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

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• 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.