Finally, We Rest -- and then Play!

On Wednesday morning, we awoke at 5 am to meet at the Centro de Salud in the nearby town of Subtiava by 6 am. Supposedly there was to be a group of nurses and doctors, with whom we were to catch a ride to a rural clinic. We arrived at 5:55 am sharp and waited, and waited, and waited... Around 6:45 am, the director of this Centro de Salud shows up and wonders why we are still there. He sort of berates saying that the group normally takes off at 5:45 am and not 6:00 am. We were a bit annoyed because he had told us 6:00 am before. Around 7:30 am we decide to ask what the plan for us was and he says we can accompany another group to the clinic in Poneloya (apparently the 5:45 am was going to another rural location.) So we wait some more. (Rick, you were right -- the national past time of Nicaragua is waiting...) Finally, we hop into a truck and head out to the beach town of Poneloya. It's remarkable how quickly the scenery changes once we leave the city. It becomes immensely more tropical-feeling and within 25 minutes the Pacific Ocean can be seen in the horizon. Ahhhh...

We arrive at the clinic, only to wait some more... By around 9:15 am, the first few patients show up. Unfortunately, there is only one doc there because the other doc is in some meeting until 10 am. Oops. So Amy basically shadows the doc while I sit with the nurse to discuss family planning options with young women. It was somewhat of a disappointing few hours as we felt more like medical students than residents. We did manage to see case of herpes zoster (recurring chickenpox) in a set of siblings. The price of acyclovir is too expensive so they prescribed dicloxacillin instead for a super-infection. The little girl looked like she had some bad impetigo. Around noon, we decided we had seen enough and headed out... to the beach!

Ah, la playa!!! Amy was SOOOOO happy because she didn't get a chance to come out with me last week to Las Penitas. While I took a nap in a hammock listening to the sounds of crashing waves, Amy went for a run along the beach. Afterward we ate at Suyapa Beach Hotel and had ourselves a gigantic fried fish each. Mmmmmm.... At night we ordered some delicious pizza in honor of our incredibly sweet and good-natured security guard, Jorge, of whom we'd grown quite fond. A funny story about Jorge is that for about a week and a half he couldn't remember my name so he kept referring to me as "Sammy" (with the "a" as in "cat"). We thought it was cute because the name was likely a combination of Amy and Cindy. Amy and I liked the name quite a bit so in the apartment I'm called "Sammy" as a joke. Sammy Su -- what do you think? I kinda like the sound of it.

Today, we rested -- finally. Amy went back to the beach for a run, while I ran some errands in town, including dropping off laundry, writing postcards (they're coming, I swear!), napping (of course), and developing pictures for the friends we'd met here. Tonight we went out with a bunch of the OB residents to Disco Bohemio for one last hurrah. The music was a mixture of hip-hop, regaton (I'm not sure of the spelling but it's a mix of salsa/merengue and hip-hop), and straight-out pop dance mixes (when played, Amy and I were the only ones on the dance floor because the locals didn't like the music!) We also witnessed our first lesbian Nicaraguan couple getting their groove on the dance floor -- good for them!

Tomorrow, we start our one week of being a true, full-blown, pool-lounging tourist. We head down to the ultra-touristy towns of Granada for zip-lining and kayaking, and then to San Juan del Sur for some serious swimming, surfing, and relaxing. I'm sure there will be many a internet cafes but likely we won't be so good about keeping this blog updated as frequently. We head back to the States on February 9th so, for those devout readers, keep checking until then. Thanks for sharing in our adventures in Leon and for sending us e-mail and commentaries. We appreciated them!

Cindy and Amy


***
1. The Centro de Salud in Poneloya


2. Siblings, 4-year old Betzaida and 6-year old Joseph, with herpes zoster


3. Amy and "Sammy" with our "bodyguard", Jorge, to whom we introduced the movie "White Chicks"


4. Amy shows off her $6 lunch -- yum!

5. Una chinita roja (red -- thanks to a Corona) and una gringita en Disco Bohemio

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