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.

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Sunday, February 2

Nicaragua - outreach programs

Hola again from Nicaragua! It's hard to believe another week has gone by here. Our last week entailed another day in the operating room in Rivas, more clinic time and community outreach. We also started doing needs assessments for a future micro-health insurance program and working on a quality improvement project for the clinic.
At the Rivas hospital in the ER
Micro-health Insurance Program

One of the homes in the pilot micro-health insurance program
We are helping one of the FIMRC interns on a project to evaluate community needs and interest in a micro-health insurance program. The program would be opt-in and members would be required to attend one educational talk per month on public health topics. Members would give their permission for spontaneous home-visits where FIMRC would conduct home evaluations to make sure members were following the advice such as covering their latrines, covering all standing clean water, using mosquito nets, etc. For complying with various aspects of the program, members earn points and when they earn enough points they are eligible for gifts to help improve their health in the home such as a gas stove or mosquito nets. 
Cooking over a wood fire in proximity or
within the home is very common in this community

We piloted the home inspection program by visiting the homes of pediatric patients who are repeatedly getting ill to evaluate for possible causes of chronic issues with parasites, respiratory infections, etc. We realized how much information can truly be gleaned about the health of our patients by visiting their environments. It also gave us more insight in to ways to prevent some of the problems that patients struggle with here such as educating about not cooking of wood fires indoors to help patients with respiratory problems. 

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.
Prenatal Program

This week we embarked on more prenatal home visits with FIMRC’s Nicaraguan prenatal coordinator, Roxana. In a half day we are able to visit about 5-6 women in their homes and within the community they have about 50 pregnant ladies at a time. We set out with our supplies including a scale, blood pressure cuff, stethoscope and binder of information.

Jenny and one of our prenatal patients giving a talk 
Upon arriving at each woman’s home (often by foot), we generally navigate some form of barbed wire fence to enter the property. At almost every home we have then been greeted kindly and someone in the family immediately goes to grab stackable plastic chairs for however many guests there are. We are often set up just outside of the home for our prenatal meetings.

Every visit begins with a quiz that investigates the level of knowledge that the patient has on the topic we will be covering.  The program entails visiting once a month during the pregnancy with a different topic dedicated to each month.  After conducting the pre-quiz, we begin with the educational portion. FIMRC has designed a great handbook for all of the talks so we are able to use the handbook to read and educate the women. After the talk, or Charla, we ask women the same set of questions for our post-test to gauge how effective the program is. Before leaving we always weigh the women and take their blood pressure. Because Roxana is not a doctor, the women still visit the doctor where he checks things like the fetal heart rate and fundal height.

Checking blood pressure at prenatal visit

Going on the home visits has been a great way to educate the women in the community. Some of the topics include: nutrition during pregnancy, fetal development, taking care of newborns and complications such as preterm labor and pre-eclampsia. To be enrolled in the program, all women agree to deliver at the hospital. This has helped reduce the rates of maternal and fetal mortality in the community because the nearest hospital is about 1.5 hours away so when complications would arise in the past, it was not uncommon for women to pass away en route to the hospital. Women in this rural community tend to have many children and to start at a young age. The educational program seems to be especially useful for the young mothers in their teens.

Las Salinas, one of our communities
Diabetic Home Visits

The diabetic home visit program is newer to FIMRC and is less formal than the prenatal program as of now. FIMRC’s diabetic coordinator (also Nicaraguan and from the community) is named Esmalda. For these visits, we check in on the homes of known diabetics in the community and measure their blood glucose (almost no one in the community has their own glucometer) and to check their blood pressure. We were often greeted kindly on these visits as well although sometimes with more hesitation because they knew our visit would entail a finger prick.
Girls hanging laundry at one of the home visits

In one morning of home visits, we traveled the dirt roads of Las Salinas to about 10 different homes of diabetics in the community. We inquired about what the patient’s had eaten so far in the day and most of them responded “solo cafĂ© y pan”. Esmalda let us known that they tend to load their coffee up with ample sugar and whole grain bread is not easily found in the homes in these communities. Most of the patients had glucose readings over 300! We were happy when we finally found one in the 170s but had multiple readings in the 500s. As medical students, we were concerned about these numbers and asked the patients how they were feeling- if they were nauseous, had headaches, etc. Most of them responded that they felt normal; we advised these patients to visit the Health Post to see the doctor. While Esmalda was impressed by the high numbers, she also did not seem surprised.

This coming week the community is hosting a medical brigade with doctors, PA's, nurses and a dentist from Texas. They are all fluent in Spanish and have been to the community before. Each day we will be traveling to different remote areas with them to set up free clinics. It should be a fun week!

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