Mac and Cheese

It's been way too long since I posted a recipe to this blog, so here is a favorite of ours. I make it way too often to be healthy, but it's just so yummy, I can't help it.

With fake crab meat

4 C whole milk
1 stick butter
1/2 C flour
Salt, pepper, mustard to taste (optional)
1 lb macaroni (or whatever pasta is in your
     cupboard)
4 C shredded cheese (I like a mixture of
     cheddar and whatever else is on hand)
Breadcrumbs (optional)
Crabmeat (fake or not, or bacon, chicken,
     green onions, or anything else you want to 
     add)

The great thing about this recipe is that, difficult as the roux is to make, once that is done and you have the cheese sauce made, you can add pretty much anything and have it be crazy delicious.

Bring a large saucepan of water to a boil over high heat, add salt if you want (I never do and it turns out fine). Add the pasta and cook until it’s almost al dente, then drain and rinse with cold water; set aside.

If you plan to top with breadcrumbs and bake it (optional but highly recommended), heat the oven to 400°F.

Heat the milk in a medium saucepan over medium-high heat until it just comes to a simmer, then turn off the heat and set aside.

Here is the hard part. In the large saucepan, melt the butter over medium heat. Add the flour and whisk constantly until the mixture turns light brown in color, about 3 minutes. Remove from the heat.

While whisking constantly, slowly add the hot milk to the flour mixture until evenly combined and smooth. It will get very thick when you first add the milk, then thin out. Don't be like me and get upset if it turns out a little lumpy the first time - it takes practice and it will still taste good.

Return the saucepan to medium-high heat and while whisking constantly, cook until the sauce thickens and coats the back of a spoon, about 2 to 3 minutes. Stir in salt, pepper, mustard or any other spices to taste.

With green onions and topped with more cheese

Stir in cheese just until melted and smooth (you can reserve some of the cheese to top the pasta if you plan on baking it). Add the pasta, any meat or vegetables you want and continue cooking, stirring occasionally, until the pasta is heated through and steaming, about 2 to 4 minutes. Serve immediately or, if baking, transfer to a 5-quart baking dish, sprinkle with the breadcrumbs, and bake until bubbling and brown on top, about 25 to 30 minutes.

All my love to you, Poppet. You're going to be all right.

I'm not sure if this is a blog post, or a tribute, or a love letter or what, but it's painful, whatever it is. We are now all aware that one of the brightest sparks in show business, a man who made me laugh until I was sick, who was a genie, a nanny, Peter Pan, a boy stuck in a board game, a doctor, a killer... is gone. We also know it was by his own hand. Reading that first headline literally took my breath away, I couldn't fully process it for a minute, but on reflection, after thinking about all the trouble he had been through for years, it didn't surprise me.

Why funny people kill themselves.

What suicide isn't. 

"Every time they make a joke around you, they're doing it because they instinctively and reflexively think that's what they need to do to make you like them. They're afraid that the moment the laughter stops, all that's left is that gross, awkward kid everyone hated on the playground."

This might be the most accurate description of myself, and many other people I know, that I have ever read. I often say that making people laugh is my favorite thing in the world, and it is. Maybe that is because I was that awkward kid no one liked, or maybe because I have clinical depression (for which I am thankfully medicated and have a wonderful support system), or because I feel like as long as I can make someone laugh, they can't possibly hate me completely. I do know that I've lost one friend already, and I know others who have started down that road and turned back.

Take this opportunity to think about whether you know someone who might fit this description. If you do, go hug them. Tell them that they matter. If you've ever personally known someone lost to suicide, you know you never want to experience that again. So go make a difference in someone's life. You might end up saving it. They ain't never had a friend like you.

Day 3 - Health Assessments and Dancing

Today we were to spend the early morning assessing our families, but when we got to the academic center to pick up the brigadistas (grade school volunteers) we discovered that the children we were expecting to do screenings on at 11 were already there and waiting for us. We quickly threw together stations for height and weight, blood pressure, eyes, ears, lice and lung assessments. There were apparently only 28 children between six and eleven years of age, but it seemed like a small (in stature, not personnel) army. Laura and I manned the blood pressure station with only one pediatric cuff and then I roamed and shot some footage of the frantic but surprisingly organized proceedings.

Once we wrangled all the children through every station we packed up and headed for the barrio. For the first (and possibly, last) time we met the only child in our family, Rosa, as well as a woman named Carla, of indeterminate relation. We spent close to two hours doing as full of an assessment as is possible when your communication is half mimed. I was proud of myself for figuring out the words for 'tapeworm' (tenia) and 'kidney stone' (piedra de riñón) when they were mentioned. My Spanish, while still by no means fluent, is coming back quickly, and I wish I had time to be immersed in it longer so I could work on improving it further. As the assessments we did contain medical information, none of it will be posted here.

I am still very uncomfortable with the living situation with regard to Rosa. The information we receive keeps changing and her answers today seemed very rehearsed, "everyone respects me and no one touches me". She also contradicted the information about what she does after school and while she stated that Carla was her mother, Carla denied this claim. That, coupled with the other suspicious behavior (Cesar having a padlock on his bedroom door) makes me question the safety of this environment. We will continue to work with the family and so will the UPOLI students after we leave, so hopefully she will get the help she needs, even if that is only with improving her reading skills (at which she is about 5-6 years behind).

After leaving the barrio we went back to the B+B for a quick change and went out sightseeing. We went up to a lookout point that had an amazing view of Lake Managua and Volcano Momotombo and watched some people zip-line, thought we sadly did not get to participate. A few people wanted to go to church so we went to the Metropolitan Cathedral of the Immaculate Conception, lovingly referred to by the locals as La Chichona (this in reference to the large number of breast-like cupolas on the roof).

Mass was of course all in Spanish and therefor even less understandable than normal for me, and being in a Christian church is no less uncomfortable in a foreign country, but the sides of the church were open, there was a lovely cool breeze and the man signing hymns and playing guitar was wonderful, so all in all it was rather enjoyable.

We sped back to the hotel for (another) change of clothes and went out yet again for dinner and dancing. Admittedly, I was kind of dreading it, but rather than have dinner and go to a club we went to a restaurant with a dance floor and ended up having an absolute blast. The sangria was good enough to rival Fernando's, the food was excellent (I got to try tongue for the first, and last, time) and that ballroom dance class senior year wasn't a total waste of time after all. Everyone just wanted to have a lot of fun (Amanda is both a good dancer and a little crazy), there were no skeezy guys present, and we got to show Managua a choreographed Macarena, so I'd call it a success. A fantastic end to a very good day.

Day 2 - Tenemos Prisa, Vamos a Esperar

The day began much the same as yesterday - already 80˚ by 7am, a filling and tasty breakfast and on the road by 7:30. OUr first stop was UPOLI, where we waited.

A note here on 'Nica time'. Like the more well known 'Indian standard time' or the French 'normalement', times are relative. An appintment set for noon might be kept by 12:45. This has lead to the existence of our trip catchphrase "tenemos prisa, vamos a esperar" (hurry up, we are going to wait). At the same time, people will wait all day in the scorching heat for a chance to see the doctor, and not once complain.

After we obtained the UPOLI students we split into two groups - one went to the academic center to do geriatric assessments and mine went to the Centro de Salud. For a few hours we did rotations through the emergency department, the vaccine center and the OB/GYN office. This was the first time Amanda, Alvaro and I had worked together without a more proficient translator than myself and it took a little work. Eventually we got into a system where I could translate between the two of them and Alvaro could fill in the words I didn't know or used incorrectly. I'm not sure if it would have been any easier if he knew any English, but he said he wished he did, which is a start. He helped me work on my vocab list and seemed interested in learning.

In the ER I took vitals (no fancy equipment here - BP cuff, watch and glass thermometer only, in addition to my bright orange stethoscope) while Alvaro took a brief health history. Amanda's first patient had venous insufficiency so she followed him to the procedure room while I stayed in intake. Admittedly, not having to actively translate made communication a lot easier and we were able to work together fairly efficiently. A number of people were there for injections (for pain, contraception or antibiotics) and I was able to do one. The preferred method here is intragluteal, which I've never done before, but I had a good teacher. The woman's leg didn't immediately go numb, so I took that as a good sign.

We got to watch PAP smears being performed in the OB/GYN clinic, another new experience for me. I unfortunately missed the skills lab we had before the trip, so I had never even practiced on a model before. The nurse in the office did the first exam and let Amanda do the second. We should go back in a few days and I want to try doing one then.

After meeting back up with the rest of the group and a quick lunch at UPOLI (fish this time) we went to the Children's Hospital for another tour. This served as yet another reminder of why I should not do pediatrics. The first ICU we went in had a number of acutely ill patients, including one with Tetrology of Fallot (a congenital heart defect that consists of four malformations that occur together) who was struggling to breathe even with a non-rebreather mask. I've never seen a human being that grey before. There was a boy in the back of the room with lupus who was so excited when we waved at him that it made me wonder how much contact he gets with other people.

The second ICU, more of a step-down ICU, had kids with more long term issues. There was a boy in an induced coma so he could heal from a car accident. He had a nurse who seemed dedicated to him and was clearly repositioned frequently; something, I might add, I have rarely seen in the states. There were a few kids with pneumonia, two with Guillain-Barré (rather exciting for me as we just learned about it in class and I was able to teach the English-speaking doctor the word 'demyelination') and one little girl with a pleural effusion. She was the one who really got to me - about two years old and she had wrist restraints to keep her from pulling on her nasal cannula; and she was just sitting up in bed and wailing for her mother. Since I wouldn't be able to work very well if I was crying all the time, I'm thinking peds is not for me.

As far as function was concerned the hospital was impressive - a huge cancer wing that did both in and outpatient chemo, a dialysis center and many others. I find it interesting that in the second poorest country in the Western hemisphere, free healthcare is considered a right, not a privilege.

Dinner was also fish, and as always, it was fantastic. Mary Beth, a Duquesne graduate accompanying us while on leave from Doctors Without Borders, made the point that part of the reason all the food has tasted so good is because it is all much more fresh than what we get in the states. The chicken we ate yesterday was probably killed that day, and never had any preservatives pumped into it. One thing after another is making me wonder why, with all the money we have, we do not live as well (in some ways) as people here.

Day 1 - Orientation

Didn't sleep particularly well last night, but what else is new? At least there were no more spiders. The day started bright and early with breakfast at 7 (rice and beans, eggs and ham, fresh fruit and yogurt) and we were on the bus by 7:45. Our driver, Roberto, has been with our group in the past and must be a masochist of the highest degree to put up with a group of American students more than once.

Our first stop was UPOLI (Universidad Politecnica) where we met the professors and students we will be working with for the next week. I will be paired with Amanda, a junior and Duquesne and Alvaro is our UPOLI student. Communication should be an adventure - my Spanish is conversational but by no means fluent, Amanda speaks even less and I don't think Alvaro knows any English at all.

One of the professors, Georgiana, gave us a brief lecture on the demographics of and chief medical problems in Nicaragua (see earlier Presentation Notes). I tried taking notes in Spanish and I'm hoping the language gets more comfortable as the week progresses.

After the lecture we all piled back into the bus and drove to the barrio where we took a tour of the Centro de Salud (health center), essentially a local clinic. They can take care of outpatient procedures (immunizations) and small emergencies like rehydration, but anything major gets sent to the hospital. We met one woman at the CS whose job it was to make sterile supplies. She made her own cotton balls, folded gauze pads and sterilized everything in the autoclave. Everything is in short supply here and so it is all precious. Maybe if we treated our system in a similar fashion we would see a difference in healthcare cost.

We each got to meet our families after that - all in the same neighborhood within walking distance of one another. The Román family is as follows:

Nelson - age 70, Grandfather (diabetes)
Nelson Jr. - age 38, Son (diabetes)
Cesar - age 34, Son, (healthy)
Rosa Esmeralda - age 13, Granddaughter (asthma)

We are unsure at the moment how Rosa is related to the others - she may be the daughter of another sibling. Tomorrow we will spend a few hours with them assessing what their major health issues might be - other than the aforementioned diabetes and asthma. After the tour of Villa Libertad (the barrio) we sped back to UPOLI for lunch (rice and beans with chicken) and took a tour of an actual hospital.

Everything in the hospital was in some way related to women's health. The labor and delivery area was run like a well-oiled machine - women here until they are 5cm dilated, then to the labor room until they are crowning, deliver in a separate room and as soon as the placenta is delivered they go out in the hall on a stretcher with their baby for observation. Two hours later they are sent to the postpartum area. From what I saw there were five beds for laboring (all in the same room) and two delivery rooms, and they deliver an average of 30 babies per day. If only we had that sort of efficiency in the US.

Dinner was chicken with rice (and anything fried in that much butter is bound to taste incredible) and we had a conference on our thoughts on the day and our ultimate goals with this program. While I am excited about helping people here, I'm here more to learn - both about nursing in general and how to make better use of time and supplies. There are an infinite amount of things that need to be changed about the US healthcare system, but we can start with cost. I'd never really considered administration and policy before, but there are so many things I want to change that I just might.

One things that especially struck me today was the attitude of the patients. They all shared rooms, in close quarters, no AC so it was about 85˚f inside and apparently it's sometimes so crowded they have to share beds. And yet everyone was grateful and happy to be there. Imagine such a thing in an American hospital.

Nicaragua Presentation Notes

• Escuela de enfermería - fundada en 1943
• Hay solamente cinco enfermeras generales y seis médicos para cada 10,000 personas
• 3.3% de población tiene 65 años y mas
• La principal causa de muertes en jovenes son accidentes
• 10.8 muertes por accidentes de tránsito por cada 100,000 habitantes
• Había 50.6 muertes materna por cada 100,000 nacidos vivos en 2012 (86.47 en 2005). 17% por eclampsia/preeclampsia, 34% por hemorragia
• 7,756 casos de virus de immunodeficiencia humana en Nicaragua
• 6,000 casos de Dengue en 2013 - sólo medicameno para los síntomas

----------------------------

• Nursing School - founded in 1943 
• There are only five general nurses and six doctors for every 10,000 people 
• 3.3% of population aged 65 and over 
• The main cause of deaths in young people are accidents 
• 10.8 traffic fatalities per 100,000 inhabitants 
• There were 50.6 maternal deaths per 100,000 live births in 2012 (86.47 in 2005). 17% from eclampsia / preeclampsia, 34% from hemorrhage 
• 7,756 cases of human immunodeficiency virus (HIV) in Nicaragua 
• 6,000 cases of Dengue in 2013 - only medicine for symptoms

Today is freshman orientation at UPOLI (Universidad Politecnica) and as we sit in lecture, pounding music rattles the windows. It reminds me of Mayfest.

In Managua

Landed in Managua and I am already reminded strongly of India. The air smells of hot pavement, diesel fumes and a sweet smell that may be flowers or rotten fruit. We each have our own beds and -naturally- there was a massive spider on the ceiling above mine. Early start tomorrow so now to bed.

Flying to Managua

Up at 5 this morning to take the Patho final at 7 and was at the airport by 9. It is now 6:30pm and we are on our way to Managua! I'm really excited to see an entirely new culture (to me), eat a lot of amazing food (that I hope doesn't make me sick) and get some new experiences with regard to nursing.

I'm still hoping I get to see a delivery but anything we do will be new and different, and therefor awesome. I'm also very much looking forward to not having any studying to do for a week! This break is very much needed.

Packing List

Underwear x11
Socks x9
Bras (sports x2) (regular x1)
Bathing suit
Scrub pants x3
Scrub top/tee shirts for clinic x5
Other tee shirts x5
Running shorts x1
Sweatpants x1
Flip flops x1
Capris x1
Skirt x1
Dress x2
Sweatshirt x1
Sneakers x1
Heels x1
Sphygmomanometer
Stethoscope
Shears
Name tag
Water bottle
Sunglasses
iPad + charger
Camera + charger
iPhone + charger
Toiletries
Meds

Pre-departure Dinner

Tonight we had our last meeting/dinner before our departure on the 26th. Mrs. Cunningham hosted and made fantastic Nicaraguan food. I'll be a very happy foodie if that is what I'll be eating for a week and a half. New camera should arrive Monday so I can test it before leaving. It films in HD so I should be able to get good footage in addition to photos.

It'll be hard to be away from Dave for 10 days but it is nothing new for us.

Will be spending the last four days here studying for the Patho/Illness I final - yikes. I just have to keep reminding myself that all I need to do is pass.