Thursday, June 7, 2012

We are enjoying the cool weather of Lima and the lovely facilities of the clinic where we have been working, but are overwhelmed with patients.  100 the first day, and then Carol limited it to 60-- but we still ended up closer to 75 for the next 2 days!  Busy-- and the same trials and tribulations with the trainees and good moments and tough ones-- but there is certainly need, evidenced by the sheer volume of women we are seeing and the numbers we are turning away (40-80 each day).  I gave my lecture to a group of 30-40 last night, and I give many thanks to Sallie for help in translation-- as I worked it into a powerpoint cutting and pasting and adjusting on a bumpy 1+ hr bus ride to the clinic each morning.  OK, off for another day of PINCC adventure.  
From Pam Lotke, MD, OB/GYN, Medical Director in Peru, June 2012

Tuesday, June 5, 2012

The true voyage of discovery consists not in seeking new landscapes, but in looking with new eyes.

The true voyage of discovery consists not in seeking new landscapes,
but in looking with new eyes.
Marcel Proust
Julio, our guide, arrived at 8:00 sharp for our walking tour of Leon.  After a few short blocks, he conscientiously sat us in the shade in front of a large mural that related the history of Nicaragua from its indigenous roots to the current president, Daniel Ortega. Interspersed with our history lesson, Julio encouraged members of our group to read aloud pieces of literature in English, merging sentiment and imagery with fact.  Lezli and I took turns reading A Roosevelt by Rubén Darío, which speaks directly and frankly to the bullying of Latin America by the U.S. government.
The U.S. is potent and great
When you shake there is a great temblor
that passes through the enormous vertebrae of the Andes
With eloquent grace, Julio described the U.S. support of Somoza, the evolution of the Sandanista revolution, and the new hope and unavoidable challenges ahead for his country.  Juio later shared that he had been picked up on suspicion by Somoza's army at the age of 14 and was incarcerated, for no reason, for several months.  He took us to the Martyrs and Heroes Museum where he showed us pictures of those who had died for the sake of their country including his step brother and many friends.  The photos were of children and helped us understand the depth of Julio's participation and his pride in the true story of his country.   " Nicaraguans now have freedom", he said " but they need to think, and care about each other to really change the country and make it better."  He was very careful to communicate that his issues with American policy were not a reflection of his feelings for the American people, and again thanked us, emphatically, for listening to his story and giving of our time and our hearts to help his country. 
Our next stop was the rooftop of the cathedral.  I love how rooftop tours give you a completely different perspective on a place.  Julio pointed out the ring of volcanoes that surrounds León, one of which was belching gray smoke.  Numerous times I had heard how "we're due for another major eruption", and my midwestern heart skipped a beat.  The land I come from offers me stability and support, but the earth here puffs and groans, spews fire, rumbles, shakes, and breaks.  The Masaya volcano was so active this week that the park was closed to the public.  It is always enlightening to look down on the markets, the plazas, and streets.  After a few quick photos of the bell towers and a pair of lovebirds, we were ready for a cool drink at the best hotel in town, El Convento. 
Both the the art center of the Ortiz Gurdián Foundation and the El Convento hotel are funded by BanPro which charges a minimal entry fee, much of which is donated to Mujeres con Cancer, a charity that helps low income women get treatment for breast cancer.  The art collection was superb with pieces by Picasso, Chagall, Miró, and a predominance of amazing Latin American art from Rivera to Tamayo and numerous very talented Nicaraguan artists that were new to me. It is a private collection displayed in a lovely Creole-Civil style home with a rose garden at its center. Nicaragua is a country of poets, artists, and artisans – on our way back to the hotel, we passed an elderly gentlemen that greeted Julio warmly.  He is a local poet that had been honored the night before where he received a stipend from the government to continue his work.  He was impeccably dressed in a dark suit and cane, despite the sweltering heat.  I found it interesting that in a country this poor, there is still support for the arts and their ability to bring beauty into our hearts with simple words, brush strokes, and notes.
After the tour, we stopped for lunch at the beach and then headed for Managua.  On the outskirts of the city we visited another artisan cooperative, Esperanza en Acción, which is run by the niece of a friend of Patricia.  The organization works with 25 groups of artisans (275 individuals) of which 95% are women and come from rural and economically disadvantaged areas.  Through fair trade initiatives, they offer artisans a fair wage ($1.25/hour as compared to the usual $1.00/day) and a worldwide market which they are working hard to expand in the future.  Esperanza en Acción consistently encourages artisans to improve the quality of their work and offers them low interest loans to help improve their standard of living.  Each individual sets the rate for pay back, according to their individual needs and living situation.  I'm honestly not much of a market person - always wondering what percentage of the price actually goes to the vendors and artisans.  These cooperatives are a win-win for everyone, and so much less chaotic.  I also loved having the artists signature on the piece and the peace of mind that came from knowing I was truly making a difference with my purchase. 
After a quick stop at the hotel for a much needed shower, we were off for dinner at El Tercer Ojo - Managua's only fusion restaurant which was conveniently walking distance from our hotel.  Ann from PINCC warmly accepted the invitation to join the group for our final dinner.
In true Patricia fashion, she encouraged each of us to share an insight from the trip.  Gratitude and Generosity were the common themes expressed around the sangria filled table.  We discussed how misunderstood HPV is in our country, how each donation counts, and how rewarding it has been to travel with the intention of service as opposed to pleasure.  We all agreed that the unique combination of the DFW itinerary has been perfect.  It was important to get to know each other beforehand to gel as a group and create an atmosphere of comfort and trust with each other before the intensity of the service work, and equally important to have this down time at the end. 
"I'm sending PINCC some real post it notes and binder clips", said Marcy.  She was on the data entry team and corrected (with a smile) my previous blog entry that the office staff had access to REAL post-it notes.  They had paper clipped numbered pieces of paper to each file to identify cases that kept falling off causing confusion and slowing down the process.  "A little adhesive would have made a big difference!" She's going to send Carol some office supplies from Atlanta for the next PINCC mission.
"I'll never look at my Ob-Gyn visit in quite the same way, " said Dani.  The trust these women put in the medical and support staff was sobering.  There was no privacy, no room for modesty.  A piece of paper toweling placed on the exam table was the only "sterile" surface between patients.  The same hospital gown was used all day.  But these women showed up because they wanted to take care of themselves so they could be around to take care of their children and grandchildren. 
Catherine also spoke to these women's courage.  Many of them thought they had cancer and cried with relief when they heard negativo.  The Nicaraguan staff spent a lot of time repeating instructions and educating patients about the severity of recurring infections and STDs and the importance of treating their partners and using condoms to prevent recontamination.  None of these are easy concepts to understand the first few times you hear them.  The patience of the staff, the volunteers, and the patients was truly impressive.
Arlene spoke to the need to equalize resources at the local level, and pointed out that although the conditions at the hospital in León were shocking to us, it is a FREE hospital where EVERYONE can see a doctor and get a prescription filled. 
Leslie's eyes filled with tears as she once more remembered the warm welcome she had experience when a young mother invited her into their modest dwelling right next to the pottery shop in San Juan de Oriente.  The family picture with Leslie at the center says it all.  Write about it, Leslie.  
An amazing memory. 
Amidst hugs and tears and promises to keep in touch, we finally said our good-byes.  We had challenged Proust's wisdom and succeeded in seeking new landscapes AND looking with new eyes.  Somehow we all knew we were returning to our "real life" changed on some level, yet to be determined.  Keep in touch gals!  I want to see posting on Facebook and will start looking for the photos in the very near future!
On behalf of our group, I would like to thank DFW and PINCC for making this mission possible.  I would also like to formally recognize that amazing job that Patricia Anderson did as leader of the DFW group.  With patience and grace and tenacity, she kept us on schedule and always had time to listen to our stories.  I especially appreciate her sense of adventure and willingness to jump into a horse drawn carriage for a tour in the rain, and her many connections that brought us to cooperatives and clinics where we could experience the results of non-profit and fair trade organizations, first hand. 
Hasta pronto y que todo les vaya bien.
Tina Romenesko

Sunday, June 3, 2012

In A Country This Poor, Every Donation Is Appreciated

In a country this poor, every donation is appreciated


Friday morning.  Our last day with the medical mission.  The load was lighter than expected as a group of 19, that we were hoping would arrive from a distant village, was unfortunately not going to be able to make the trip to the clinic.  The interpreters were sent into the hallways to do patient education and do interviews accessing the level of knowledge patients had about health issues in general, and cervical cancer, specifically.  Shannon was always able to get a smile from the kids and the adults with her bright effervescent personality.  At 19, she is the youngest member of the DFW team, and by far the most energetic!  By around 12:30, we were completely done with patients and were packing up the suitcases that organize the medical supplies, getting them ready for their next stop.  Peru.  Dr. Pam and her kids, and Carol were leaving for Lima the next morning for another PINCC mission. 


The Nicaraguan staff of doctors and nurses plus Jenny had made plans to take both the PINCC group and DFW out to lunch to culminate our mission.  We sat at the same large table where we'd eaten the night before.  It was inspiring to see how the entire group had gelled.  Spanglish was heard at all levels as we connected as colleagues outside of the confines of the hospital corridors.  There were lots of snapshots and smiles and exchanging of email addresses.  Dr. Pam addressed the group and offered her thanks to each and every one of us for our important role in preventing cervical cancer through education and training medical personnel.  Five certificates of graduation were distributed amid rounds of applause and tears.  The recipients varied from Ob-Gyns, to Family Practice Physicians, to nurses, and one nurse's aid that had only completed an eighth grade level of education.  What is particulary amazing about this screening method is that it can be performed by any trained medical personnel, which makes it much more sustainable in developing countries.  We posed for our group picture in the restaurant garden, and said good-byes for another 15 minutes before finally dispersing the group.  An amazing experience that has filled all of us with a deep sense of gratitude.


That evening we met for dinner in the hotel lobby and shared, again, some of the high and low points of the trip.  I donated my headlamp to Carol - an essential piece of equipment in the VIAA process.  Because of headlamps, clinics don't need to have electricity to do screenings.  She was thrilled, exclaiming that this headlamp would go to Antonia, the nurse's aide that had just received her certification.  We were also leaving our scrubs and various pieces of clothing from running shoes to t-shirts.  "In a country this poor, every donation is appreciated,"  explained Carol. 


A few of us rounded up the evening at Via Via, just around the corner from our hotel, dancing to the rhythm of a local salsa band.  Tomorrow we head for Managua. 

Friday, June 1, 2012

"Quando quiero llorar no lloro, y a veces lloro sin querer¨" - Rubén Darío

Quando quiero llorar no lloro

Y a veces lloro sin querer" 

Before heading for the hospital, Patricia and Carol worked together to assemble the group, in full scrubs, for a photo.  These two groups have melded seamlessly into one over the past 5 days.  In our group meeting, the PINCC volunteers admitted they were skeptical about the  " Dining for Women" volunteers when we came in on Sunday.  They´d already had a full week together and were very close, but the lines have completely blurred now and I can sense a gratitude that flows beautifully both ways between all of us.  Ann and Karen have even expressed an interest in joining a DFW group when they get home.  Another full circle. 

The hospital day typically begins for the PINCC group with a teaching session in one of the meeting rooms, briefing the Nicaraguan doctors and nurses who take written tests, are asked to interpret photos of lesions and suggest treatment plans, and also work on bedside manner and patient etiquette with the U.S. staff.  Carol had asked me to share my son´s experience using breath (pranayama) for his spinal taps when he had cancer 20 years ago.  Ross is now 26 and cancer free.  The techniques are similar to the LaMaze technique used in childbirth and help patients focus on their breath instead of the procedure and discomfort (a.k.a. pain), breathing in through the nostrils and out through the mouth, very slowly and rhythmically.  It is also a great way to connect directly with patients and offer support.  The doctors were very open to the suggestions and appreciated Ross´s story.  I also slipped in a mudra for relaxation: Prajna Prana Kriya.  You curl the index finger into a small ring and place the index fingernail at the base of the thumb on the inside.  It is very effective for reducing anxiety and again, offers another focus that helps the patient remember to relax into the procedure instead of resisting it.

I was agained assigned to Karen´s room (yay!) and the other interpreters headed to the hallways to do patient eduation.  Everyone is getting more comfortable with our role as volunteers and finding new ways to help everyday.

By around 1:30 PM, we had seen our last patient and were given a tour of the hospital, which was very eye opening and sobering.  The hospital was built during the Samoza regime as a private hospital but is now the official teaching hospital for the university.  It does not have air conditioning, except in conference rooms, offices, and a few treatment rooms, has almost no natural sunlight (which naturally kills bacteria)  and is very difficult to clean.  There is an open area in the middle of the building where the generators are housed allowing pigeons access to the hospital corridors on a regular basis.  Patients have to bring their own linens upon admission and it isn´t unusual for two patients to share one bed.  Yes. You read that correctly.  When Carol first started coming down to Nicaragua in the 80s, they were still sharpening and re-using needles.

Our first stop was the basement where the Emergency room is located along with the Pharmacy and Pathology.  I had noticed that our patients were given their specimens to deliver on their own to Pathology with their name scotch taped onto the bottle.  A different level of quality control than we are used to in the States.  The morgue was also in the basement.  When our guide, Carmen, asked if we´d like to see it there was an emphatic No, Gracias from the group.  The "mor-gay" was not going to be a part of the DFW tour.....

Maternity was on the second floor.  We walked into a large room which 8 moms and newborns shared together in the sweltering heat.  We wished them congratulations and asked the names of the babies.  Ernesto, Gonzalo, Maria,...HILLARY.... and KEVIN!  Lesli, our infectious disease control expert, noticed a used catheter sticking halfway out of a garbage can in the middle of the room and tried to steer everyone around it.  The hospital averages 15-20 births a day, and has a small NICU with incubators, respirators, and monitoring equipment.  More serious cases are referred to the Pediatric Specialty hospital in Managua.

We visited Orthopedics, Med-Surg, Infectious Diseases..., but the most heart breaking area for me was Pediatrics, where the mothers were sitting with their sick kids in crowded rooms, with little to do and lots of time to think.  I expressed the compassion of our group to a couple of mothers wishing them good luck from our hearts to theirs and couldn´t help but imagine my time in the hospital when my own children were ill.  The hospital was a refuge for me where I felt safe and supported.  I could barely control the tears as I recognized the fear and pain in these mother´s eyes.  As we left the building, everyone expressed a renewed gratitude for the state of medical care back home.  It´s certainly not perfect, but the standard of care is completely at a different level.

After a long day - a few of us headed to the Museo de Rubén Darío.  Darío is Nicaragua´s most famous poet and he is from León!  The museum is the house where he lived for most of his childhood and is also where he died.  Doctor Sara´s husband and mother-in-law run the museum so she had encouraged me to seek him out and get a personal tour, which we did!  He proudly explained each item in the museum in great detail, from his funerary mask to his writing table.  Darío was sitting on this very curb, writing poetry, at age 6 and is credited with changing the way metaphor is used in the Spanish language.  He was influenced by Poe, Emerson, and Whitman, and spent quite a bit of his life in Spain, Paris, and New York.  We learned about his many lovers and tried translating some poetry that was preserved in the original written form. They also house a small library that is available to university students studying Spanish literature.

As we wound our way back to the hotel, Patricia shared that she had nearly dropped into a pot hole on one of  her errands.  Pot hole doesn´t accurately describe the state of the streets here.  There are huge holes in the sidewalk that come up at a moments notice, so you have to look down with every step.  AND, the drivers totally have the right of way.  If you try to cross in front of them they beep at you, impatiently.  So walking around is a full on sensory experience!

Carol had arranged dinner at an open air restaurant - where we all sat at a huge table and shared stories, old and new.  Dr. Pam´s and Dr. Ilana´s kids rain between rain drops and played games at the end of the table as we waited for dinner.  The kids have been a wonderful addition to the group.  A true breath of fresh air with all their energy and enthusiams.  Two of Carol´s friends also joined us - sisters that have been helping with the intakes in the morning to get patients into treatment rooms more efficiently.  One is a nurse and the other, a biologist.  Fascinating, dedicated women from León.

I´d like to close this blog entry with part of a poem by Rubén Darío that speaks to the emotions that each of us have experienced in our own unique ways here in Nicaragua.  Tears connect our hearts in compassionate caring and often appear when we least expect them.  Thanks for the permission, Rubén.  To tears.

Quando quiero llorar no lloro

Y a veces lloro sin querer" 

"When I want to cry, I don´t cry

and sometimes without wanting to, I cry"

Felicidades a Mamá

Felicidades a Mamá 

(Gracias a dios - I just learned how to do accents on this Spanish keyboard!)

There was definitely an energy of celebration in the air as we headed toward that hospital in the morning.  Mother´s Day in Nicaragua is a national and obligatory holiday.  Imagine that!  Only the restaurants and stores are open and everyone is shopping for mom!  As we passed the market, I saw a large table completely filled with mother´s day cakes, a yellow cake with bright white frosting and lots of red frosting roses with Felicidades a Mamá written across the top.  I bet there were 50 of them, monitored by two young boys, towels in hand, swatting at the ubiquitous flies that were trying to land on these masterpieces.  

Because of the holiday, we expected our patient load to be much smaller, in fact the entire clinic was on skeleton staff except for the PINCC group.  Carol couldn´t justify an entire day off in a 5 day training so she and Jenny had  encouraged patients to come and get their cervixes examed for mother´s day - giving themselves the gift of health.  

The PINCC translator, Sallie, was needed to translate a document for Dr. Pam, so I was upgraded to translator for Karen, the Nurse Practitioner from Spokane, in a treatment room.  We saw 6 patients with various needs and there were also 3 Nicaraguan doctors in a very small room with two fans, duct taped to the walls.  It was my first view from the other side of the table.  I felt the pressure of accuracy as I was interpreting the results of tests and treatment plans.  I dropped out of my logical / grammatical mind and into some numinous space that seems to be able to speak medical Spanish!  Karen is a wonderful teacher and briefed me between patients so I could understand the terms I was translating!  I learned so much first hand and was able to experience the conditions these doctors and nurses work in.  We are definitely not in KANSAS anymore.  Everyone is very professional, but the rat poison on the floor, use of one hospital gown for the entire day, and placing a piece of paper towel on the exam table to provide a clean surface for each new patient are just a few examples of the limited resources they are working with on a daily basis.  Our exam table didn´t even have stirrups for the woman´s feet.  She had to hold herself in the compromising position necessary for examination, sometimes placing her foot on the doctor´s knee while they performed the inspection.  More than once, I found myself leaning over a patient, coaching her to breathe, and holding her ankle at the same time to stabilize her foot on the table as she had a procedure.

We brought our donations today - which filled one entire side of the corridor.  Gloves.  Hospital gowns.  Scrubs.  Shannon is a pre-med student and also works at a clinic, so she had an entire extra suitcase filled with an amazing variety of medical supplies that she had lugged with her from South Carolina.  Each of the Nicaraguan medical staff filled a bag with medical goodies.  It was a rare treat for all of them and much appreciated.  Just about everyone in the DFW group brought something, from toothbrushes to ibuprofen and specific supplies. 

Carol had predicted that it would be a half day - due to the holiday and around noon there was only one patient still watiing to be seen for a procedure.  Carol asked her to wait while we had our private Mother´s day celebration so everyone else could go home.  Jenny had purchased flowers for each of the mother´s in our group ( a Nicaraguan tradition) and our last patient was thrilled to be the first to receive a rose while sitting in the hallway in her hospital gown with the group!  The smile on her face spoke volumes!  Jenny had also brought in a Mother´s Day Cake.  just like those we had seen in the market on the way to the hospital that morning, which we all shared.  I´m sure this was one gynecological exam this last patient will never forget! 

The DFW group headed for the beach around 2:30 PM, but I opted to stay back and write and do yoga.  So.  One of them will have to do the beach update!  I know they were able to take nice walks, had access to a lagoon perfect for swimming, and fresh seafood for dinner.  That sounds pretty good.

I shared dinner with Ann and Sallie from PINCC.  We had to make a reservation and put down 200 Córdobas because of the mother´s day rush.  We got there at 7 and the place was half empty but as we prepared to leave at 8:30, things were really getting going.  We shared a delicious margarita and as he brought out agua con gas and a big glass of ice I asked if the ice was made with agua purificado.  No - was the answer.  Hmmmm.....  My margarita was on the rocks......  Rocks are ice.......  We all said a little prayer, and drank warm seltzer water with dinner.  Carol had explained to us the first day that the water pipes and sewer pipes run side by side in Nicaragua and are open so microbes can easily pass from one pipe to the other  That description had firmly instilled the fear of Monteczumas revenge in all of us.  We reasoned that the tequila had probably kiilled any errant bugs that might upset our intestinal tracts.  

We headed for bed as soon as we got back to the hotel.  Two mother´s days for me this year.  Monteczuma wouldn´t dare take revenge on a mother on her second mother´s day.  Right?