Nicaragua spring break 2012

1. Christopher Jaeger Ghazala Khan Stephanie Schley Melissa Bayci Sarah Willits Alex DeMare Alex DePorre Laurie Bossory Lucy Boekelheide Sara Singer Nicaraguaspring break 2012

2. FIMRC • FIMRC is an acronym for the Foundation For International Medical Relief of Children. They are a non profit organization that uses a combination of clinics, community outreach, and education to improve maternal and pediatric health all over the world. We chose to work with FIMRC because our faculty was familiar with the organization and knew that it was reputable and safe. They were able to accommodate us at their Limon location during the week of our spring break. The FIMRC staff members were all a pleasure to work with which made organizing the trip in a short time period feasible. ~Sara Singer

3. Organizing The Trip • In selecting an alternative spring break experience for first year medical students we wanted to select an organization that would allow students to gain a first-hand familiarity of the diverse experiences of international health care, particularly in a third-world country as it would provide a greater awareness for students of the need, as well as to juxtapose to our own healthcare in America. In selecting an organization, we wanted to keep a number of things in mind: • The organization should offer one-week experiences at a reasonable price and have experience working with groups, in particular medical school groups. • The location should be safe. • The location should be accessible due to spring break length time constraints of traveling. • The organization should focus on providing sustainable, high quality health care. • The organization and site should offer a medical experience on par with M1 skills. • There should be an opportunity for students to provide meaningful assistance to the local community, such that it is not only the OUWB students benefiting but a mutual benefit. ~Stevie Schley

4. Overview of our Trip • Students were able to gain a variety of healthcare experiences including: • Working with nurses of the local health post to visit schools and go house to house to vaccinate children as part of Nicaragua’s March vaccination campaign. As well, children were given anti-parasite medication and vitamin A. • Checking in patients at FIMRC’s bi-weekly clinic visits by a pediatrician and observe the pediatrician seeing patients. • Help develop and present educational health talks on microbes and trash. • Work with FIMRC’s nurse to visit the outlying communities and do blood sugar and blood pressure checks on identified diabetics. • Assist in holding informal community meetings on diabetes and maternal health care. • Help provide bi-weekly therapy for 2 children in the community with cerebral palsy. • Visit the local (1 hour away) government hospital to shadow surgeons. • Maintain the FIMRC building site and local health post through clean up and painting. ~Stevie Schley

5. Reflection • Overall, I couldn’t have asked for a trip that better aligned with the first year medical school experience and skill sets. I believe that all of the students greatly benefited from the learning experience in gaining a better appreciation for the needs of the underserved, an understanding of global health care, and increased their cultural awareness. ~Stevie Schley

6. Pediatrician • On Tuesday and Thursday afternoons, FIMRC would organize for a pediatrician from one of the nearby hospitals to come visit their clinic. The pediatrician traveled via taxi for over an hour to spend the afternoon with the local children and infants. All of the volunteers were able to sit in on the patient’s consult with the physician. For those of us who did not speak Spanish, a FIMRC employee would translate the conversation for us. The consults would take place in a small room towards the back of the clinic, a room probably no greater than 40 square feet. The room contained a small table with a handful of supplies for the doctor and two plastic chairs for the patients, typically a mother and child. • ~Laurie Bossory

7. The Pediatrician’s Office

8. Pediatrician • The pediatrician often diagnosed the children through a short conversation with the parent and a short physical exam with minimal diagnostic equipment. For the two days we interacted with the physician, the only diagnostic tools we saw were his stethoscope and tongue depressors. The physicians would write out a note and prescription for the parent on a plain white piece of paper that had been torn into quarters. The “pharmacy” was in a room next door that was smaller than most walk-in closets. It contained mostly donated meds that had been arranged on a large bookshelf. The physician would stay until all of the mothers and children had been seen. ~Laurie Bossory

9. Helping the Pediatrician The Pharmacy

10. Thoughts on the Pediatrician • We were also able to see this same pediatrician when we visited the OR at the hospital. As we watched two caesarian sections through the course of one morning, we noticed that the physician caring for the babies immediately after they were born was the same physician who came to the clinic earlier in the week. This made our group reflect on the diverse responsibilities of this one pediatrician. It was an extremely enlightening experience to witness health care and routine doctor visits in Nicaragua compared to the United States. ~Laurie Bossory

11. The Waiting Room

12. School Visit and Microbe Presentation • We went to a school to teach the children about microbes. This was a relevant topic as the environment is dirty and lacking in sanitation and knowledge of personal hygiene. Parasitic infections are especially prevalent in children in this area. • We wrote a brief informative presentation about bacteria, viruses, parasites, and the importance of hand washing in Spanish with the help of a translator. We wrote a song in Spanish and sang it with the class, demonstrated proper hand washing technique, and used glitter sprinkled on the student’s desks to represent the spread of microbes. • It was nerve racking to be forced outside of our comfort zones; singing in front of a class and presenting in a foreign language. Our warm reception by the students quickly calmed our nerves and we all felt comfortable and were able to have fun. • The students were very attentive and eager to participate. It was heart warming to see how happy they were to see us and we all felt proud about the important information we taught them. ~Sara Singer

13. The Students

14. Hand Washing Demonstration

15. Sanitation Education • One morning a group of us went to a local school and taught an elementary class how trash could affect their health. First, we explained the difference between organic and inorganic trash, and how long each takes to decompose using posters. Then we explained how the mosquitoes could become dirty from the trash and make them sick. To emphasize this, we played a game where they had pieces of paper that signified trash, and they had to put them in the proper place before “mosquitoes” (the group teaching) tagged them and made them “sick” and they had to stop where they were. ~Sarah Willits

16. “Basura” Presentation Playing the “Basura Game” game with the school children

17. “Charla” • On one of the days, I went with our nurse, Jessica, and two other FIMRC volunteers to a town called La Virgen to lead a charla(informational talk) about diabetes. Before we left, Jessica explained to us how the lack of information and resources affected treatment of diabetes and its adverse effects. For example, many of the diabetics she works with have very poorly controlled diabetes (with blood sugar readings upwards of 300), and did not understand how they developed diabetes, nor how to control it to prevent adverse effects.  In our charla, we explained to the participants what diabetes was, how they developed it, and how to control it. We stressed the importance of exercise and daily monitoring of blood sugar. In addition, we addressed the difficulty of maintaining a diabetic diet while surrounded by a culture in which the main staples consist of rice, bread, fried plantains and juice with additional sugar added, all of which are detrimental to a diabetic. During our charlait was important for us to have many visual aides, such as pictures, and less words, because the majority of the participants in the program could not read or write. • ~Melissa Bayci

18. Blood Sugar Testing • One afternoon, we went door-to-door to check blood sugars of diabetic people in another town called Cukala. In addition to their blood sugars, we recorded the patient's age, weight, blood pressure, time of last meal and what they ate throughout the day. It is FIMRC's hope that we can use this data to more tightly control their diabetes. We then counseled the patients about diabetes in the same way we counseled the participants in the charla. We emphasized exercise in their daily routine, and explained how to make better choices while eating (for example, drinking Diet Coke instead of regular Coca-Cola). We also explained to them the importance of good foot hygiene. ~Melissa Bayci

19. Blood Sugar Testing

20. Reflection • A few patients really stood out to me when we were checking blood sugars. One patient that we tested has a blood sugar of 415, and we started an IV on her to try to decrease her blood sugar. What was amazing to me is that she claimed to be asymptomatic and was surprised that her blood sugar was so high. It was hard for me to imagine how someone with such a high blood sugar could feel so normal. • Another patient that we visited had a whole-leg amputation. She initially went to the doctor because of painful ulcers on her leg that were not healing in a timely manner. At the time of the doctor appointment, she was officially diagnosed with diabetes (but no one knows how long she was living with it before officially being diagnosed). During this encounter, I truly realized the importance of education in healthcare. This patient thought she was taking a medication to lower her blood sugar (something like Metformin), but when the nurse looked at the pill, she discovered it was an antibiotic. ~Melissa Bayci

21. Reflection • I really enjoyed counseling patients about diabetes, and it gave me a chance to no only use my Spanish language to reach out to patients, but also allowed me to put into practice skills that I learned in our Arts and Practice of Medicine along with the sciences that I learned in our BFCP and Cardiovascular courses. All in all, I feel that the things I learned during diabetic screening was very valuable and gave me a great venue to learn and practice medicine. ~Melissa Bayci

22. Vaccinations in Nicaragua • The most profound and influential experience during the FIMRC program was the opportunity to administer vaccines, vitamins, and anti-parasitic medication to rural Nicaraguan men, women, and children. Although Nicaragua is the one of the poorest countries in the hemisphere, the Nicaraguan Government recognizes the incredible medical, social, and economic benefits that can result from a strong immunization campaign. The national government, therefore, provides free vaccination and medication services to all citizens by using local outpost clinics to monitor and facilitate the campaign. Local aid workers frequently visit homes and schools to monitor individual vaccination records, administer indicated immunizations, and answer any questions related to the program. ~ Alex DeMare

23. Vaccinations and Medication

24. Administering Vaccines • While most OUWB students accompanied nurses into local primary schools for a DPT vaccination program, another student and I had a very different experience by traveling to local villages and homes along with two healthcare workers. We spent the morning trekking through dense forests, scaling hills, and crossing streams to visit some of the most remote villages and homes. The families we encountered lived in utter poverty, subsisting mainly on farming, and lacked many basic resources. Despite these conditions, they were delighted by our visit and quickly yielded their vaccination cards for the health care workers to read and analyze. Throughout the morning, we visited over 50 homes and administered hundreds of vaccinations, vitamins, and anti-parasitic tablets to men, women, and children. ~Alex DeMare

25. The Journey The villages that we visited were not accessible by car. We hiked through the mountains, over streams, and even crawled through barbed wire!

26. Reflecting on the Experience • It wasn’t until we were walking back to a more civilized area that I really started to internalize the entire experience. My actions had made a direct positive impact on the local community, and I felt reaffirmed in my desire to study medicine. Now being far from the forests of Nicaragua, I often use this memory as a positive force to focus and dedicate myself during periods of fatigue or self-doubt. ~Alex DeMare

27. Cerebral Palsy • In addition to pediatric and pre/post-natal care, and disease prevention and health education programs, the FIMRC Limon post also organizes special classes for children with cerebral palsy. There is a gap in the government health and education system for children with special needs such as cerebral palsy. There are schools, which are funded by the government and hence, free to the public, that are specialized for children with special needs. However, there is an age cap of 6 years on these programs. Furthermore, transportation to these schools is a major barrier for mothers. Those kids who are too old for these free schools but require special attention, training, and therapy have nowhere to go. FIMRC sponsors a program that picks up children suffering from cerebral palsy from their homes and drops them off at a public community center, where the FIMRC nurse leads a therapy session for them. • ~Ghazala Khan

28. Physical Therapy • We joined Jessica, the Limon FIMRC nurse, as she led one of these sessions. She began by massaging the children’s joints and limbs and we helped her as she went on to go through various exercises using toys with different sounds as stimuli to motivate them. It was amazing to watch as Jessica guided the kids to perform various exercises with utmost patience and total encouragement. It was difficult to watch the kids struggle in pain as they got harder, but these exercises are crucial in their development and future quality of life. We learned different exercises from Jessica and were able to work with the kids on our own, which was a very rewarding experience. The mothers were grateful and they listened intently as Jessica gave them advice on how to practice with their children at home as well as more health tips for their care. ~Ghazala Khan

29. Physical Therapy OUWB students working with children with Cerebral Palsy

30. Hospital Visit • We had the rare opportunity to travel to the local hospital in Rivas and observe procedures being carried out in the surgical ward. Caesarian sections, an inguinal hernia repair, a cyst removal, and a knee replacement were just a few of the procedures we witnessed as guests of the hospital. It was a wonderful experience for we got to scrub in, walk into the surgical field, and get as close to the procedure as our curiosity warranted. Some of us got to observe our first live births and others took the opportunity to ask questions of the surgeons and note the distinct differences between American and Nicaraguan medicine. Overall, shadowing in the surgical ward was a highlight of the trip. ~ Chris Jaeger

31. Ready for Surgery

32. Painting • On Wednesday we all gathered back at the health clinic after lunch. Caroline brought out the paint cans and we all partnered up to begin painting. A few of us worked next door at the government clinic to sand rusty poles and give them a fresh coat of paint. Others painted the posts of the fence between the two clinics. Other groups before us had started the job, and it certainly made the clinic look welcoming and cheerful. A couple of the girls worked on painting a FIMRC sign for the clinic and it turned out beautifully. Although it may seem small compared to the other activities we did during the week, I think at the end of the day we all had a lot of fun and felt that we had left a lasting mark on the clinic that will be there for years to come. ~Alex DePorre

33. Painting

34. Leisure Time • Being from Rhode Island (the Ocean State), I grew up around the waves. Beaches are like home to me and the beach in Nicaragua was no different. Laying in hammocks and listening to the waves, I felt more relaxed and at ease than I had since medical school started in August. Everyday after working with FIMRC – hiking to family’s homes in rural Limon or giving vaccinations at the local schools – we headed to the beach. As brave souls like Alex DeMare attempted surfing, I struggled to stay above the harsh and relentless waves. Even as someone who grew up with the ocean, the rip tide was frightening. It reminded me how powerful the ocean can be and how helpless we can feel in it - like a child being tossed around by the waves. For me, the leisure of Nicaragua was all in the ocean. It made me feel like a kid again – small in the best possible way and free. The overwhelmed and tense feelings of medical school disappeared because on that beach, I was home. • ~Lucy Boekelheide

35. Beach Horseback riding on the beach Relaxing and enjoying the view

36. Leisure We enjoyed lots of traditional Nicaraguan food Zip Lining

37. Pictures