underserved health care. We appreciate any time you take to read our reflections and any donations you might offer.
Please click the “Donate” link on the side for more details on how to give directly to these communities.
Saturday, February 22
Tuesday, February 11
Carolina and I had the fortune of observing surgeries yesterday and today. We saw ETVs, traditional shunt placements, as well as a spina bifida procedure today. This last procedure was really remarkable.
Picture a 7 day old child, tiny lungs receiving air through a tube in her mouth, little monitors all over her body, laying on her stomach as she is draped with sterile sheets for surgery. The myelomeningocele is the mass protruding from her lower back, the sign that her spinal cord did not correctly form and is bulging out. It means she may be at risk for paralysis, absent bladder control, chronic constipation, and other problems.
Everyone in the room closed their eyes to say words of protection for the child, then scalpel is handed to the surgeon, and to the tune of gospel music, he makes the first cut. We watched in awe as the a small fountain of fluid splashed out, and was quickly sucked up by the scrub tech's syringe. The mass that had looked so solid quickly deflated before our eyes, and skin was further opened up to tackle the damaged spinal cord, that quarter-sized piece of nervous tissue that would dictate so much of this child's future.
Over the next 45 minutes, he separated out the cord, all the while explaining the procedure to us. He expertly wrapped it in the dura, as if swaddling it, and sutured it closed, after which he finished up by closing the skin.
It's true that these problems are rare, far less common than malnutrition, malaria, or diarrhea in a child. However, there was something so profound in seeing this procedure, in seeing a small child get a chance she may have otherwise not have received. My experience at Cure really stimulated my thoughts regarding access to medical care in low resource settings. I have no answers, but only thoughts on more questions. Where should resources be funneled? Does every child have a right to a cure, if it exists? If so, what impact does this have on low-resource, high-need care?
Sunday, February 9
Welcome to Huaytapallana, a nearby mountain and glacier. Last Saturday, we reached a altitude of 17,400 feet and all experienced dyspnea first-hand. We enjoyed hiking together with our faithful guides to help us along the way.
|Laurie was the first to go|
We even got to go sledding with trash bags at the top! Since there was an edge leading to rocks below, we caught each other with a rope to avoid injuries.
|Chris and Phil keeping Laurie alive|
This was not exactly fail-safe, but it worked!
|Phil, Laurie, Danielle, and Chris (not pictured: John and Jared)|
During last week, we resumed our individual work at doctors offices. Please read Phil's great verbal account of the many things we have been able to experience here in Huancayo.
Another great experience has been going to an orphanage for children with HIV/AIDS, or who have been physically abused. We spent our first visit playing games like Red Light Green Light, Duck-Duck-Goose, and Simon Says. These children were a pleasure to meet.
|Chris helping a child with Red-Light Green-Light; Laurie tries to cheat with her child for the win|
|Phil and Danielle are fantastic at all they do|
A visting lecturer from the USA spoke to the Medical Society in Huancayo about hand washing. I think it was a good topic for the doctors here as hand-washing seems to be sparsely observed.
Education and provisions of alcohol-sanitizer, soap, running water in clinics, and hand dryers might be a good use of energy in our future endeavors.
Wednesday, February 5
Last Friday our group did a hypertension education and screening campaign in a smaller pueblo in the hills outside of Huancayo. It took us about 30 mins in bus to arrive, through dusty roads that wound enough that one of our girls got car sick. When we arrived I realized we had been there the previous Saturday on one of our tourist excursions with our family. In the center of town is a cathedral loaded with religious icons. And outside the church is a huge stone cross that my señora told me is 500 years old. It has four sides, of the two large sizes, one depicts the crucifixion (very defaced making it the most difficult image to appreciate) and the other side has the Virgin with baby Jesus. The two smaller sizes have images of two monks, I don't know if they are particular ones or not. Around this cross on all sides people come and burn candles to ask God for something. And they wait until the candles burn entirely down. Different colors and arrangements signify different types of requests I was told. The aura of devotion of the faithful that are gathered is impressive. Chris took good pictures when we were there the first time. This time, our work was across the street from the cathedral in a convent. On arrival there were maybe 20 mostly old people that were seated in a big open room that had a few tables and chairs where we would do our visits. Laurie introduced us and gave an overview of blood pressure, hypertension, and preventative measures. Then we split up into teams. The really old people gravitated to one corner of the room where Danielle checked their BP and talked to them about various health concerns. Like in the States, the old folks took longer than the other patients. I laughed when I was done checking my patients' pressures and I saw that Danielle had a lot of old folks seated around her table waiting their turn for a SECOND consult to discuss more issues.
|Peruvian medical student Freddy was working with Danielle|
After the intro, I went to one corner of the room and started "seeing patients." I asked their name, age, medical history, social history and wrote this all down on a paper and then took their BP twice and and then their pulse and respiratory rate. Then I listened to their lungs and heart with my stethoscope (mostly just to oblige them bc they saw the other students in our group auscultating patients at their stations). This town and this population was distinctly different than Huancayo, I could tell as soon as I started to be near the people. This was truly the Andean pueblo. The women I thought were 50 were in their mid 30's. Most women wore the dress of the campo (five layers of skirts of worn fabric and straw hats). When I inquired about occupation, 90% told me they worked in the "chacra," which means intense manual labor farming. And their worn leathered hands proved their response. Their speech was markedly more difficult for me to distinguish than my Huancayo host family members and physician friends. More than one was illiterate. More than these pieces of evidence though, is just the palpablility of poverty that was present, I've seen it in patients I've met in the Hurley ED, and it was the same here. Part of it is a smell, but a bigger part of it is a deeper feeling from your soul that tells you that this fellow human lives at a lower standard of living than you do.
Most of my "patients" had systolic blood pressure below 100. Probably because they physically exerted themselves for long hours each day and nobody smoked and nobody drank alcohol and nobody had diabetes and nobody had a family history of heart disease or hypertension and nobody was overweight. But everybody wanted to talk about a health issue. And like I've experienced already once or twice in Peru, they all gave my medical opinion great deference, and showed me that they cared deeply about their health, and said "thank you doctor" and "bless you doctor" about 1000 times.
|Photo by Danielle Chang|
Among these events though, stands out a particular encounter. After a few hours of sitting at the same table and having conversations, I was feeling ready for a break. Then she came and sat down after another patient vacated the chair at my table. I'd be lying if I didn't admit I wanted just to be done with talking to her before we even started. She smelled liked poverty. She had only a few teeth. I couldn't understand her hardly at all. She had food crumbs all over her lap and her dress was tattered. I knew it was going to be hard for me, practically and emotionally and I didn't want it at that moment. Finally after a few minutes I decided that I would seek a translator, which I hadn't needed to do yet. I decided this because I thought she was telling me that her son was punching her. And also I thought she was telling me that she was having bloody nipple discharge. Then Natalia, our Peruvian FIMRC director, came over and translated. The patient told that her husband had beat her for years and now her sons were following suit. She told that her husband forced her to work by begging on buses. She told that she had no family in the area, except her husband's extended family, who all hated her. I had to get this story later because I could understand neither her nor Natalia's Spanish through their sobs. Also because I had to maneuver her husband to another area of the room when he approached the table and accused her of lying and dementia.
I didn't talk to her after I guided her husband away. The sisters and someone Natalia talked to them for about 1-2 more hours. Now I don't know what will happen to her. The experience was another lesson for me about the assumptions I make without realizing or intending to and how easy it is for me to misjudge a person and a situation. Easily she was the patient that had the most at stake that morning.
All in all, it was a demanding morning, both mentally and emotionally. It really covered a lot of of the primary care roles: health screening, education, patient reassurance, and unplanned psychosocial troubleshooting (of the utmost importance).
|Lunch with Nuns and Community Volunteers after the campaign - Delicious!|
Sunday, February 2
|At the Rivas hospital in the ER|
|One of the homes in the pilot micro-health insurance program|
|Cooking over a wood fire in proximity or |
within the home is very common in this community
Quality Improvement Project
Having worked at the community health post for the last few weeks, we have noticed a few aspects of the clinic that desperately need some improvement. The most glaring problem is the absolute MOUNTAIN of unorganized charts that piles a large bookshelf. The health post where we work is the largest in the area-with over 3,000 patients. And with over 600 new children born per year-the volume of patients is always growing.
Documentation of health records in Nicaragua is an absolute mess. When someone is born, the government issues that person one health card with a number on it. If they lose the card, it's gone forever. So when someone enters the clinic for a visit-it's really a toss up of if they still have their health card or not. Because the charts are organized by this issued number-it is impossible to find someone's chart without the number. The doctor then sees the patient without a past medical history and simply writes about the encounter on a piece of paper. All around the health post, piles of these loose papers sit without knowing which chart they belong to. In talking to Domingo, the current physician at the health post, he says that it is one of his greatest challenges. He sees patients who present with new complaints but do not know why they were hospitalized a month ago. He is continually making decisions without an adequate view of the patient. Then without this documentation, it is very difficult for him to follow up on a patient.
Our goal for the next few weeks is to create a system that the nurses are able to easily use to find patients. We have made a notecard look-up system where the patient can be looked up alphabetically by first name (everyone has a few last names and prefers to go by a different one). The notecard has name, issued number, and birthdate on it. Then we bought new folders for all of the charts (the old ones were falling apart) and organized them by a brightly labeled patient's number. This way, if a patient comes in and does not know their number (most patients), they can be looked up by first name, then using their number, their file can be found Hopefully this will then allow Domingo to have a full picture of the patient and also practice better follow-up.
|Jenny and one of our prenatal patients giving a talk|
|Checking blood pressure at prenatal visit|
|Las Salinas, one of our communities|
Wednesday, January 29
Today and the past two mornings from 7-12 am, I've went to a private clinic called Clinica Cayetano Herideria. It is called a clinic but it also has multiple ORs and also two inpatient floors (one for OB patients and one general floor). It also has multiple floors of sub specialty ambulatory clinics, as well as a 4 bed Emergency Room. Although it is in situated in a very dusty area of town, the building is distinctly taller than the surrounding structures and has an exterior of marble and emerald tinted glass. Inside is also pretty swanky. Mostly private rooms with private bathrooms on the general floor, I think there's 12 rooms on the general floor and 10 are private and 2 have two beds. OB floors is all private rooms, maybe 6. All the rooms have leather couches and flat screens on the wall. In the basement is every form of imaging apparatus that I know about, including a Siemens brand CT machine that from what I can tell by appearance only is the same model that Hurley has.
I've been following attendings who manage both inpatient floors as well as the ER visits. Most of the general medicine inpatients are not critically ill, most have either pneumonia or are surgery patients (a post-appy patient, a transurethral bladder tumor removal patient,and multiple ortho patients). The first two days I was there I followed an attending named Dr. Poma, who is in his 2nd year out of medical school. He doesn't speak English so it's been difficult to understand everything that's going on about of the time, but also no doubt is good practice to have medical themed convos in Spanish. It has been similar to my experience following a resident in the states, he gave me lots of mini lectures that were complete with drawings and tables and he pimps me about differential diagnoses from time to time, so I've actually feel like I'm expending a lot of mental energy to follow him around all morning. He was great to be with and, like I'm discovering is typical of Peruvians, is very generous. By the second morning he was inviting me and the rest of my group to dinners with him and excursions to the jungle with him. These kind of invitations at first were awkward because obviously we barely know these ppl but I am realizing that 1) everybody down here invites everybody they meet to things all the time and 2) that about 50% of the time ppl don't actually follow through with their invitations.
Then today I was sent with another doctor, named Dr. Vacilio, who was a bit older. Like in the states, different attendings have different personalities, so it was a different experience. He was less interested in teaching me, but also we had a lot more patients than the last few days so were pretty busy. He was pretty friendly and explained things in good detail to patients, but definitely was more "machisto" than Dr. Poma and other younger docs. I think this stereotype of Latin men is fortunately fading with my generation. He would flirt hard and pinch and poke EVERY nurse as we went to the different floors, and then in front of a big group told me that when he was in medical school he would always date two women at one once. By American standards it was entirely over-the-top unprofessional, but nobody here really did anything more than roll their eyes and most just laughed at his jokes.
Another difference that I thought I'd mention is how medical care and medicine is paid for here. Cayetano is a private clinic and it was very often that the issue of payment came up from a patient. Multiple times I observed a patient in the ER only complete a part of the work-up and take their prescriptions, lab orders, radiograph orders or results and leave to take these to another site to get care. An interesting example is a patient came to the ER with a head wound that he got the day before at his job in the mine a few hours from Huancayo (between Lima and huancayo is a large mining industry). The patient had a bandage over about a 4 inch wound in the middle of his forehead. In the ER, Dr. Vacilio looked at the wound and wrote him a prescription for lidocaine, a syringe, suture, a needle, and antibiotics. Then his sister that was with him ran across the campus to the pharmacy and bought all the things that were needed for Dr. Vacilio to suture the wound. Then he sutured the wound. Also, none of the ortho tools and implants for elective surgery are kept in house, but are ordered when a patient comes in that needs those things. For example, a man with a work injury that broke 3 metacarpals and one of his wrist bones was admitted and given a soft cast and pain meds for two days while the pins that were needed to surgically reduce the fractures were ordered. Another patient who was a seamstress was injured on the job by a needle breaking and lodging in her thumb was admitted in the afternoon even though her surgery couldn't be done til the next day. I tried to talk to Dr. Poma and Vacilio about why these patients were admitted when they couldn't have surgery that day, but unfortunately I never really understood a firm answer they gave.
Despite several differences, I am constantly struck by similarities. A twenty-something came in with back pain and was accompanied by his mom, who asked a TON of questions...which is exactly what my mom would do if I went to the ER.
More things have happened but I will have to write tmr.
Day 19 (1-29-14):
We've done a few things since my last update. Mostly my hospital experience has been at the same Clinica Cayetano that I've been at for these past two weeks. I've been going in from 7am - 1 pm and then going home for lunch. Then in the afternoon we have been doing different campaigns or going to an orphanage. The Cayetano clinic folks continue to be very welcoming. A woman who I believe to be some sort of HR director invited me to go with them the past two mornings on an excursion to the Judicial Office of Huancayo. This office, which I was told has 200ish employees, made a contract with Cayetano to come and do a bunch of health screening stuff on site, including physical exams, vital signs talking, EKGs for persons older than 50 years, a blood draw, and a vision exam station. I felt really priveledged to be invited since this wasn't really arranged by FIMRC. When we first got to the building and went to the basement area where the stations were set up there was a lot of court employees crowding the area and Initially the flow of people through the stations was really disorganized with people not getting the right paper work for that station and people skipping around the stations and not following the flow, which made for confusion and people having to wait around because others went out of turn. I jumped in with the doc who was doing physical exams, but I only stayed with him for about 30 mins because he was ignoring me and not involving me in the interview or exam. So I left that station and found a nurse I recognized from the Clinica and asked if I could help her with EKGs. And I'm pretty happy I did because she taught me how to place all the EKG leads and work the printer, and after a few patients I was running the EKG station. This was a good experience because I was able to talk to each patient that came in and enjoyed the conversations we had. I did that from 9-1 probably. Then today I went back for day 2 of Cayetano clinic at the court, but there were fewer patients and I spent most of the morning talking to one nurse about Peru in general, the Peruvian medical education system, public health issues in Peru, and the Peruvian health care system. It was a really great convo because I learned a lot. For example, she told me that there are not very many heart disease patients or diabetes or kidney failure patients in Peru and also that very few Peruvians smoke tobacco. From what I've observed in the hospital and in the streets, I believe her. She also told me about the people in huancayo having a high incidence of volvulus because the low atmospheric pressure causing lots of gas expansion in the gut. No idea if that's right, but I enjoyed the convo. Then she explained To me how the public hospitals Carmen and Carrion were for people who didn't work, or worked for small shops or manual labor jobs. And that Peruvian who worked for a bigger company Were automatically enrolled in the government insurance available in Peru, called EsSalud (in English, This is Health). These individuals had auto-payroll deductions and were able to go to any of the EsSalud hospitals in the country, hospitals which exclusively treated EsSalud patients. However, while EsSalud is better than no insurance (ie the public hospitals), but still isn't great (long waits, etc). Therefore, chains of private clinics and inpatient and even operative services have developed (like Clinica Cayetano), for which people pay out of pocket for quicker attention and more luxurious environments. I'm not sure if you can buy extra insurances that cover expenses of those clinics.
In the afternoon we have done a few different things. Twice we have given first aid presentations to the Huancayo Serenazgo, which seem to be like a neighborhood watch type group because they clarified that they aren't police, but they wear camo uniforms and drive around the city in labeled tanks. At first hearing that were supposed to do this, I wasn't excited because I recognize that we aren't really knowledgeable in first aid topics. But we spent a long evening making talks and posters about different first aid topics and it seemed like it would be okay. Then when we arrived at the site for the first session, the 40 some Serenazgo that were present stood in a ine and at attention. This made me feel even more inadequate, because how could we possibly teach these professionals anything? But, and I think to all of our surprise, they were all super engaged, asking questions, discussing their own experiences with rescuing people, and even taking notes during all our lessons. Then after about 2 hours of lessons, we took about 30 minutes of photos at their request and that was it. We did this session 4 times as a group so all the serenazgo were Able to participate.
Finally, we have spent two afternoons at orphanages. One that was pretty big and had a big play ground. The other that was smaller, with only an indoor play area, and had fewer children and was specifically for children with HIV and a few of their siblings that didn't have HIV. Both experiences were simply running around for 2 hours without a break and entertaining small children that were hanging all over us begging to be spun around or lifted up or pushed on the play equipment.
P.S. Our family is simply amazing. The experience would definitely be worse without them. The señora is a cute grandma that dotes on everyone and we try our best to make her laugh with our jokes. She micromanages us like little kids, but it is with such affection that we don't mind. Like she tells us to tell David that he should sit in the front of the cab after he has climbed in the back, or to tell Danielle to go put socks on because the floor is cold, etc etc. They are a really tight family with all four apartments on their complex being occupied by their brothers and sisters and their spouses and kids.
Sunday, January 26
We held a blood pressure screening at the oldest elementary school in the city. We screened around 150 adults and encouraged participants to visit their regular doctor.
|MPH Student Beth working hard on Hypertension Posters|
|Our 5 booths for the Hypertension clinic|
Another event this past week was a fluoridation project for the children in school. Along with a local dental students, we visited classrooms and drizzled fluoride liquid in children's mouths.
|Chris applying fluoride to a child|
|These teeth were some of the better ones seen during the campaign|
|All in all, the kids were happy!|
|Preparing for First Aid Campaign|
- CPR (John and Beth)
- Heimlich maneuver on adults and children (Chris and Emily)
- Trauma (Laurie and Danielle)
- Intoxication and Electrocution (Chris)
- Emergency labor and delivery (Phil)
|Phil teaching the most important things for emergency labor|
|Chris giving Phil a life-saving hug demonstration|
|John and Beth with Peruvian medical student, Freddy, teaching CPR on home-made dummy|
|Danielle teaching cervical-spine support while simulating car extrication|
|Laurie speaking to TV interviewer|
|Margot (left) and Julia (right) are a dynamic daughter/mother hosting pair, featuring their garden|
|Beautiful Catholic church|
|Wari Willka ruins - most recent excavation by Danielle Kurin at UC Santa Barbara |
|Chris, Laurie, and Phil on top of ridge overlooking Huancayo and nearby mountains|