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.

A la playa!!!

Amazing day today - starting with finding keppra!!!

Then it was off to the beach with 3 peds residents, an ob/gyn resident and my attending from the last two weeks. We went to Las Peñitas, which is only 20 minutes or so outside of Leon. Spent the day in the shade, relaxing, eating fresh seafood and drinking some cerveza. Couldn't have been a nice way to spend my Saturday.

Pretty nice, huh?

We had a great time, but I think the residents miss someone else too...

Happy Friday

Just a reminder that kids are kids everywhere. Had a great afternoon playing with this little guy :)

EKG

Meet my little patient who has Kwashiorkor. We were trying to figure out his potassium level the other day and an EKG was going to be the fastest way to check. Stickers? We don't need them!!! We have suction bulbs with metal cups and EKG gel plus weird metal clamps. Amazing.

I am constantly in awe of my patients and even more impressed by the physicians I work with. They have so little but are more dedicated to learning than many. They constantly read, ask questions, search for new answers to old problems and find new ways to combat these problems given their limited resources. Every day that I leave the hospital I am struck by just how lucky am I... this is the gift I am given every day.

We've got scanners, yes we do! We've got scanners, how about you? Oh. You don't?

Short post today...

So we have a patient who is 6 years old with intractable (incurable) seizures. When I say intractable, however, I mean that we've only tried three medicines. These are the only medicines we have. My job today was to write a letter to a stranger in the US who might be able to send us some Keppra. Because we don't have in. In ALL of Nicaragua.

My patient's symptoms consist of morning headache, seizure and ataxia (wobbliness). These symptoms are terrifying for physicians because they may herald the diagnosis of a brain tumor. Does she have one? We don't know. Why don't we know? Because the CT scanner is down this week and won't be available until next week. MRI? It's in Managua.

I was asked the other day if my hospital in the US had a CT scanner and the only thing I could say was yes. There was no way I could tell my new friends that not only do we have CT scanners but we have a LOT of them. And a lot of MRI machines too.

Epic

As my colleagues in the US get ready for the transition to a new electronic medical record system, I thought I would write about notes today. Here is an example of our charts (more on how we got that EKG later). They're basically just clipboards with a lot of papers stuffed into them. There is no logical order and pages are not numbered. Generally, there is a cover sheet with the list of diagnoses, then the H&P, followed by daily notes, labs and X-rays. Yes. The X-rays are physically present on this clipboard and I get the hold them up to the light to read them and feel like a real doctor. 

We write 2 notes per day and then the on call team will write another one overnight. Here is a note from one of my patients this afternoon. Notes follow the same SOAP format that we're taught so at least that part was easy to figure out.

All clinic records are kept in the book below and I'm still not sure how it's organized but somehow it travels with us every Tuesday and Thursday. Below you can also see the red stamp they use to authorize prescriptions and a prescription pad - carbon paper is used to make copies of most documents. 

So, when Epic starts to make your head hurt just remember: at least it's better than this. 

Desnutricion

We currently have two patients admitted with malnutrition. 

The patient pictured here also has Trisomy 21 and congenital heart defects that have not been repaired. The other has Kwashiorkor, which is a severe protein deficiency that we all learn about in medical school but, I imagine, very few in the US have ever seen. It is truly humbling to see all of the stigmata of this condition. No one exactly knows how this patient got so malnourished - it may be lack of resources, pure neglect, or a combination of both if there are too many children in the house. This patient was admitted over the weekend and was not able to receive adequate therapy because there was no albumin (protein) in the hospital. We also could not correct his low platelets because there were none. The combination of no resources at home and none in the hospital is amazing to me. At Duke, we admit patients for "failure to thrive" when they fail to grow as we expect all healthy newborns to grow. This child is 19 months old and weight 4.5 kg, which is far below all of the curves that we plot our infants on. We rarely have shortages of medicines and even then we have many other options. Impresionante. 

La playa

Had a wonderful day at the beach - didn't bring my camera because I wasn't sure about where we were going but I will bring it next time. For some visuals, here's where I was: http://www.playaroca.com/

On our way out we took the public bus - 13 cordobas (which is about 50 cents) will get you onto the most crowded school bus you have ever been on. I was literally grabbed, pulled onto the bus, and pushed to the back with at least 50-75 other people. Amazing. Luckily the bus was going fast enough that there was good air movement.

Spent the day sitting in the sun, watching the waves, swimming and learning to play poker. All in all a lovely day.

Back to work tomorrow where adventures abound...

Lazy Sunday

... sitting in a rocking chair. Drinking coffee. Playing with the baby kittens. Going to the beach later. This is the life :)


Sadly I also have to create a presentation on urticaria later today but that can wait. 

Great day yesterday celebrating 33rd anniversary of the '79 Sandinista revolution here in Nicaragua. There was a big parade that we joined - people are very politically motivated here and it's interesting to see how much pride they have in the democracy that is here, although it's debatable how functional it is. Will have to learn more from Jaguar Smile. Spent the rest of the day wandering through the city and then out to a bar last night for beers and conversation. 

They're here!!!

Meet the new babies. Mommy is doing just fine :)

It's almost time

Our pregnant kitty is going into labor.

Here goes nothing...

Thanks to some peer pressure from my mom, I'm starting a blog to share my experiences here in Nicaragua over the next 2 months. I am in Leon, which is on the west coast of the country and am working in the Heodra Hospital in the center of town. 


I arrived on July 3rd late at night after a harrowing ride from Managua. Woke up the next day and stumbled out into the sunlight and the hustle and bustle of the third world. Really felt transported immediately and it took a couple of days to get used to. 

All in all, Nicaragua is as wonderful as I remember it. SO hot but my room has AC so I do have some respite and in general i'm getting used to it. I am staying at a boarding house of sorts that houses lots of travelers and I'm making some good friends. There is also a pregnant cat who is going to pop any day now!

So far I've completed two days of work, which have been exhausting. There aren't a lot of patients but the hospital is like a whole other universe. It's dirty, hot, crowded. Yesterday there was a corpse in the hall waiting to be taken down to the morgue. There are no resources - one ventilator, no infusion pumps. I had to learn how to calculate my own dilution from normal saline to 1/2NS then figure out how many drops per hour would be in 18 ml/hr because we have no infusion pump. It's totally insane but i'm learning a lot - especially how much we take for granted. I am finally figuring out how to write notes and will be doing presentations on Monday. It feels like med school again where it takes 30 minutes to learn how to say "regular rate and rhythm, no murmurs, rubs or gallops."

On the fun side, went to pilates class last night and then out dancing with my new friends. Had a great time and loving a day of rest today... except that I may be doctoring the cat delivery.

Sending besos.