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 café 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!

Nicaragua- Project Limon

A recap of some highlights from last week in Tola, Nicaragua at Project Limon:

 

Caitie, Jenny and Nicole outside the hospital in Rivas

We have had a lot of fun different opportunities so far between working in the clinic and hospital to many community outreach programs. Some of our outreach experiences have included: 

Community tours

Our community is in the Department (like a state) of Rivas, Nicaragua. The community, Tola, is very rural and is comprised of 5 smaller neighborhoods. We spent an afternoon walking through the communities to get acquainted with where we are and learn more about our surroundings. We visited some of the Tiendas and restaurants but there isn’t much for sale here and the nearest grocery store is about an hour away.  We visited the local cemetery and noticed all of their caskets were cement and above ground. We saw the salt fields where they harvest salt from the ocean. 

Cemetery in Las Salinas, Rivas

There is a bakery, Paradise Bakery, but they don’t have baked goods on hand, its all made to order days in advance. Similarly, many of the “restaurants” are found in the homes of women who are known to be particularly good cooks in the community and open their living rooms for dining at lunchtime. A typical meal always includes beans and rice or gallo pinto (bean and rice mixed) and some sort of meat, especially sea food.

Typical Nicaraguan meal

The Natural Healer

We spent an afternoon visiting a local natural healer. She was in her eighties and grew up with other natural healers in her family. Despite many non-western methods she also prescribes things such as anti-parasite medications when she thinks they are indicated. While we were there she diagnosed us individually with ailments from parasites to slipped vertebral discs.

The natural healer working on Jenny

Diabetic and Prenatal home visits

We divided up and spent a few afternoons visiting patients in their homes for diabetes and prenatal checks. For the diabetic visits we checked every patient’s glucose and blood pressure and spent some time counseling. For the prenatal visits, FIMRC has a program where they visit the home of every pregnant person in the community once a month and go over an educational curriculum about pregnancy and motherhood. We all really enjoyed the opportunity to get out in to the community, meeting different members of the community in their homes. 

Physical therapy and clean-up

Tomeny helping us with the clean-up

Every Friday morning, FIMRC runs a therapy clinic for children with various special needs such as children with developmental delays, learning disabilities, cerebral palsy and more. We work with the children every Friday doing physical therapy and learning games. They always finish with a good game of musical chairs. This week we also helped cleaning up the center inside and out, including weeding with machetes and burning the yard waste (the method of trash removal around here). 

Jenny tending to the fires of our yard clippings

FunLimon Carnival

A local community foundation, FunLimon, put on a carnival Friday evening were we participated by creating a health Jeopardy game for kids to play and gave out prizes from the donations we brought. The game was a big hit (or more so the prizes) and we had a never-ending line of kids. A few other local organizations set up informational booths and there was a bouncehouse, a clown running games and cotton candy. Also, 3 major league baseball players came down to run a baseball camp over the weekend and were signing autographs at the carnival. 

Showing off our handy work - Jeopardy game behind us

Us with most of the FIMRC Nicaragua group

We could go on about all we are experiencing and learning and all the great people in the community we have been getting to know, but that's it for now!

"jumping" picture as we head off for a hike

Nicaragua!

Hola desde Nicaragua! Jenny, Nicole, Caitie and Rachel here. After a night stay in a lively, beautiful town, Granada, we arrived at our site Sunday morning to get acquainted with our new neighborhood in Limon II and settle in to our house. Our little casita is in the back of a complex bordering a small rainforest. In our two days here, we have seen a small scorpion, a scorpion/spider hybrid, grasshopper and geko (all our in our house) and a gang of howler monkeys showed up in the early morning at the rainforest behind our hosue, waking us up with their screams.

Our casita for the next 7 weeks

The complex is nestled on a small dirt road in Limon II, a small community in the state of Rivas, Nicaragua. The complex is owned by a couple from Florida who are coordinating our living arrangements. We eat breakfast and some dinner in a common area where a local Nicaraguan cook prepares food. The beach, Playa Santana is a short walk down the road from where we are staying. It is a gorgeous beach on the Pacific Ocean and is relatively remote.

La playa Santana near our house

Today was our first day at the clinic. While here will be working at the FIMRC clinic (the organization we are here with), the Health Post clinic (a local public clinic) and at the hospital in Rivas, the nearest large city. We will also be doing community outreach projects such as diabetes home visits and prenatal home visits.

The FIMRC clinic site

The FIMRC clinic is housed in a public building that was donated to FIMRC by the community. There are latrines out back for restrooms and a jug of clean water is kept inside the clinic. A few giant pigs seem to hang out near the back of the property. All of the walls inside were painted by previous FIMRC volunteers with an emphasis on pediatric topics such as colors and animal names. The clinic is staffed by a Nicaraguan doctor, a Pediatric Surgeon, who sees general pediatric concerns in the small community a few days a week.

Inside the FIMRC clinic, the small Farmacia on the left and the Consultas room on the right. 

Today we unloaded our donations that we brought in the morning and saw patients with the doctor in the afternoon. We already saw the Pediatric Tylenol and Hydrocortisone creams we brought get put to good use as we sent patients home with their necessary medications.

The procedure room in the Health Post clinic

Tomorrow we are working in the Health Post clinic (just next door to the FIMRC clinic) with a general practice physician. We will see adults and kids there but we are told that there will be a lot of pediatrics and obstetrics in the area. 

That's it for now. Adios de Nicaragua!