Pictures!

We just got back from meeting up with Maritza's second cousin, Juan Carlos, who is currently a fourth-year (out of seven years total) medical student at UNAN-Leon (the university affiliated with the hospital in which Amy and I have been working). He is a sweet 22-year old guy who rises at 5:45 am and studies until 1 am every night. We spent a few hours chatting and listening to a live Nicaraguan band at a local bar, El Divino Castigo. He's the only soon-to-be doctor in a large extended family and so has started fielding health-related questions from many relatives already.

It was hard to say goodbye to the OB residents, medical students, and nurses today. The best part of every internation rotation has always been meeting people and creating new friendships; the worst part saying goodbye and wondering when the next time we see each other will be.

Cindy

Here are some pictures as promised:

1. The beautiful home of Maritza's beautiful family in Matagalpa

2. 10-year old Jason (Maritza's nephew) with the three 1-month old puppies

3. Amy with 3-year old Kenneth (Jason's brother), who brought out each of his toys one by one to show us

4. Maritza's mom with grandchild #37, 6-week old baby Joseph!


5. Lorena, Maritza's youngest sister and proud mother of the three boys


6. The best place in Matagalpa to find hand-made guirilas (corn tortillas) -- que rico!


7. Amy and I at Selva Negra feeling happy after a belated breakfast and cup of fresh organic coffee


8. The swans line up for a photoshoot


9. Amy enjoying her new digital camera at Selva Negra, where there are also many hiking trails


10. The chapel at Selva Negra that looks like it's straight out of a fairy tale


11. Our taxi driver, named either Wilmer or Wilber, stops to let us take a picture of Matagalpa


12. The view atop of a hilly street in Matagalpa on our way to the bus terminal


13. When was the last time you rode a school bus -- for 4 hours?


14. Hospital Escuela Oscar Danilo Rosales, the UNAN-Leon affilliated teaching hospital where Amy and I are working


15. The OB residents, Dr. Danilo, and me


16. Their version of the Friedman curve (based on a huge Latin American study), filled out *hourly* by residents and med students and required for every patient!


17. The lone external fetal heart monitor in L&D, more often than not it seems that the tracing is "non-reassuring" and the patient is off to a c-section. :( Evil.

Our Own "Amazing Race" Weekend

Welcome back to the States, Jimmy D! Thanks for your e-mail to Amy and me. Before I forget, I wanted to comment as well about c-sections here. Fortunately, there are Russians, Kochers, and all the usual surgical tools -- including the beloved bladder blade. Because they do vertical skin incisions, some make bladder flaps and some don't. The uterus is always closed with two sets of running locked stitches. The peritoneum always closed (locked) and the fascia is also closed with locked stitches. If it's a vertical incision, it's vertical mattresses for the skin; if it's a pfannensteil, it's a running subcuticular. The residents are pretty fast with their sections and babies are out in about two minutes (literally), but closing is another story because they also keep the uterus inside on top of using sutures for everything... I told them I'd dig up some much-needed grapas (staples) for them when I got back to the States!

Alright, enough medical stuff -- on to a recap of our weekend, which Amy and I decided felt like our very own "Amazing Race" in that we had clear objectives in mind but not the organization, punctuality, or paved roads we're used to in the States. But the chaos is what helps make the memories...

***
THE AMAZING RACE - NICARAGUA, Episode 1:

Our mission goals:
1. Have laundry done by the weekend
2. Meet up with Maritza's family in Matagalpa on Saturday afternoon/night
3. Try a guirilla and visit the famed church in town
4. Purchase 4 lbs of coffee each at Selva Negra, a German-owned coffee farm
5. Catch the 3 pm express bus back to Leon on Sunday

**Amy continues the blog....***

1). So getting the laundry done here is pretty simple. We drop it off at "Big Foot," an Aussie-run hostel where you can pay $3.50 for a weeks' worth of clothing for two petite chicas. Wash, dry and fold! A bargain. They also sell these awesome brownies. Also of note- the residents are OBSESSED with our matching scrubs. I promised one of the anesthesia residents that she could have mine, and I think I may have made her year. She reminds me of it everyday. Task is completed!

2.) El terminado. Imagine a chaotic center with no ticket booth, no list of schedules, vendors and their children running every which way selling everything from religion to red soda pop. Nicaraguan buses are large yellow school buses with colorful decorations on the side- Bob Marley, Jesus- the important things...... Miraculously, Cindy and I somehow to found the correct bus. However, it was overflowing with people on the way to Matagalpa. Wisely, we decided to wait for the next one as the trip is approximately four hours and without AC or an intact shock system. After a seemingly endless journey over marginally constructed roads we arrived in Matagalpa, the "Bay area of Nicaragua," a pleasantly cool and mountainous region. We were welcomed by Maritza's loving family who spoiled Cindy and me with adorable babies and puppies, delectable food and plenty of smiles and hugs.

***Cindy continues the blog...*** (this blog has been written over the course of three days)

3.) Maritza's sister, Lorena, took us on a stroll of Matagalpa center including to its main church in town. Afterward we waited in a looooong line for freshly-made corn tortillas called guirilas, a Matagalpan specialty. They were slightly thicker and sweeter than regular tortillas and quite delicious.

4.) On Sunday morning we took off to Selva Negra (www.selvanegra.com), a large self-sustaining coffee farm 12 kilometers away. It was started and continues to be run by the same German family. Aside from cultivating organic coffee, they also raise cattle, chickens, and pigs, along with growing flowers and vegetables. We found out on our microbus tour of the farm that they have something like 300 workers, who also live there. They're provided with housing, schooling for the kids, baseball teams, a medical clinic, and three meals a day. Additionally, once the kids graduate from elementary school, they can receive scholarships to a private secondary school in town, and eventually even to a university if they wish to continue. It's an interesting concept to have such a self-sustaining farm and community. Their website has more information for those who are curious. Oh yes, and their coffee truly is delicious. We both purchased 4lbs worth!

5.) After taking the crowded non-express bus from Leon to Matagalpa on Saturday with many, many local stops, we decided to try to catch the 3 pm express bus back. It was a challenge buying tickets as we were first told we could purchase them in advance, so we went to the bus terminal on early Sunday morning. When we got there, they said we couldn't purchase them until after 1 pm. We returned to the bus terminal around 2 pm only to be told that the bus was somewhere behind the terminal. We walked around and found one lone bus and hopped on, only to be told that there were assigned seats. So we hopped off, unsure of how to purchase these elusive tickets, only to be told that the guy selling the tickets was ON the bus. So we went back on the bus and finally bought our two tickets and sat down in seats #41 and #42. It was nice to be on a direct bus with no stops, allowing us to secretly sing along with and enjoy the 80s music without interruptions. We're talking classics from our childhood like: "Eternal Flame", "The Eye of the Tiger", and "The Search is Over" just to name a few!

We arrived back in Leon at 6 pm, collected our washed laundry, and was then pleasantly surprised to be met by Jorge (our very sweet and funny night-time security guard who we call our "bodyguard") and his shy 5-year old son, Franklin, of whom we had only seen pictures.

Overall, a fun filled 36-hours -- mission accomplished. ;) We took lots of pictures and will try to upload them later tonight if energy suffices. For now, we're off to our last day in the hospital. Tomorrow (Wed and Thurs) we will be trekking out to Poneloya, a beach town, to work at a rural clinic!

Amy and Cindy

TGIF again!

First off, a shout-out to Dan and Robin for generously donating five hours of their Thursday evening as our proxies for scheduling night. (Scheduling night is when all twevle members of our class sit down to try to figure out the schedule for the coming year, and suffice it to say it can get difficult with people not wanting to work on certain holidays or wanting vacations at certain times.) Amy and I hope our class provided enough fermented beverages to help set aside any recurring thoughts of, "Why did I volunteer to do this again?!?!" We are both extremely pleased with our schedules so muchas gracias! Something funny did happen though while we were discussing the results of the scheduling. The exchange went something like this:

Amy: So were you happy with the scheduling results?

Cindy: Oh yeah! Robin did a great job!!

Amy: Yeah, Dan did a great job, too. I'm sooooo happy to not be working on Christmas or New Year's. God, I would hate to be the person doing Women's Health that block. Can you imagine? Taking call on BOTH Christmas Eve AND New Year's Eve???!?!? How much would that suck?

Cindy: Hmm... yeah. Guess who that person is?

Amy: Oh -- (gulp)

Cindy: Yup, me!

With all due respect, the truth is it's not that bad and I don't mind it. I just thought it was funny. (Seriously, Robin -- I'm thrilled with my schedule. Thanks! :)

*****

After my last bad experience with the delivery, I decided to look up some information on episiotomies to figure out for myself whether they are necessary or not. Coincidentally, Amy did the same independently after our discussion over dinner that night. Separately, we both found that the most recent evidence shows that routine episiotomies are not justified, and in fact, worsens tears, increases postpartum pain, and can cause dyspareunia and anal incontinence (if midline.) I printed out a couple of abstracts of studies (including one specifically focused on the high prevalence of episiotomies in Latin America -- somewhere between 85-95% for primiparous women!) and showed them to my third-year resident. She said she concurred with much of it, but that, however, because she was at a teaching institution, her attendings still expect it to be done. Even in the States it can be difficult to change old ways, and this is even more apparent in the field of obstetrics.

As would be expected, the residents often like to ask me how things are done or not done in the States. The consensus of our discussions is that medicine is a few steps behind in Nicaragua, and the reason is obvious: lack of resources. Last night I was scrubbed into a couple of c-sections with a 2nd-year resident, Juan, who has an 8-year old son. Jokingly, I said, "Let me guess, he was delivered by c-section." Actually, he wasn't, but that was because Juan was only a medical student then. Now that he's been doing OB/GYN for almost two full years, he says his next child will be delivered by c-section because it's a controlled environment. However, he did offer that if they had epidurals and continuous fetal heart monitoring he, he would be more comfortable with a normal vaginal delivery. I can see where he's coming from. When the resources are limited, you're better off being overly cautious and avoiding emergencies and catastrophes because the resources aren't there for an immediate rescue.

One other thing that's kinda funny is that I brought with me my "Essence" OB handbook, made by one of our very own residents. Many of the residents who have seen it have wanted to make a copy. You may have found yourself a market down here in Nicaragua, Jeff!

Here are some pictures from the hospital:

1. The OB delivery room

2. El Quirofono (operating room)

3. Neonatal resuscitation area in the OR

4. C-section for a breech (legs first) baby, me holding the beloved "barba" (bladder blade)

5. Premature baby in the UCIN (intensive neonatal care unit)

6. An albuterol nebulizer machine

7. A baby with neonatal jaundice getting phototherapy

***

I decided to take a trek out to the local beach, Las Penitas, today after a post-call morning nap. (Amy didn't join me because she was sleeping and recovering from a night out in Chinandega with an anesthesiology resident, Roxanna, who was eager to show her around her hometown.) After a somewhat disappointing visit to a local Guatemalan beach a few years ago, I wasn't expecting anything spectacular. I was pleasantly surprised though. The beach was quite clean and had beautiful crashing waves. The best part was that there weren't too many people there, and of those who were there, 95% were native Nicaraguans. Amy and I have both commented that one of the main reasons we have enjoyed Leon so much is because we don't see too many tourists around town. It's refreshing. Both of us have been to Costa Rica and felt repulsed by the ridiculous number of backpacking gringos or recent college grads on an extended, potentially lifetime spring break.

I met a cute little 11-year old girl, Lupe, who was selling little sculptures made of shells. I bought three of them off her on the condition that I could take her picture. Sharply, she snapped back, "Sure, but only if I can take a picture of you, too. I'm good at taking pictures." We exchanged picture taking and I realized I had a packet of Elmo stickers with me (Amy and I had brought stickers in the case we were working with kids in the hospital or clinic). I gave her the two sheets and she asked me if I had more because she has twenty other brothers and sisters. Twenty?!? I said she was lying. She said, "Ok, well I have only eight brothers and sisters but we also live with nine cousins!" She was very cute.

Some pictures:

1. Hotel Suyapa Beach, the "swankiest" place on the beach according to Lonely Planet and locals. I enjoyed a coke and rum (Flor de Cana, Nicaraguan brand) here.

2. Near sunset, the fishermen on lanchas (boats) head out to spear some fish

3. Lupe, savvy saleswoman of 11 years old

4. A satisfied customer!

5. Locals watching the lanchas head out

***
Alright, off to catch some zzzzzs. We're headed to Matagalpa in the Northern Highlands about four hours away this weekend to meet the family of one of the medical assistants with whom we work in our Family Practice clinic. There are supposedly lots of organic coffee farms as well and the weather should be cooler -- thank goodness!

Cindy

Spanish Errors

Speaking in a second language always seems to pave the way for some good laughs to a native speaker on the receiving end. While my spanish is decent during the day, it definitely starts to get sloppier the more tired I get. Here are a couple of good examples on my last call:

I was asked to evaluate a patient who was in the hospital for preterm labor and had returned from the bathroom thinking she may have broken her bag. Afterward, I presented my findings to the chief resident and said: "Esta paciente es una mujer que ha tenido tres ojos antes de este embarazo.", which translates to "This patient is a woman who has had three EYES before this pregnancy." "

Ojos = Eyes
Hijos = Children

Oops. Even funnier was when I was scrubbed into a c-section at 3 AM with the third-year resident. Here, staples are too expensive so they close the skin with sutures, specifically vertical mattresses (a type of stitch). The resident requested another pair of suture and forceps for me to help so I asked "Cochones verticales?", thinking I was asking "Vertical mattresses?" Everyone started laughing because it turns out I had asked instead: "Vertical homosexuals?"

Colchones = Mattresses
Cochones = Homosexuals

It's remarkable how a simple little "L" can make a BIG difference...

This week a group of orthopedic surgeons and their staff from North Carolina are making their sixth trip down here to donate lots of supplies (and a fluoroscopy machine!), perform seven to eight operations per day, and do some teaching to the residents and attendings. Eventually, according to Amy, they hope to donate $10,000 to open up a special "orthopedic ward" -- pretty remarkable. Operation Smile is also currently in Nicaragua making its way around the country to operate on children with cleft palates. At dinner last night I was telling Amy how seeing how these two groups can make a drastic difference in such a short amount of time actually made me wish I were a surgeon in some ways. Amy reminded me, though, that currently we are in the "tertiary center"of Nicaragua, where there are residents, attendings, etc, and so don't feel as "needed" per se. However, if we traveled even 10-20 miles out of Leon, we'd be in a more rural location where suddenly the skills we've learned during our family medicine training would be more valuable.

Today was a hoppin' day in Labor & Delivery, with too many patients to available beds. There were something like twelve patients and only eight beds, so the unfortunate last four had to just sit in a chair or walk around. Crazy. I did a delivery today that left me with an unpleasant taste in my mouth - figuratively. First, there was a first year male OB resident and nurse yelling angrily at the patient to push harder even though she was doing a great job. Here, it seems if the baby is not out in five minutes, they get ridiculously impatient and say things like, ¨Don't you want to see your baby? Why aren't you pushing harder?!?¨ At one point the resident actually put all his weight on the woman's belly to "help" her while continuing to yell at her. Then, there was the extremely nervous pediatric intern obsessing about bulb suctioning and telling me to immediately put the baby on the mom's belly prior to cutting the cord (traditionally done here). I've tried not to be too critical vocally during my days in the hospital because truly Amy and I are guests and who is to say our way -- the U.S. way -- is the best way. But today was tough. I think the bottom line is that I need to review the literature to decide for myself what is, first, safer, and second, more considerate to the mom and baby.

Cindy

Recuperating

Thank you, Amy, for the recap on our weekend. I was too worn-out from the two-day trip to contribute yesterday and was instead busy nursing numerous blisters. That hike was probably the second most difficult one I've done due to the intense heat, serious leg muscle cramps, and carrying an extra 30-lbs on my tiny little back. My most difficult hike was two years ago in Guatemala, where I summitted Volcan Santa Maria, whose peak is at 12, 372 feet! Then I was fighting altitude adjustment issues. Likely, though, in both cases the main problem was poor conditioning -- too much arroz y frijoles (rice and beans)! Anyway, climbing Volcan Telica was a pretty unique experience as we ended up camping right next to one of Nicaragua's most active volcano at 3481 feet. Fortunately, there was no grand eruption overnight and we returned more or less in one piece, plus an additional 1-cm thick layer of dirt from head to toe that turned the shower water quite disturbingly dark...

But here are some pictures that made it all worth it, not to mention the wonderful travel companion and memories. ;)

1. An aerial view of Volcan Telica ("borrowed" from http://www.volcano.si.edu/world/volcano.cfm?vnum=1404-04=), last major eruption was in 2004.


2. The very beginning of the trail, with another volcano in the background. (Amy is the one with the large blue backpack.)

3. The boiling mudpots of Hervideros de San Jacinto, a prominent geothermal area along the hike to Volcan Telica.


4. Almost there! Finally, the crater of Volcan Telica is in sight after a long hour stretch of uphill climbing in drenching sweats.

5. Our camp site, shared with another group of hikers.

6. Cindy atop the crater (but not too close to the edge...)


6. Amy atop the crater (also not too close to the edge...)

7. Hikers waiting for a well-deserved beautiful sunset


8. A "Lion King"-esque tree at sunset

Cindy and Amy v.s. The Volcano

We left off writing about our day on FRIDAY- so I'll pick up from there.

I'm really enjoying anesthesia/surgery at the hospital. So far I've been intubating and performing initial airway management and then scrubbing in on the cases. One of the coolest cases on Friday included an eight year old girl with necrotizing fascititis (dying internal tissue) from a snake bite. From hip to toe -- the entire leg was open with rotting flesh. We cut and washed out the dying tissue and did a loose approximation of the skin. The little girl will probably stay in the ICU for the next several weeks for antibiotics. It was nothing like I had ever seen. I have to agree with Cindy that while the hospital is extremely poor, people seem to be well attended. They are more conservative with material and reuse just about everything from intubation tubes, bovies, sterile gowns, etc.

Cindy mentioned that I spent part of my lunch break visiting two patients that are disabled and working as mechanics. The man renting us the apartment, Santiago, helps them as well as other people with physical disabilities assimilate into the workforce. It's amazing how people here simply WANT to work and contribute to society- while so many of our patients at home present to our clinic with disability forms to be completed for far less significant afflictions.

SATURDAY
The alarm went off at 5:45 and we stumbled out of bed to head off to Quetzaltrekkers- an organization that helps street children by raising funds through backpacking trips to volcanoes. To own own meager supplies we added 150 ml of bottled water, food, sleeping bags and tents. By the time we put on packs again- they weighed about the same as a four-year-old child. We were led by an Austrailian bloke named Nigel and another guide-in-training- Janine.

I was really excited because I correctly guessed that Janine was from Chicago after 3 minutes of talking to her- I love doing that!

We started climbing at about 9:00- we passed several fields with oxen and workers on horses. One particular worker donned a T-shirt with the logo "Latinas-gone-wild.com" We walked for several hours through dusty roads with a few brief, much needed breaks under the infrequent trees. After the third stop at Nicaragua's most perfect Mango climbing tree, we did one of the hardest 45 minutes of hiking in our life. The combo of the heat, dirt, elevation, unsteadying rocks with the 30 extra pounds on our backs made it especially challenging. I kept trying to psych myself out- "It's just like a cardio class- no more,"

After an intense climb- we stopped for lunch.
Cindy asks "Do I have anything on my face,"
I respond: "No- do I?"
Apparently, I had dirt all over my face and looked like I had just survived a war zone. We thought this was funny and it became a joke throughout the day. Having similar eating tastes, Cindy and I were both stoked that lunch did not contain mayonaise and cheese.

We arrived at the campsite and base of the volcano after another hour of hiking. The we set up camp and laid motionless in the shade. While the rest was appreciated- we (mostly me) were still covered in an inch of grime and sweating.

The volcano we visited, Telica- is one of several active volcanoes in Nicaragua and quite impressive. We stood close to the edge and watched the smoke eminating from 150 meters below. The views of the sky were particularly beautiful- We could see far into the distance to other volcanoes, farms and our own town of Leon. We enjoyed a colorful sunset- but agree that the best sunsets in the world are in L.A. due to the exceptional "marine layer," aka smog.

After a campfire, dinner and marshmallows- we had an intense game of Uno under headlamps with our fellow campers. Exhausted, we struggled with finding a comfortable spot on the floor of our teeny-two-person tent and eventually got to sleep. During the night, the wind was especially powerful and nearly blew away our tent if it weren't for the collective 200 pounds of Cindy and I weighing it down.

Our second day of hiking was significantly easier as we had consumed nearly all of the food and water and went down the volcano with gravity on our side. There were a few close calls with sliding down the gravel and rocks, but we made it back with no major injuries. Our first meal back was gregariously appreciated with generous portions of Nicaraguan comida tipica- rice, beans, chicken, platanos- yum. We arrived back to our apartment, greeted our security guard (and HUGE fan of Celine Dion) Jorge and basked in the gloriousness of water and soap.

Amy

TGIF!

It's only been five days really but I'm wiped out -- the result of the hot-sun, speaking in a second language, and navigating around a new city, hospital, and culture. I think Amy would agree with me. (She's currently scrubbed into some surgical cases.)

I delivered another baby today to a primip without an episiotomy, or laceration. Phew. There were different nurses and residents around this time and, again, they were equally skeptical and providing much commentary throughout. The poor laboring woman. One nurse told me she'd rather have an episiotomy than a vaginal laceration. I guess to each her own. I also brought in the two vacuums that Labor & Delivery donated. The residents played around with it on each other, making lots of ring marks. There are hardly any instrument-assisted deliveries done here, but maybe they'll get to see one or two before Amy and I leave.

Amy did a very cool thing today. She made two "home-visits" to home-bound patients. Santiago, our main contact person here, runs the Polus Center, a non-profit organization for social and economic development. One of his main projects has been trying disabled men find jobs. Some of these men are amputees (I'm not sure from what, possibly the war and landmines?) and some are paraplegics. Today, Amy went to see two of them on behalf of Santiago and their respective families. I'll try to egg Amy on into writing a brief entry about what that experience was like. One comment she did make to me was after seeing pictures in Santiago's photo albums of these unfortunate men on crutches trying their hardest to work on farms and in the fields. Their desire to work despite their obvious handicap contrasted the number of patients we see in the States applying for disability for pretty vague reasons.

Tonight we're headed to see a local Nicaraguan salsa band to which my R3 OB resident invited us, and then tomorrow we're off to hike and camp at a nearby volcano. Sorry no witty remarks or funny stories today -- I'm feeling pretty pooped. Hopefully the weekend will rejuvenate us and we'll upload fun pictures from our weekend. Stay tuned!

Actually, I just remembered something I wanted to mention. On my overnight call, I ended up "sleeping" on a table because there are no call rooms for residents so residents sleep wherever they can, including patient beds (when there is no patient in it, of course, although the thought did cross my mind...) There was a strike about 1.5 years ago for higher resident and physician salaries. Before the strike the residents were paid nothing, zero, nada. Since the strike they now receive about $450 US dollars a month, which is still not much. They work q4 shifts from 7am to 3pm the next day, but on the intervening days they work just from 7am to 3pm. At night the residents run the hospital and attendings are called in possibly once a month. The one thing that remains the same in the US and Nicaragua is . . . paperwork! There is a "monton" of paperwork and residents are always busy filling them out, and, of course, the interns have to do the brunt of it. Because I wrote an H&P that got a lot of laughs because of its elementary direct translation from English, I'm exempt from the paperwork. Here's an example that made the R3 resident laugh aloud.

General: La paciente esta alerta y comoda. Hace algo ruido durante los dolores pero no esta gritando... (The patient is alert and comfortable. She makes some noise during contractions but is not screaming...)

Alright, Amy's back and we're going to get ready to head out.

Cindy

C-section, anyone?

I've just recuperated from a busy night on call working on labor and delivery, where they average 15-25 deliveries in 24-hours. I delivered my first Nicaraguan baby, a 3400 gram porker (considered large here), to a first-time mom. When I told the resident and nurse I was *not* going to do an episiotomy (they do it on all primips), the fourth-year resident snickered back, "That's fine. Just have fun stitching up your big-ass tear..." It turned out thanks to Felipa teaching me about super-crowning and controlling the head at the perineum, the patient had only a very small 1st degree tear that needed one stitch. The nurse and med student were quite impressed. I received a "Muy elegante, Dra. Su." from nurse Carolina which helped bring down my blood pressure and heart rate, as I worried I was going to blow it and they would laugh at the ignorant and haughty American who was suturing up a large 2nd or 3rd degree tear. Phew.

The amount of c-sections in the hospital is hovering around 40% and the past 24-hours in the hospital were no different. Perhaps, actually, there were slightly more c-sections than normal, vaginal deliveries. I miss those! A couple of thoughts why the c-section rate is so high: 1) VBACs (vaginal births after prior c-section) at all, 2) limited use of fetal monitoring, and 3) hardly any use of instrumental delivery (no vacuums or forceps). Reason number two is mostly from my own personal observation. They have only one fetal monitor machine and use it on a limited basis. For example, yesterday there was a woman who came in at 3 cm and hadn't progressed after a few hours on pitocin. They decided to put the fetal monitor and toconometer on her and saw a 20 minute strip of tachycardia with a couple of variables (not decels). She ended up with a c-section because of that strip. In another case, a woman with preeclampsia had a somewhat flat-looking 20 minute strip (minimum variability) but otherwise was asymptomatic and having contractions. She went to section. When I asked the residents if they had the ability to have an indefinite number of fetal monitoring machines would they be inclined to use it on all patients throughout their entire labor. Their answer was yes. It seems to me that they should either use it all the time or none of the time. Otherwise, sometimes decisions to have a c-section are based on a twenty-minute snapshot fetal heart strip.

Another woman had a primary section without a trial of labor because on clinical exam (including the beloved pelvimetry exam we residents in the States get poor training on) and some "Johnson formula" they use to calculate macrosomia suggested that there was going to be cephalopelvic disproportion. The baby turned out to be 3800 grams so not meeting macrosomia by our definition (their argument is that Nicaraguans tend to be smaller than North Americans, which is true, but I've had tiny Mexican women deliver 7, 8, 9-lb babies vaginally). It would have be interesting to see if she might have been able to deliver that baby vaginally if given a chance. A last comment is that so many of the fundal heights at term measure 30-34 cm. I was pretty shocked, at first thinking oligohydramnios, IUGR, or just something bad in general. The residents argue that it's a combination of Nicaraguans being smaller people and the prevalence of malnutrition in the country. I think I agree with them on that one.

Overall, I have been impressed, though, by the residents and the way they run the hospital. For the most part, in labor and delivery anyway, they manage complications like we do. The residents are incredibly smart here, as there are only two public medical schools (one in Leon and one in Managua) and they are super-hard to get into. It is the only field where the tuition is free, making it that much more competitive. Thus, these residents are the creme de la creme. They are intelligent, hard-working, passionate, and quite amiable. Their clinical skills and knowledge base are quite immense as they are always reading textbooks and studying.

My partner in crime, Amy, is currently crawling into bed because our apartment is on a loud street and she hasn't been sleeping well. While I was on call last night, she was putting together a 56-slide powerpoint presentation for a 6:30 am meeting with an anesthesiology attending, Dr. Gomez. As expected, he was impressed, and she was doing intubations with him all morning. Good job, Amy!

So we are working hard on our elective away, getting to know the residents, attendings, and nurses, and just enjoying being in Nicaragua, where everyone we've met has been so friendly and welcoming. The hospital doesn't get too many foreign visitors (we may be the first from the U.S.) so they are all eager to ask us about life in the States and to practice their English. I'm hoping to spend the majority of my three weeks doing OB and weaseling my way into actually doing the c-sections , while Amy will be spending a few days in each department (surgery, anesthesiology, pediatrics, and OB). We're also hoping to try to head out to a rural clinic for a day or two at the end if we can.

By the way, for those not in medicine, I realize much of the blog is filled with medical jargon and I apologize. It's hard when most of our days have been in the hospital. This weekend we'll be going on a two-day camping trip to a volcano so will have more "non-medical" things to share. And hopefully lots of pictures as well! Stay posted!

Cindy

First Day in the Hospital

We had our first day in the hospital and spent an unfortunate amount of time shadowing. Hopefully, we'll rectify that tomorrow.

In any case, we spent the morning rounding with the high-risk OB team, where we saw cases of pre-eclampsia, preterm labor, pyelonephritis, and a sad case of a woman measuring small for dates carrying an anencephalic baby to term who likely would not survive the delivery. Afterward, I spent the rest of the day in labor and delivery, while Amy was triaging (or more like watching the OB residents triage) in the ER.

A couple of interesting things I learned today. First, an abortion of any kind is illegal in Nicaragua - even an unruptured ectopic pregnancy (for non-medical readers, an ectopic is when a pregnancy is somewhere else outside the uterus). Theoretically, according to the law, one has to wait for the woman with an ectopic pregnancy to show signs of instability (pain does not count) before proceeding. The third-year resident did tell me, though, that often many of her attendings will still go ahead with it prior to its rupture because of its obvious danger to everyone but the ignorant lawmakers. I also learned that one can deliver a baby without any of the many tools we use in the States. I'm exaggerating, of course, as I know it's possible. More, I felt sort of lame on just how much I rely on machines, intrauterine devices, etc. to perform what is a natural process. I felt embarrassed telling the third-year resident that my fancy $120 Littmann III stethoscope had never touched the belly of a pregnant woman before. "What? You can hear the baby's heartbeat without a doppler??" And, get this!, the residents use their very own hands to estimate the frequency and strength (calculating pseudo-montevideo units) of contractions and to rupture membranes. Pitocin drips are "calculated" based on the number of droplets per minute. Crazy. Tomorrow I take my first "turno" (call) and will get to experience all this firsthand. I'm actually looking forward to it, as I'll sure be learning new skills...

Today Amy told me, "Boy, you sure get ogled at." as many calls of "Ooh, chinita, chinita!" finally surfaced as expected while walking on the streets (and even during a funeral march, if you can imagine that!) In one particularly funny incident, I was inside a store asking for directions and Amy was striking up a conversation with the guard outside that went something like this:

Guard: Is she (meaning me) Japanese?

Amy: No, she's Chinese.

Guard: Oh, are you Chinese, too? (To his credit -- sort of -- Amy had on dark sunglasses and a large hat.)

Amy: No, I'm American.

Guard: Oh, why are you friends then?

And he was being completely serious. Bizarre. The other day, our driver Julio also asked me out of the blue: "So does your father own a Chinese restaurant?" Random. Oh well, maybe I'm just a target for seemingly ridiculous questions, as I've had some patients in Santa Rosa ask me if I'm Mexican. Hmmm... Anyway, I'm off to relax a bit before learning to use my stethoscope on parts of the body other than the heart and lungs tomorrow. Wish me luck!

Cindy

Amy's Debut Blog Entry

***Amy writes:***

We awoke today well rested after a full day of traveling and decided to check out the town of Leon in slightly cooler early morning temperatures.

We made our way to the bank where apparently there is only one outdoor ATM where people wait hours to get money. A polite lady with an adorable 9 month-old told us people start lining up an hour and half before the bank opens to stand in line. Wow!! We nixed that idea and went straight for Nicaraguan comida tipico.

We discovered this cool cafe that served gallo pinto (rice and beans) with fried plantains- all for about $1.50. For dessert we bought a bag if fresh fruit in the central square for $0.33. What a deal!! After a delicious meal, we went to the Basilica de la Asuncion - originally built in 1610- and then rebuilt in 1748 after a fire. It is supposedly the largest cathedral in all of Central America. We climbed about six stories and were rewarded with a fantastic view of Leon.
After a little exploring, we met up with Dr. Morales, the head of anesthesia at the hospital and apparently our liason to the residency program. The hospital is huge- four stories holding about 600 beds. They seem pretty flexible about what we can do there in terms of our area of concentration and were suprisingly quick to ask us when we want to take call.

(Amy is off to a shower after a full-day of sweating like a pig -- Sorry, Dan, if I've tainted images of your wife for you...)

*** Cindy continues: ***

So when asked about call by Dr. Morales, the conversation basically went like this:

Amy: I'd love to take call every third night. I feel underworked at our hospital.

Cindy: I agree. I think maybe we should just take call every other night actually.

Amy: Oh yeah, good idea.

Ok, if you believe that dialogue, well, obviously you are a stranger / internet stalker reading this blog.

Basically, we delicately told him we'd be willing to work as hard as they want during the week but that we'd like the weekends to explore their beautiful, precious, __________ (add another superlative you can think of) country. It looks like we may end up taking "turnos" (7 am - 3 pm shifts) Mondays and Thursdays. Are we crazy? Well, we figured we'll keep track of post-call hours and get extra money when we get back to Santa Rosa... ha ha. We'll be taking calls together so should be a fun time. The plan is to start off in obstetrics and then switch to pediatrics.

The hospital is pretty shocking in the sense that everything, including the facility and the equipment, appears old (or at least older than what we're used to, even at Sutter). We took a tour through all departments: surgery, ICU, NICU, peds, OB, emergency, etc. We even got a chance to watch a c-section. I was getting excited and thinking, "Cool, we can do this!" when she started making a long vertical incision, and then I suddenly didn't know what was going on. One remarkable thing I took away in just the two hours we spent getting to know the hospital and its staff (including residents) was how much waste we consume in the States. For example, during the c-section, all the gowns and drapes were made of cloth so as to be able to recycle them. I remember so many times in the OR in the States materials getting thrown out because some tiny non-sterile corner of an unfortunate med student (usually me) touched it. Needless to say, as we start working in the hospital more the differences will become more glaring. Hopefully, the intent of quality of patient care will be the same, though. We''ll let you know.

Alright, the sun has set and we can now leave our apartment without drenching our T-shirts so we're off to grab a bite to eat.

Amy and Cindy


**********


Some pictures:


Views of Leon from atop the Basilica de La Asuncion: (the white building in the first picture on the left is the hospital de Universidad Nacional Autonima de Nicaragua, where we will be working!)









Our apartment (the second floor with the balcony):

From Santa Rosa, CA to Leon, Nicaragua

After last-minute packing and shopping runs, Amy and I left on Saturday night to catch a red-eye flight to Miami on our way to Nicaragua for our 4-week elective. Thanks to previous renowned bomb-carrying passengers, not only did we do the usual removal of jackets, belts, and shoes, but also I had to toss my beloved 8 0z tube of Neutrogena face wash. Amy's husband, Dan, had asked me in the car on the way to the airport what my one must-have comfort item was. After some thought I named that tube of face wash. Sigh. Feeling dejected and the sprouting of an opportunistic pimple, I also realized that we had entered the wrong gate when Amy asked which direction we were headed. So we exited and walked halfway to the next terminal, only to realize that, in fact, we had entered the right gate. (My terrible sense of direction never ceases to amaze me.) So back we went. We had a deja-vu moment, including the scrutinizing of my ziploc bag of bottled items (now minus the face wash) by the exact same security guard.

At the Miami airport we experienced the nosy intrusions and innocent assumptions of other travellers. We started debating whether Kaiser clinics truly provide better efficiency and patient-directed care. As we were concluding that in fact Kaiser patients had equally long wait times and difficulties seeing one's own doctor, an eavesdropping older woman sitting next to us decided to chime in: "Well, I've been a Kaiser patient for over twenty years and I always get to see my doctor!" Later on, just prior to boarding the plane, an overzealous provost (at an American university located just outside of Managua) gave us his name, e-mail, office number, home phone number, cellphone number, the name of his mother, her phone number should we not be able to reach him, etc., in case we were to get sick and in need of a doctor. We thanked him and chuckled to ourselves. Boy, were we glad we were traveling with our personal favorite doctor...

Fourteen hours after our departure from Santa Rosa, we made a wobbly, squeaky-wheeled landing into Managua. We smiled big smiles upon seeing the bright blue sunny sky and, more importantly, a man holding a sign: "Cyndy and Amy". Relief. As I told Amy, it's always good to feel accounted for. We hopped in a car with our driver and history teacher, Julio, to the colonial and academic city of Leon. Apparently, Leon had been the first capital of Nicaragua but then got caught up in a sibling rivalry type fight with Granada. The result was the naming of Managua as the capital, since it was located between the two cities. We also learned that while Nicaragua is the second poorest country in the Western Hemisphere (second to Haiti), it is actually the safest country in Central America.

Our apartment is fabulous. Water runs on Mondays, Wednesdays, and Fridays, and the bathroom is just a short 100-yard walk away. Just kidding, Mom! The apartment is actually located on the top floor of the office building of our main contact person, Santiago. Currently, he remains a "Charlie"to us (hint: TV show) as we have only communicated via e-mail and phone. Anyhow, we have two separate bedrooms (each with air-conditioning), a large kitchen, a spacious bathroom with shower, internet, and a night-time security guard named Jorge. We are in "downtown"Leon and right next to a comtemporary art museum. Everything we need is walkable. This includes banks, supermarkets, restaurants, cafes, bakeries, a movie theater, and, oh yeah, the hospital. Yes, the real reason why we're here. :P We had ourselves a delicious dinner of broiled corvina, french fries, rice, salad, and cold Victoria beer (the Nicaragua brand). The weather is quite summery, probably in the 80s, with a refreshing breeze. We're wearing shorts, t-shirts, sunglasses, and sandals. Life is pretty good right now.

Tomorrow we meet Santiago (I'll let you know if he looks like Bill Murray) and Dr. Morales to figure out where we can help out the most in the hospital. We'll be here from January 14 to February 9 and will try our best to keep this blog updated and include photos. So keep on checking and send a comment if you'd like. We'd love to hear from you!

Cindy