Tuesday, February 25, 2014

Week 4/Departure (2/3-2/14)

On Monday, I restarted work at HEODRA. I found out that the patient with septic shock that I admitted on Friday had been sent to the ICU because she wasn’t maintaining her blood pressure after 3L of IV fluids. In addition, a man who had likely had an ischemic stroke the week before was doing much better, including eating and speaking almost normally. I spent my last few days again working at HEODRA. I gave away all the gifts that I had brought for Sebastian and his family, and thank them for their hospitality. I really enjoy spending time with the family, and time and time again I’m struck by how similar to my family they seem, from the chatter around the dinner table to how much they all seem to care about each other.

I felt like I accomplished a great deal during this rotation, from my medical equipment sterilization analysis to the breastfeeding project to Spanish classes and work at HEODRA. My Spanish improved considerably during this trip (I even learned a new verb tense). I am excited to continue working on the autoclave project and figure out how to get it funded. As always, the strongest memories I will take back with me are the people.

Weekend (2/1-2/14)

My sister gave me the book Infections and Inequalities: The Modern Plagues by Paul Farmer for Christmas, which I have been reading while being here. Nearly all of the lessons that he draws from his work in Haiti apply in some way or another to Nicaragua. On Saturday, I spent the day reading and spending time with Sebastian’s family, including his brother, his sister-in-law and his niece and nephew.

On Sunday, Sebastian and I went to the beach again. We went to a beach whose name literally translates as “little rocks,” and needless to say, it was a little rocky; we had to avoid submerged stones, but it was beautiful nonetheless, especially in anticipation of returning to the weather in New England. After we returned from the beach, I was able to watch most of the Super Bowl. Peyton Manning seemed to be playing like Tom Brady in the AFC Championship: misfiring his throws and unable to get his team fired up. I tried to convince Sebastian to watch some of the Super Bowl with me, but he kept insisting that he did not know the rules. Instead, he watched a telenovela.

Sunset at Las Pinetas

Week 3 (1/26-31/14)

On Monday, I went to El Tololar with Magda from CIDS to meet up with Stephanie to interview Carlos, a nurse there, lead the breastfeeding project focus groups, review the results with the community, and solicit their ideas for a possible intervention to improve breastfeeding rates. The interview with Carlos was very informative, especially in three key ways. First, Carlos informed me that there actually was a lactation program in El Tololar in the 1990’s, but that it stopped because of a drive to make the services provided by each health center more uniform. Second, he informed me that there are already designated community members in each sector whose job it is to support breastfeeding.

Finally, he reported that they did not see very many cases of postpartum depression at the health center because most of it was seen at the hospital after delivery. I found this a little hard to believe because women are usually not in the hospital for more than a few days postpartum, and therefore many cases would present after discharge. Fortunately, however, a psychologist recently started working at the health center and is there one day per week.

Stephanie Muriglan, MD (Fitchburg PGY-3), Ebar and Magda present their
breastfeeding project results to the community in El Tololar.  

Unfortunately, no men came to the health center for a second men’s focus group, but 11 women and five children came for the project results presentation. Magda from CIDS helped tremendously with the results presentation. Most women did not seem particularly surprised by the low rates of exclusive breastfeeding for the first six months, and they reiterated many of the findings from the study, that some of the challenges included having to work, and thinking that their milk was not sufficient or that the baby needed other food or drink for various reasons. In addition, the group had three main ideas for how to improve breastfeeding rates in the community. First, they said that because incorrect information seemed to be coming from their mothers, many of whom gave information about breastfeeding, that it might help to do an educational program for their mothers. Second, they suggested that a community health worker could visit their houses because time was a limiting factor in participating in any program. Finally, they suggested a public health program along the lines of the one that existed previously.

Noah Rosenberg interviewing Carlos, a nurse at the clinic in El Tololar

On Tuesday, Stephanie and I started work at HEODRA, me on the internal medicine service, and she on the OB service. I am working on the nephrology service with the Department Chair of Internal Medicine as well as the Chief Resident. We only had two inpatients on the service initially, but many others come in for hemodialysis. Our first inpatient has hypertensive nephropathy and was on peritoneal dialysis. He presented early with SBP and is being given antibiotics, and is fortunately doing well. CKD, as many other chronic diseases, is challenging to have in Nicaragua.

For example, this patient has a fistula ready for hemodialysis (HD), but there are only six hemodialysis machines in Leon, and they are all being used at capacity by other renal patients, so he would have to go to Managua for HD. Our second patient presented for right flank pain and was found to have proximal obstructing ureterolithiasis with hydronephrosis. He has a history of ischemic cardiomyopathy, type 2 diabetes, diabetic nephropathy with stage 3 CKD, so he is a poor surgical candidate. Currently, he is essentially being managed medically because his pain has improved, though he has not yet passed the calculus. Stephanie and I will be working at HEODRA all week.

As the week went on, we had many more admissions, getting to maximum of 10 patients at one point. On Friday we had admission after admission, one of whom was a middle-aged woman with septic shock likely due to a UTI. In addition, her sodium was 103, the lowest I have ever seen (my senior resident said he had seen 100) and her creatinine was 12. She had dysuria and progressively worsening symptoms for 15 days before coming to the hospital, I learned from her family. We bolused her with fluids because she was extremely hypotensive to 80/40 and started ceftriaxone. In case she needed pressors, as my senior resident recommended, her family went to the private community hospital and bought a central line kit because HEODRA does not have them.

She was completely obtunded when she arrived, and after 2 liters started to be able to respond verbally, but her blood pressure remained in the 80-90/50 range. When we left for the day, she was on her third liter of IVF and seemed to be doing better, but her blood pressure remained tenuous. I was amazed that this patient was treated on the regular hospital ward because I think she would have gone to the ICU initially in the US. My senior resident essentially had me or the intern stand next to her bed at all times taking her BP every 15 minutes. Situations like this emphasize the material differences in our health care systems; for example, what if her family had not been able to buy the central line kit?

On Monday, I will see how she did. Obviously she needed fluids because she was in septic shock, but my great fear was that giving her so much fluid could be complicated by her severe hyponatremia and that we might cause central pontine myelinolysis by correcting her sodium too rapidly.

Weekend (1/25-26/14)

Sadly, Sebastian’s uncle was just diagnosed with what appears to be a renally-based tumor. He went to the doctor for back pain, and had an ultrasound that revealed a large left renal mass. Sebastian and I went to visit him in the hospital on Saturday, and I was able to look at his CT scan because all the patients here have their imaging right next to their bed. He has a large, necrotizing left renal mass without radiographic evidence of metastasis. He is going to have a thoracic and head CT tomorrow, and then he is planned for surgery on Wednesday next week. His spirits seemed relatively high, all things considered, and he is now asymptomatic and pain free.

With a mix of happiness and sadness because of his uncle’s illness, on Saturday evening, we went to Sebastian’s nephew’s wedding—my first Nicaraguan wedding. It was held in a beautiful Catholic church, the Iglesia de la Merced. At the ceremony, I had the very unexpected opportunity to meet the Nicaraguan Cultural Ambassador. After the ceremony, we went to the reception, which was held near Sebastian’s house in the former hospital for Leon. The building served as the hospital in the 1800’s, and was founded by a Dr. Debayle, an important figure in the history of Nicaragua. There was a mariachi band, which Sebastian sung with. I met many of his family members that I had not yet. It was a very enjoyable evening, and a wonderful opportunity to get even closer to Sebastian’s family.

Attending a wedding with the Perez family 

On Sunday, we went to Las Pinetas, one of the beaches near Leon. The weather was beautiful, an uncharacteristically mild day. We swam in the ocean, and walked up and down the beach, and afterward stopped by Sebastian’s brother’s house on the way back to Leon.

A mariachi band at the wedding

Week 2 (1/20-24/14) Language School and Medical Equipment Sterilization

Spanish class would occupy every afternoon this week. My teacher, Carmen, has a number of family members who are doctors. She said she enjoyed reading and brought in The Little Prince, Collected Poems of Ruben Dario, and the newspaper all for me to read in Spanish. We discussed everything from capitalism to socialism to absurdism to Nicaraguan history. I reviewed tenses with her, including the present, simple preterit, imperfect past, and future. She gave me homework, and had me read Spanish out loud to her, which was a useful exercise for me because it was something I have rarely done.

Stephanie and I met with Magda and Dr. Herrera from the Center for the Investigation of Demographics and Health (CIDS) on Wednesday to plan for the breastfeeding project groups. Next week, Stephanie and I are going to spend an afternoon in El Tololar, so that we can present the breastfeeding project results, and I can lead the men’s group as well as interview Carlos about the counseling that he provides about breastfeeding. This week, I also completed a large proportion of the research for my medical equipment sterilization project and completed the preliminary analysis.

Briefly, the clinic in El Tololar has to turn away gyn and dental patients about one day per week because they do not have sterile medical equipment. The current equipment sterilization practice is taking tools back to HEODRA (the main teaching hospital in Leon) by bus or truck for sterilization there. Because patients are being turned away in the current system, the clinic has expressed interest in obtaining an autoclave for sterilizing medical equipment onsite. For my project, I am completing a comparative cost-benefit analysis to help determine the optimal solution. I found that compared to the status quo or chemical equipment sterilization, an autoclave was indeed the optimal solution to the clinic’s need to sterilize equipment because of the degree to which it would increase their capacity to provide services to patients.

I also watched the Nicaraguan baseball championship with Sebastian’s dad and brother. I ended up watching the final game, Rivas vs. Managua, and Rivas won 13-8. When I lived in San Juan del Sur in 2009, I passed by the Rivas baseball stadium a few times. This weekend, a nephew of one of the Perez’s is getting married on Saturday, which they invited me to. Then, on Sunday, Sebastian wants to go to the beach.

Weekend in Estelí (1/18-19/14), or Another Side of Nicaragua

When I was trying to think of a subtitle for this post, I thought about all the ways in which I saw facets of Nicaragua that I had not before. For example, geographically, Estelí is in the north of Nicaragua, where it is much cooler than Leon. In fact, it was somewhat humorous, as many of the Nicaraguans there wear large puffy jackets that I associate with New England winters. I was wearing a t-shirt and the temperature honestly felt perfect to me. In Estelí, we stayed at Sebastian’s friend, Esperanza’s house. We tried to walk to a waterfall in Estelí, but unfortunately Sebastian wasn’t able to make it the whole way there. We also visited a nunnery in Ciudad Dario (named for Ruben Dario, the most famous Nicaraguan writer). It was a cloistered community, meaning the nuns are never allowed to leave the grounds. We met with the Mother Superior, and she asked me many questions about my faith, and it frankly ended up being one of the most in-depth conversations about religion that I have ever had in Spanish--or any other language for that matter.

From there, we took a bus to Matagalpa, where an ex-girlfriend of Sebastian’s lives. We spent the day with her and her daughter, and I managed to find the Patriot’s game on TV. Too bad they lost, but they really did not seem to be playing with intensity, and Brady’s throws just were not on target. Shortly after, while on the bus leaving Matagalpa, we passed a traffic accident, in which three people, two men and a woman, had died. The moment it became clear what happened, everyone on the bus except me jumped up and pressed themselves against the windows.  Again, I was struck by how many more cars it seems like there are on the roads. It seems like Nicaragua may need to do something at the national level to quell the rising tide of traffic accidents

El Tololar (1/17/14), or Living in a Material World

We awoke bright and early at 5am to take the bus to El Tololar with Pamela, the dentist at the clinic in El Tololar, a rural town about 45 minutes outside of Leon. I can think of few things more surreal than traveling down a rutted dirt road at 7 in the morning on a Nicaraguan chicken bus, when Madonna’s “Material Girl” comes on the radio. As if the differences in material wealth were not clear enough, the bizarre timing of the song further emphasized this point, as well as the global ubiquity of American culture

Dr. Urrutia was not in clinic that day, but I was able to ask Pamela many questions about her use for an autoclave, which she said the clinic definitely needed; every patient she saw required sterile instrumentation. She currently keeps some instruments in a sterilizing solution, and others are trucked back to Leon for sterilization at HEODRA, the main academic teaching hospital. I worked with her clinically as well, but the pharmacy was out of local anesthetic, so unfortunately, the four tooth extractions and one incision and drainage that needed to be done all had to get antibiotics and ibuprofen and were instructed to return next week. Tomorrow, Sebastian and I are traveling to Estelí to meet up with a friend of his, which I am looking forward to.

Arrival/Week 1 (1/15-16/14)

For the first time during my three trips to Nicaragua, the muggy wave of air finally felt less jarring as I stepped off the plane and up the jet way. Cesar, who has driven me to or from the airport probably about four times now, met us at the airport exit. We fell into a comfortable conversation about how his father was doing, his favorite baseball team (the Red Sox), and his English classes. Driving past Lake Managua, the second largest lake in Central America, all the beauty of Nicaragua streamed back to me. Before long, we arrived in Leon, me at the Casa de la Familia Perez, where I stayed last year, and Stephanie Muriglan (Fitchburg PGY-3) at the Tortuga Boluda Hostel.

The Perez family welcomed me back literally with open arms, and were all speaking so quickly and at once that I could initially hardly understand a thing. My host brother, Sebastian and I went to a coffee shop to catch up, and I had the best (as well as only) fresh papaya juice that I have ever tasted. I will omit his name because we discussed his tenuous health, which unfortunately, forced him to take leave from his work in November.

We returned to his house and had dinner with his family, which is so much like my family it’s uncanny. Everyone gets together for dinner and talks 900-milion miles per hour. After dinner, we took our nightly walk, as I encourage Sebastian to do for exercise. During our walk, one of the things that struck me was just how colorful, both literally and figuratively, Leon is. For example, at 9 o’clock at night, we just happened to walk by a religious gathering where his parents and 8-month-old nephew were. We had just had dinner, but of course we were offered plates of gallo pinto (rice and beans) and sweet rolls.

There was a small albino boy at the gathering, and I learned from Sebastian that that they call albinos “angels.” On our way home, I had just been talking about how it seemed that every year there were more cars on the roads in Nicaragua, when a bicyclist crashed into a motorcycle. The motorcyclist was uninjured, but the bicyclist was having extreme difficulty weight bearing on his left leg, so I suggested he go to the hospital for an X-ray, and he finally relented.

Stephanie and I planned to go to El Tololar the next day, but neither of our phones was working, so we were unable to let anyone know that we were coming. We spent the next day getting settled and fixing our phones. Later that day, I visited a medical supply store in Leon, where I obtained a quote on an autoclave, a vital piece of data for my project on the optimal method of medical equipment sterilization for the clinic in El Tololar (more to come on this).