Week two in the DR...

            On our day trip across the border to Haiti there were three patients with cholera.  They have their own small building known as the cholera ward. We were told that cholera is not that uncommon in the more remote areas, many of which lack latrines. A few days later we were surprised when a patient showed up at the hospital in Restauracioń with cholera.  The doctor has treated cholera patients before and made a clinical diagnosis, that was later confirmed by a laboratory a few days later. Fortunately, this patient was the only one we saw.  This presented an opportunity to go out to the community and educate about cholera.  We prepared scripts and we literally went door to door in selected neighborhoods.

            Dr. Ricardo also anticipated the need to educate and raise awareness about Zika virus, so a few days after the cholera education, we hit the streets again and spread the word about mosquito borne illnesses (dengue, chikyngunea, malaria, and zika). Much of the education was geared at eliminating mosquito breeding grounds, ie.) standing water.  I am happy to report that we finished this project before the CDC travel warning. All credit goes to Dr. Ricardo, he is amazing!

We do get to have a little fun too.  More on that later.

 

Tragedies on buses and Training for bomberos

As we depart La Merced for the next phase of our journey, I wanted to post about a particular experience that meant a lot to me.  For my primary outreach project I have been working with FIMRC Peru to develop a series of "Emergency Preparedness" didactics for their partner communities, with the goal being for me to train one of their staff to head up the project for sustainability into the future.  Like I mentioned previously, the first lesson FIMRC requested was to teach CPR to laypeople in rural native communities, which I had some ethical dilemmas in doing.  The compromise I made was to teach the CPR lesson I designed to first responders in the city, which for La Merced is basically just the volunteer firefighters ("Los Bomberos").

And then, something tragic happened - a couple days before the lesson a bus crashed just outside the city.  The driver reportedly passed a car on a two-lane road only to be confronted with a potential head-on collision as he turned onto a bridge.  Rather than swerve back into his own lane, the driver did the unthinkable - he jumped out of the door onto the road, leaving the bus to drift sharply to the left, through the bridge's guardrail, and into the river below.  14 people died, and many more were critically injured.  The bomberos responded to the scene but many would later relate to us that they felt unprepared.

And so, two nights later we came to their firehouse to teach CPR.  I was worried it would be too basic for them. Quickly, though, we found that many basic skills were unpolished or unlearned.  I had them demonstrate taking a pulse, and many reached for the ulnar side of the wrist, or lateral to the SCM in the neck, or somewhere else that wasn't likely to elicit a pulse even in a healthy person.  I was happy that we could identify such a basic deficiency and provide an effective learning intervention.  So it was too with the CPR - many did not perform fast enough compressions, or deep enough compressions, or even more importantly, did not know the indications for CPR.

It was gratifying to be able to teach this lesson.  More importantly, the FIMRC staff member I've been mentoring for my project took well to the lesson and really seems primed to continue teaching this and other lessons we design going forward.  The biggest goal for me in global health projects like this is to achieve self-sustainability of any intervention I design, and I think this was a great start toward that end.

At the end, the fire-chief thanked us and related that she wished we had only been able to come a few days earlier, before the tragic bus accident.  Hopefully implementing this program will be a small step towards making sure that the next time tragedy strikes, they'll be that much better prepared in their response.

UPDATE 1/30/16: Dinah (FIMRC Field Operations Manager, in navy blue t-shirt above) has informed me that in the past week Alvaro (the FIMRC-Peru staff member I'm training for their "Emergency Preparedness"project, in red above) has independently taught the CPR lesson in addition to a Wound Care lesson I prepared and taught with him last Friday.  It's only one repetition and just a start towards sustainability, but this made me so happy :)

-Nick

Week 1 in DR and Haiti

Greetings from the Dominican Republic, where the coffee is strong and the music is always playing!
We're happy to say we arrived to Restauracion without any security issues or lost luggage.  Each of us were placed with a family within walking distance. It was a little bit of an adjustment not having internet or hot water, but overall we've felt very welcomed and almost at home here.  Here in Restauracion, FIMRC coordinates many activities here and in Haiti every week.  The mornings are usually divided between the hospital and the local clinic, except for the one day per week we go to Haiti.  The afternoon usually focuses on educational activities at a local school, library, or by going door to door to educate the locals.  In January we are focusing on HIV/AIDS education.

The view from the FIMRC office.

Living in Restauracion: Life here is very different from what we are used to in the US.  We have scheduled power outages every other day.  Running water tends to alternate with the electricity.  Oh, and we don't flush toilet paper! Every night there's music playing at various bars throughout the town. It is a bit humid here but none of us can complain when the temperature hovers around 80F.

Group discussion.

Visiting Haiti was a very touching experience- the living conditions there are extremely bad.  They still have cholera outbreaks. Their access to water and electricity is much more limited.  Most houses resemble shacks and have dirt floors.  Many Haitians try to escape poverty by crossing through the porous border into Dominican Republic only to face low wages, racism, extortion, and possible violence.

The group in Haiti.

A Very Delayed Week 1!

¡Hola de Costa Rica! Amanda and Andrea did a wonderful job sharing some of our most meaningful activities during our first week.   Im going to try to give a close-up look at our clinic that we travel to in the city of Alajuelita.  During our first week we were able to get acquainted with our host families and the routine of the clinic. 

The main reception area where we check in patients.

Patient waiting area

 Our main volunteer area

Our roles for the day, where we get to alternate each day. WR= waiting room, EX R= Exam room, Pharm= Pharmacy, SK= Soup Kitchen

The clinic is integrated into the community of the small town of Alajuelita due to its high concentration of Nicaraguan immigrants.  The immigrant situation of Nicaraguans is interesting because they are considered "illegal" yet they are accepted to contribute to society through construction jobs, waste management and other jobs less likely to be in demand among Costa Ricans.  Despite their contribution to society, they are not able to purchase Costa Riccan social health insurance and therefore cannot obtain routine healthcare from various E.B.A.I.S. centers or Equipos Básicos de Atención Integral en Salud which serve as first-line health centers.

We see many women and children as well as teenage and adult males.  The doctor provides acute care for non-emergent cases as well as chronic disease management. The clinic helps with managing chronic conditions by giving them a starter regimen for their needed medications as well as plenty of patient education.

I really enjoyed being a part of a few child psychology sessions with the clinic Psychologist, Tatiana.  The conditions that are endured by families can cause young children to find unhealthy and dangerous coping strategies, and it gives me hope that starting regular sessions would improve their coping skills now as well as later during their adult years. 

Looking forward to meeting more people of Alajuelita and being a part of FIMRC's Proyecto Alajuelita!

-Huda

Early week 2 update

What a great weekend.  Waterfalls, hiking, swimming in rivers.....it was some good R&R before starting a very busy week 2.

Velo de Novia, one of the waterfalls we visited

But now....back to work.  Yesterday was a longer day, working at the hospital in the morning before spending the afternoon and evening at the Chanchamayo prison for a health campaign.  We identified some sicker people there then at the health campaigns last week. Some examples included: out-of-control diabetes and hypertension, bloody cough and fevers concerning for tuberculosis, an unidentified neck mass concerning for a thyroid nodule, and a woman with stage III uterine cancer who recently developed rectal bleeding.  Interestingly, the accounts given by the prisoners sometimes did not match up with those of the prison's medical staff, who tended to downplay the concerns of the prisoners.  I'll leave that open to interpretation.  

This morning more work in the hospital, this time in cardiology. Tonight, we're going to the fire-station where I'll be leading some CPR teaching.  The firefighters are, from what I have been able to gather, the only medically equipped first-responders here in La Merced.  Unfortunately, they're all volunteers and many don't know how to use their equipment or perform basic life support procedures like CPR.  

There's some interesting and controversial ethics behind teaching CPR in developing countries, as highlighted in this paper by Friesen, Patterson, and Munjal from the past year.  I have some misgivings about designing CPR lessons for lay-people in rural native communities, which I had been asked to do originally by the FIMRC-Peru administration.  Without getting into it too much here, though, I see less of an ethical dilemma in teaching CPR to designated first-responders who are going to be taking ambulances to medical emergencies with or without me.  So I'm excited for tonight.

Hasta luego,

Nick

Costa Rica - Weekend Update

 After a wonderful first week in Clinic, the #treschicasinrica were able to have some fun-- we headed to the Arenal Volcano as a part of a tour package that included travel, two meals, and some time in the relaxing natural hot springs that are warmed by the heat from the volcano. Along the way, on the three hour journey to  La Fortuna, the district where the volcano is, our wonderful tour guide Edgardo pointed out beautiful landmarks and educated us on the rich history of Costa Rica. 

One of the most interesting things about Costa Rica is that it is such melting pot of culture. About 9% of the population consists of people born in Nicaragua, escaping the circumstances of their country. They are the largest ethnic group that our clinic serves outside of Costa Rican locals. Because many of them are undocumented citizens, they are not eligible for the social insurance, and must pay out of pocket for healthcare costs, or come to clinics like ours. However, their children are still eligible to go to schools here; not only are they eligible, but it is mandatory; parents who do not send their students to school (Nicaraguans and Costa Ricans alike), may face a fine or worse consequences. 

Huda & I with two of our fellow FIMRC volunteers, Courtney & Sabrina at Volcan Arenal

In addition to citizens from other countries in Latin America, the Caribbean (east) coast of the country is home to a large percentage of citizens of Jamaican descent that migrated decades ago for better work opportunities. As our tour guide put it, Costa Ricans welcome other cultures as their influence as far as food, and music only serves to enhance Costa Rican culture!

Volcan Arenal, which is active but has not erupted since December 2010. 

Some of the hot springs we bathed in at The Springs resort near Arenal

We will update with  more of our service projects in the coming week! 

Pura Vida!

Amanda

Hola from Santa Ana, Costa Rica from the #treschicasenrica !

I think I can safely say that all three of us girls feel extremely happy to be here and lucky to have this opportunity. A week has already passed and so much has happened that it's hard know where to start.  I'll give you a quick overview of the week from my perspective!

Saturday: Our arrival was a little complicated.  Between the 3 of us we brought 6 bags full of medical supplies (each weighing 30-50 lbs), our own personal suitcases and backpacks.  This made for an interesting trip through Customs when landing in Costa Rica.

2 of the 6 bags of medical supplies we packed and traveled with, they were up to 50 lbs! Thank you Donors!

Amanda, wondering how we managed to carry all 6 bags through both airports, customs, and have them arrive safely at the clinic.

Sunday: Our FIMRC coordinator, Rita, helped organize a trip for us to visit a National Park in Costa Rica called Manuel Antonio. This was a wonderful way to get acquainted to Costa Rica. Our driver picked us up at 6:00 am and we headed to the national park where we did a small hike and saw monkeys, sloths, and raccoons (up close and personal) and ended up at the most beautiful beach!!

The beach at Antonio Manuel National Park.

One of the many monkeys we saw along our hike to the beach.

Monday: The first at the clinic was very exciting.  The mothers at our home stays made us breakfast and packed our lunch before the van picked us up and took us to the clinic in Alajuelita with the other volunteers!  Most other volunteers are undergraduate and pre-medical students volunteering for 1-2 weeks.  The employees of the FIMRC clinic were excited for our arrival, because they know we will be staying for 6 weeks and they have a wonderful existing relationship with MSU College of Human Medicine.  They are also excited that we speak Spanish and have a good amount of medical knowledge!  Lastly, I think they were most excited by all of the WONDERFUL medical supplies we brought with the help of our donors--- Thank you!

My breakfast: egg scramble with ham and cheese, tortillas with white cheese, grapes, orange juice, and coffee.  This was a lot of food, but breakfast is the biggest meal of the day here! 

Volunteers at the clinic on Monday, with Diyon (in costume), the Alajuelita Clinic coordinator.  The clinic employees are AWESOME and were so welcoming.

Tuesday: From 8:30am -12:00pm each morning we rotate working through different areas of the clinic (we'll speak more to this later).  Afternoons are usually reserved for education and some play.  Tuesday, we prepared a "charla" or mini educational talk for a group of boys from Alajuelita (the city where the clinic is located).  After, we played dodgeball and kickball with the kids-- they are very athletic and very competitive!!

La charla: the educational talk prepared about healthy eating.

Volunteers and players after the games!

Wednesday: Sick day for me :( but my wonderful group members gave another charla about the importance of breastfeeding and its benefits! 

One of the women attending "la charla" holding the poster with information about breastfeeding.

Thursday: Some mornings we rotate at the soup kitchen in Alajuelita which is partially funded and supported by FIMRC.  On Thursday, Amanda, Nicole, and I went to the soup kitchen to help prepare and serve lunch to many families in the area that also visit the clinic for free medical care. At night, we went to a well known restaurant in Costa Rica called "Mirador Tiquicia" where we were able to enjoy a show put on by Costa Ricans who performed dances very traditional to the country. 

Amanda and Nicole preparing lemonade at the soup kitchen.


The show at Mirador Tiquicia.



Mirador Tiquicia is on the top mountains overlooking the cities below.  The view is spectacular!

These were just a few highlights from our stay so far.  It's been a wonderful week in every respect.  There is still so much more to say about the families we stay with, our work in the clinic, and the people we have met.  For now, we are looking forward to exploring the country more this weekend-- hasta luego! --- Andrea (Huda and Amanda) #treschicasenrica   

Catching up with the last few days

First off, internet here in La Merced is extremely spotty so this is the first time I've been able to get online since Monday.  We've been busy, though, so there's a lot to catch up on.  The highlights:

Tuesday - We worked with a local women's organization in a couple different communities.  Part of the visits were general health campaigns, with the pre-med volunteers taking vitals, Accuchecks, BMI, etc., followed by the three of us looking over the results and offering what basic health counseling we could.  The other part focused on domestic violence, which is a big problem in Peru.  This included a segment where me and one of the other volunteers acted out a domestic violence skit, which Mey took a video of and is now holding me hostage with (Just kidding Mey! But seriously delete that video).


Wednesday - Trauma service.  Wound care is a bit different here, though perhaps in predictable ways. All wounds get copious amounts of iodine and alcohol, regardless of perceived contamination.  The reasoning is that they consider all wounds to be contaminated, at least at this hospital.  Related: there is not a lot of hand-washing.  Interesting case of the day: tense, swollen, dusky tissue surrounding a snake bite on a child's ankle.  DDx: Local necrosis primary to the snake bite versus evolving compartment syndrome.


Thursday - We went to a small native community called Belen, where we are helping them build a small school building for their kids.   This is one of two communities where FIMRC will be implementing the Emergency Preparedness program they asked me to help develop, so I was very excited to meet everyone today. Anyway, our day today consisted of climbing an hour up a mountain into the jungle, chopping down 5 trees, dragging them back down, and putting up the frame of the building:




We'll be back to finish the building next week, and we'll likely do our first Emergency Preparedness session as well.  Tomorrow it's off to another native community (the other one my project is going to hopefully be deployed in), where we'll be doing hand-washing teaching among other things.

Also excited for this weekend, when we'll take a little time for ourselves to go hike a waterfall in the nearby jungle.

Hasta Luego,

Nick

LMU Peru 2016: Primeras Impresiones

Nick: It was great to back in the emergency department for the first time in a few months, but this time it was in Peru!  The department wasn't all that different from what we see in the united states, but certain things did stand out.  It's mostly staffed by non-emergency trained physicians, similar to the original U.S. ED's or some contemporary rural ED's that haven't been able to hire emergency physicians.  The doctor I worked with today had excellent clinical acumen, and it was clear they rely a bit less on testing and radiology than we do.  It was a good shift, and I learned a lot.  I'm excited to go back, keep practicing my medical Spanish, and build relationships with the doctors in the ED.

In the afternoon we planned out our outreach activities for the rest of the week, some of which we'll be working on tomorrow.  It's shaping up to be a good week!

Johnathan: Our trip started off a little rough, with my donation baggage getting lost somewhere between Miami and Lima.  But I knew it would be a fun trip when in the first hour of our arrival, I was able to use my English, Spanish, and Chinese.  We spent our first day on travel and getting to know some of our teammates from Massachusetts and New York and then began our clinical experiences today.  Along the way, I got to try my first Peruvian street dish, choclo con queso (corn with the largest kernels ever and a side of cheese).  Today was our first clinical day and I got a taste of their internal medicine outpatient work with one of the most popular and hilarious doctors in the hospital.  Our hosts here in Peru have been amazing as well.  The host family made a great dinner of Peruvian tortillas (a kind of chicken omelette) and the staff, Dinah and Allison, have been incredibly helpful.  All in all, not a bad start.

Mey: I have been looking forward to this trip and it has not disappointed. On the plane, I sat next to a Peruvian lady who had married a Chinese man and was excited to meet a Chinese girl going to Peru. Even though my Spanish was limited, we had a great conversation and she offered to take us around Chinatown in Lima. So far the people have been amazing in Peru. The driver's wife knew Cantonese and I was so happy to chat with her. We spent the next day traveling from Lima to La Merced. The back drop of the Andes was breath taking. The massive rolling hills, waterfalls and winding roads was worth the long ride. Today was our first clinical experience here. I got to go to San Ramon, the next town over, and volunteered in the maternal/child department. What could be better than working with moms and their babies? Oh, and the coffee here is YUMMY.

Joe: The residency interview season caused me to arrive a little later than the rest of the group to Peru.  Unfortunately, this caused me to miss a few days of activities and to travel alone on the two day journey to La Merced.  It was definitely an experience traveling all the way from Michigan at 7:00 AM to Lima by 10:00 PM, making it all the way through customs and to the Hostel by 12:00 midnight, and riding on the 10 hour bus trip from Lima at 8:30 AM to La Merced where we arrived at 6:30 PM. Que una viaje larga!  I was on the second level of the bus and had a FANTASTIC view of the rolling, serpent-like roads that clung close to the mountainsides.  Often the road followed the natural tributaries of the Amazon river that carved out valleys in the mountains.  On first impression, the people of Peru are very kind, helpful and interested.  The city of Lima was a bit rough, but just outside it the Peruvian countryside is breathtaking.  I cannot believe how crazy the drivers are here.  Although I have experienced the insane driving of Haiti and other countries, in Peru it is a completely different ballgame because one poor move and you might find yourself rolling down the slope or crashing into the mountain side.  I look forward to investigating and learning more about this beautiful country. Stay tuned!

Welcome to the MSU-CHM Underserved Electives for the Leadership in Medicine for the Underserved Program (LMU) blog for 2016!  We are excited for our trip to the following countries:  Costa Rica, Dominican Republic at the Haitian border, and Peru!  Please take time to return to the blog to see how the medical students and the communities are doing throughout the 8 week experience.  There are also 4 students remaining locally working at various clinics and community areas, so be watching for their comments!  For those of you who have donated to the cause, I thank you.  For those of you following because you have a special person participating, thank you for your encouragement and support of that student!  We are off to our countries and sites on Saturday, January 9, 2016 and shall return on February 24, 2016.  Bon Voyage! Salud!  You shall hear from us soon!  Dr. Rae Schnuth