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.