Every day is a school day

Last night I went to a lecture on the State of Healthcare after the election. Wow. Big topic. Back to that in a moment.

From the moment I started medical school people have asked me questions about EVERYTHING. I was warned that this would happen but didn't realize how quickly it would happen or how many different subjects I would be expected to be well versed in.

What do you think about health insurance?

Do you want to open your own practice? (aka do you want to start your own business)

How do you feel about charter schools? Public education? Health education?

Do you think that malpractice lawsuits should have caps?

This is where I remind you that I went to medical school. Not law school, business school, an education program or a public policy program. I do not know anything about these topics but I am somehow asked questions about these things all the time. This became a huge issue during the Accountable Care Act debacle and the more recent election where I was suddenly asked for my "professional opinion" about these issues. I can give you my professional opinion about flu shots (get one) and how much juice your kid should drink (4 oz) but when it comes to all this other stuff I'm just as lost as the next person.

One of my dearest friends has just embarked on her journey of "civicization" where she intends to learn more about how to be an involved and active citizen. Join her journey here: http://civicization.com.  This has inspired me to try to learn more about what it means to have a "professional opinion" in my profession. Hence my attendance at this lecture.

The first thing I noticed was that there was only one doctor on the panel. One doctor to represent the profession in a lecture on the future of our profession. This is a trend that I've noted in a lot of debates on the subject of healthcare - there are no doctors there! The future of our profession is being dictated by people who are not part of it - which, in my opinion, violates the definition of a profession. This is a larger issue and unfortunately I have no real answers at this point but I hope to keep working to find a balance between taking care of my patients and learning how to advocate for them and my profession throughout my career.

Every day is a school day.

Privileged

Privilege means a lot of things to a lot of different people. Today I reminded what a privilege I have to be involved in people's lives at a time when they are changing.

Today I was covering the hematology/oncology inpatient team while the interns are on their retreat. One of our patients was diagnosed officially with leukemia today and I was privileged to be present at the family meeting where this was discussed with his parents. I cannot even imagine the mind numbing quality of this news - your perfect child has cancer and we are going to start chemotherapy tomorrow. This time last week he was at home playing and being a normal kid. He is, of course, still a normal kid for all intents and purposes, but his path and his story are now completely altered. And there I was. Just sitting there, watching, allowed to be present.

Being present at this kind of meeting is one of the "hallmarks" of being a doctor - the famous "how to give bad news" event. Remember to pause frequently. Follow the parents' lead. Don't give too much information. Don't shy away from the scary words but always leave hope.

Today's conversation went about as well as one could expect it too and I went home today wanting to call everyone I know to tell them how much I love them. Today is the first day in a new journey for this family and I wish them nothing but blessings from here on out.

It continues...

So I was talking to my amazingly wonderful friend, Justine, the other night about her new blog. To start with, it's amazing and everyone who might read this blog should read it - http://lostonholiday.wordpress.com/

As we were talking about her starting out, I realized how much I miss writing on this blog and realized that my meducacion is far from over and I still have plenty to write about here in the good old USA.

Pop quiz, hot shot

Wish List

For my final days in Nicaragua I am running around trying to fulfill the wishes of the amazing people Ive worked with at the hospital. The head of nursing for pediatrics gave me a wishlist, which I was able to fulfill using money graciously donated by an anonymous donor and a member of one of the church brigades. So far I was asked for

1. An electric double burner to boil water (This purchase has answer my mother´s constant question "How do you have a hospital if there is no hot water?!")
2. Pots to boil said water
3. Standing fans to keep the patients cool
4. Pitchers of water to store boiled water

The residents will give me a list this afternoon. I am amazed at the simplicity of these requests and so happy to be able to provide these small conveniences. 

Heroes y Martires

Today at 9am (which really meant 10am) the entire hospital took a two hour break from work to celebrate the life of Dr. Oscar Danilo Rosales Arguello, for whom the hospital is named. El doctor was assasinated fighting for the Sandinista revolution again Somoza and today is the 45th anniversary of his death. There were lots of speeches about Dr. Rosales and some history about the war followed by about 30 minutes of songs supporting the current political party, the FSLN. While some of us go back to the wards, there is a large group of people going to visit his grave with snacks in hand. I didnt realize how many songs there could be supporting a political party. Are the Republicans singing songs today? I think they do it better in Nicaragua...

3 days until I´m home... hard to believe it.

Contact Precautions

 

I cannot believe that this is my last week in Leon. I spent the weekend relaxing at the beach and catching up on some reading and then it was back to work today.

Pictured above are two patients who have been on the Infectious Disease service for two weeks. They both have significant underlying diseases that leave them without good immune systems and are hospitalized for more acute issues.  Right next to each other. Yes. Because of a lack of space in the hospital all of the wards are open leaving airborne pathogens to fly freely around the room. Our kids with hepatitis are kept in another room together but there are no private rooms at all. While I dont think I will ever LIKE putting on yellow paper gowns before entering a patient's room, I am now truly humbled and grateful for their existence.

If I had a hundred dollars...

 

So a few posts ago I mentioned the small school that has opened in our hospital that was created to help children continue their education while hospitalized. Unfortunately, they are under funded and the teacher was easily able to give me a list of things that they could use.

 

Enter an anonymous friend and colleague of my mom's who generously donated $100 for me to buy art and school supplies for the children. Let me tell you... $100 goes a LONG way here.

 

How long?

1.  4 boxes of Legos
2. 3 story books
3. 20 boxes of crayons
4. 5 boxes of jumbo crayons
5. 12 coloring books
6. 10 word match games
7. 4 abicuses
8. 5 water color sets
9. 4 paint brush sets
10. 2 stencil kits with letters and shapes
11. 10 packages of modeling clay
12. 9 boxes of colored pencils
13. 3 reading/writing books for basic reading skills

 

 I am beyond grateful for this amazing contribution and cannot wait to get it to the hospital tomorrow!!!

If you give a kid an iPod...

He´s going to take some pictures. This is my amazingly wonderful patient who is admitted for IV antiviral medications to treat CMV - a viral infection that is common for most of us but hard for this guy because he has HIV. This infection has left him mostly deaf but we´ve been having a lot of fun anyway.

This week I`ve been teaching him to play solitaire and we´ve spent quite a lot of time on coloring books. Needless to say, the ID service has been a bit slow this week.

What has been amazing to me was how fast my patient picked up on the iPod after NEVER having seen one. It´s the total opposite of the toddlers we see in the US who are trying to swipe books to get them to act like iPads. It`s nice to see what kids are like without the technology distractions and I am giving him no more than 1 hour of `screen time`per day.

Today he has been making jewelry with his great aunt and I am the proud owner of some awesome earrings that I will never take off. 

Desfile

Not sure why but there was a huge parade outside of our door this morning. Nice way to wake up on a Sunday. We're off to breakfast down the street and then back to the beach for some serious relaxation

. 

Gracias

Weekend Travels and more

This is a bit delayed but my computer is still out of service. This means, however, I've been doing a lot more real things like reading books, writing postcards and traveling!

Last weekend we went to Matagalpa where a lot of the coffee plantations are. The trip was great and so was the weather... 75 degrees never felt so good. We went to the Selva Negra plantation on Saturday and took a great tour of the plantation and learned oh so much about the coffee industry. For those of you in Durham, Joe Van Gogh sells coffee from this plantation so you can buy some and think of me until I get home. We spent a lot of time at coffee shops throughout the weekend resting and getting over caffeinated while looking at the gorgeous mountain views.

The trip back was a little less pleasant and involved getting wrong bus times from our hostel, taking a bus that required a "transfer" (which means stand on the side of the highway and wait for another bus), and then a man vomiting on the floor of our refurbished school bus. Sigh. Despite all this we had a wonderful time and it was great to see another (cooler) part of the country.

This week has been pretty low key thanks to some major holidays. Tuesday was the Griteria Pequena, which celebrates the Virgin Mary for saving Leon from a volcano about 70 years ago. It's a lot like Halloween and everyone runs around asking "Que causa tanta alegria?" ("What causes such joy?") and then people give you candy. Lots and lots of fun. Today was another free day, which I happily spent at the beach.

Hoping to post more this week.

Coffee!!!!

We are off to the mountains where it is cooler and where they grow coffee. So very excited.

I leave you with the best picture of the kittens.

SCIN

This week I started working in the special care nursery. Most of the babies here are typical late preterm babies who need to feed, grow, and learn to breath a a normal rate. The patient pictured here has transient tachypnea (fast breathing) of the newborn. (Note the jar of thermometers that are the old school mercury kind and are sometimes washed between use)

Just like at Duke, this baby gets a fancy oxygen hood to help him out until he gets the hang of breathing. My attending is great and I´m learning a lot. 

These babies are not premature in any way but are getting extra cute!!!

Say a little prayer...

Sorry it´s taken awhile to post the story behind this picture... my computer had a run in with my friend´s cup of tea and i´m afraid to say the outcome has not been good. Also sorry for the errors in this post - I´m using a german keyboard that is not quite the same as ours.

Anyway... this is a picture of one of the many church service groups who come through the hospital from the US to give the children small gifts and the pray for them and their families. I´m still not sure how I feel about these groups. I´ve been able to watch them from afar because for whatever reason when i´m wearing my white coat people dont recognize me as a foreigner. Most of the people who come through do not speak Spanish and I can see all the wonder and some fear in their eyes - it reminds me a bit of the slum tourism I´ve heard about in other countries where people pay money to get the "third world experience." I am probably being too hard on them but I cannot help but feel protective of my patients when I feel as though they are being looked AT instead of looked after. 

Of note, the woman here in the blue shirt did give me quite a large monetary donation to help buy some supplies for the hospital. I will be asking out department chair to make a list for me and then we all can see just how far $100 will get you with medical supplies here.

From the personal side of this trip, we spent an amazing weekend in Granda and Masaya taking the time to enjoy to expat spa life and get some shopping done. Now I just have to figure out how to fit my hammock in the resident room...

One month old!!!

New results list

So when we order labs, there is generally a 3-4 hour delay in getting results. There also appears to be only one scheduled lab draw per day - I haven't totally figured this out yet. We stalk the new results just as well as any doctor anywhere. Getting them back can help decide management for our patients and, more importantly, whether or not they can go home. To get these results, however, requires walking down four flights of stairs to paw through this box of new results looking for your patient. Not ready yet? Walk back up and come back later. I will never complain about taking the stairs again.

Design

Shout out the the amazing Justine Haemmerli for helping me to spruce up the blog :)

You can find her @ http://makebigmoves.wordpress.com/

I will also take this opportunity to show pictures of the kittens who will be 1 month old tomorrow.

Trouble is coming...

Abandonado

Last night we admitted a patient with periorbital cellulitis - an infection of the skin and soft tissue around the eye.

Looks pretty uncomfortable but this two year old couldn't have cared less about not being able to open his left eye. Generally this infection is treatable with antibiotics but with the degree of swelling and the involvement of his right eye we thought it best to keep him in the hospital for IV antibiotics to make sure everything was being treated quickly and effectively. Hospitalizations are always hard on patients and their parents and this case was no exception. Around 10 am mom approached us at our work station and announced "Voy a abandonar" aka I'm leaving and taking my kid with me. 

While adult patients in the US are allowed to leave AMA (Against Medical Advice), it's relatively uncommon for us to have parents decide to take their children out of the hospital. This raises a number of issues given the fact that while the parents are the legal guardians and can make decisions for their child, children have a right to be protected from bad decision making on the part of their parents. In many cases all it takes is a good talk, involvement with social work and sometimes the patient resource manager before these issues get sorted out and we are all able to proceed with caring for the child in question. 

Here in Nicaragua, parents have the absolute right to remove their child from the hospital whenever they see fit. My co resident explained to me that this is actually very common. Almost every day when we are read the list of patients (who was admitted, who died, who was born), we are also told about how many "abandonados" there were. 

We explained to our patient's mother the serious nature of her son's infection and the possibility that it could affect his vision or spread to infect his brain. It's hard to have to explain these things in such blunt terms and it's even harder to do with a sobbing 17 year old mother. At the end of the day she decided to stay so he'll be getting good treatment and should get better soon :)

Child Life

What is child life? 

Well, according to the Child Life Council, specialists who work in this field are "trained professionals with expertise in helping children and their families overcome life’s most challenging events."

At Duke we have an entire department of people who are dedicated to helping children and their families cope with their hospitalizations and/or with difficult outpatient procedures. The people I've met who work in this area are incredibly talented individuals who somehow manage to make things less scary, less painful, and less confusing for our patients. Their work includes distracting patients who are undergoing procedures to providing companionship or a playmate for a patient whose family cannot be with them at all times. 

The children on our wards here in Nicaragua have no such thing. Not only do they share a room with up to nine other patients, but they also have to endure painful procedures without anesthesia and having to watch other children undergo similarly terrible procedures. We have one television for them to share but for the most part they are BORED. 

 

With only three patients on service today I was bored too. Enter flag making!!! We made flags out of prescription pads, tape and pens and had a great time decorating them and parading around the room. I'm bringing some crayons tomorrow so they should get a bit prettier :)

Medical records

Our attending asked us to pull some charts today. We were pointed toward a stack, told "there are the charts from July 22nd," and then ignored. We proceeded to sift through hundreds of pages of poorly bound charts. Good times.


In other news, here's an updated pic of my malnourished patient who is now standing on his own (sort of) and is on his way home!!!

Discharge talk

This is a poster in the emergency department in the hospital that outlines warning signs for new parents to look for after bringing their baby home. Great visual example and helpful knowledge for new parents. This has been updated with translations :)

1) If he is irritable and cries a lot

2) If he is difficult to arouse

3) If she will not breastfeed or vomits after every feed

4) If he is breathing heavily and you can see skin pulling in between his ribs

5) If there is redness around the umbilical cord stump

Working from home

Kitten pictures will follow in abundance. Here's your daily cathedral shot.

There's no such thing as a free lunch

But there are plenty of free medicines from drug representatives!!!

Today after morning report (which is mostly just a list of the patients who are admitted with case presentations on Tuesday and Thursday) we had breakfast brought to us by representatives from Unipharm. In addition to empanadas and orange juice, we also got massive quantities of free prescription medications. 

Drug representatives have been banned from most academic medical centers so my experience at Duke has been completely devoid of interactions with them. From working/shadowing in some private clinics, I was able to meet some drug reps in the past. Generally, they had good relationships with the physicians they were working with. They would bring lunch and then talk for a few minutes about whichever drug they were bringing that day - the talk included recent studies that showed why this drug was awesome and that was that. The doctor was then free to give these samples to patients.

Today's visit was different. There was no technical discussion of any of the medicines being handed out. Also, we got literally bags full of different medications from antibiotics to iron supplements. Finally... these drugs aren't for patients. They are for us. To keep. When I asked what I was supposed to do with all the medicines I was told "Take them home for when you're sick." Can I give them to patients? "No."

I'm still trying to work this one out...

Good morning

The light in this house is amazing in the morning.

SIDA

More later for this post but we're about to head out for a drink to send off one of the housemates who is going on holiday for a couple of weeks.

Part of my rotation on the infectious disease service is going to the outpatient clinic with my attending. Tuesday is HIV/AIDS clinic. Below are two patients who acquired this infection while their mothers were pregnant with them. Thankfully, they are both doing very, very well.

Again... more later.

Infectología

Pictures below are not for the squeamish!!!

Back to work today and I'm now on the infectious diseases service. We have our own patients and our own room (with AC!!!) to care for them in. Our current census involves 2 patients with hepatitis (most likely hepatitis A, the kind you get from drinking bad water or eating contaminated food), 2 patients with abscesses and another with possible dengue. There are no certain diagnoses for the hepatitis patients or the dengue patient because the laboratory at our hospital does not run these tests. In order to get results we have asked the parents to take samples to private labs and they will have to pay out of pocket for the results.

My shocking moment of the day was helping the kid pictured below who has had a retropharyngeal (back of the throat/neck) abscess for about a week. It has gotten bigger and bigger and was finally drained by surgery yesterday. Since then it has been draining well but is certainly not close to clean and is obviously immensely painful.

The ENT doctor came today (I'm not sure but I think he only comes once a week) and helped us out by exploring the wound and cleaning it out a bit more... without giving this kiddo any pain medicine. Nope. Not one drop. He had gotten some tylenol about 2 hours before but that's it. Here's the ENT with his cool (read: old school) headlamp.

The whole process went well even though I thought the patient, his mother or I would faint at any moment. P.S. it was about a trillion degrees in the room and there were 15 people in it. 

Off to prepare for rounds tomorrow. The word on the street is that my new attending is a stickler for details.

And they're off!!!

Island in the Sun

Today was an amazing beach day... not just because of the perfect whether, but because we were guests at the Surfing Turtle Lodge. http://www.surfingturtlelodge.com/

Pedro, the owner, has just moved back to Leon and while searching for a place of his own we were lucky enough to get to know him in our house.

To get to the lodge we took cabs to Poneloya, followed by a boat to the island and then a horse cart out to the lodge. It's gorgeous out there. Pristine beaches, lovely accommodations and some amazing food. We took full advantage and had a wonderful and relaxing day at the beach.

Revolution and Relaxation

It's been a great few days... without work!!!

Thursday was a national holiday celebrating the triumph of the popular revolution over the Somoza dynasty in 1979. No one was working and we all spent the day reading, resting, and relaxing. 
Here is the interpretation of the holiday from Rosario Murillo, who is the first lady of Nicaragua:“With every 19th, the complete life, the good life. With every 19th learning. With every 19th growing. With every 19th uniting. More brotherly, more generous, stronger of heart. With every 19th better prepared, more content, more Christian, more socialist, in solidarity. More pretty Nicaragua. More free Nicaragua. We give thanks to God for another 19th. Thirty-three times 19. Thankful, blessed, thriving, from one victory to another. Giving thanks to God because there’s peace, there’s love, and dignity. The 19th of July. Thirty-three times 19. Nicaragua will continue to triumph.”

Yesterday was also free to give everyone a full weekend. The hospital is on holiday staffing with just people on call working. I took the opportunity to explore Leon a little more and see some of the sites.

First stop was the Catedral de Leon, whose construction began in 1747 and went on for over a hundred years. The largest cathedral in Central America, it was voted by the Nicaraguan National Assembly as the country's 'building of the millennium'. This architectural jewel is also home to Rubén Darío's tomb, guarded on one side of the altar by a sorrowful lion.Read more: http://www.lonelyplanet.com/nicaragua/leon-and-northwestern-nicaragua/leon/sights/architecture/catedral-de-leon#ixzz21H1C945m or at http://en.wikipedia.org/wiki/León_Cathedral_(Nicaragua)

Speaking of Rubén Darío, next stop was his home, which is now converted into a museum. The poet moved to Leon when he was 40 and in the museum the life and history of Rubén Darío has been portrayed on the walls. Some of his belongings are on display, including his bed, his bible, and some of his writings. The items are set up in several rooms, and the museum is well maintained by a university of the city (the UNAN).

Took a short break for a delicious iced latte and then on to the Museo de Arte Fundación Ortiz-Guardián, which is billed as "the finest contemporary art museum in Central America." The museum itself is in a lovely old house with amazing courtyards and fountains. The art work starts in the Renaissance and moves through to present day. Artists are varied and include Picasso and Diego Rivera. 

All in all a lovely day. This city is so wonderful and full of art, culture, music and delicious food. 

Nap time

These kittens are amazing and getting cuter every day. I can't even stand it.

Eyes are opening!!!

Olla quemada

Pics from last night out on the town. We went to Olla Quemada, a nice bar and music place. http://laollaquemada.blogspot.com/

Kind of dark, but there is delicious Flor de Caña rum and coke plus an origami crane that our friend, Silvio, made. 

Here is our friend, Luis, who decided to get up and sing even though this was NOT a karaoke bar.

A few pictures of the son of the lead singer of the band who rocked out like a true rockstar.

Followed by a blurry shot of me and Meredith

Reading

"To visit Nicaragua was to be shown that the world was not television, or history, or fiction. The world was real, and this was its actual, unmediated reality." from The Jaguar Smile by @SalmanRushdie

Rainy day

So, you want to be a doctor?

Today was fairly slow so I had some time to talk with the residents about what it takes to be a doctor here in Nicaragua.

Step 1: Finish secondary school and then go to university where you will complete 1 year of general studies. After this year you take a test to see how smart you are. If you do well on this test, you can have your choice of career. 

Step 2: Five years of medical school learning mostly basic science. 

Step 3: Intern year. This is more like our clinical years in medical school. You spend 2.5 months in each of the core specialties like surgery, OB/GYN, internal medicine, pediatrics. 

Step 4: After intern year everyone is required to do 2 years of social services where they work as general practitioners in rural communities throughout Nicaragua.

Step 5: Complete an exam to enter residency. Or stop. A lot of people are general practitioners. There aren't very many residency programs or teaching hospitals here so a lot of people will just stop at this point.

Step 6: If you're lucky enough to get a spot you can enter residency, which is 3 years for all specialties. While you are in residency you take call every 4th night... for all three years. Rotations are about 2 months long. Residents get three weeks of vacation per year in addition to multiple national holidays. 

So... sounds pretty similar to what we go through. Speaking of national holidays, there is one tomorrow so no work for this girl :)

Below is a picture of my novio who was discharged today. Sad face.

Sunday dinner

Spaghetti carbonara made by our Italian housemate, Paula. Great food. Great company. Living the dream.