Saturday, June 15, 2013

I am always doing that which I can not do, in order that I may learn how to do it. - Picasso

I am always doing that which I can not do, in order that I may learn how to do it. - Picasso

by Tina Romenesko

As we wandered through the soggy streets toward the clinic, we were all a little sad that this is our last day.  It has been challenging, and fulfilling, and wet, and long, and filled with laughter, tears, good news, bad news, and lots of hard work.  Each of us has been challenged to do, to see, to be, something that stretches our edges.  In service work, expecting the unexpected is the norm.  We only saw 30 patients today (instead of 45-50) because we needed to clean all the speculums and pack up the PINCC suitcases with equipment and supplies.  The Nicaraguan trainees also took their written tests and all agree that they have learned A LOT in the past five days.  

Today there was a cancer diagnosis, which is always a staggering reality.  This woman has four sons - the youngest is six - and she will have to go to Managua, as soon as possible, for more diagnostic tests and treatment.  She doesn't have the money for the trip and hopes she can find help affording treatment.  Many women die because they can't afford treatment.  Joyce and I were called in to bring her to a quiet space to process the bad news.  Joyce is our PINCC team grandmother that has spent the past two weeks walking through puddles and up and down cobblestones with her two walking sticks.  Despite having MS, Joyce has ridden on boats, walked the beach, and held many hands during our time in Pearl Lagoon.  A fierce warrior with the biggest heart I have ever known, she offered sage advice.  "Take it one step at a time.  Talk to your family - and remember its okay to ask for help."  I held this brave woman's hand and told her about my son that is a 21 year cancer survivor, diagnosed at age 6.  We drank apple juice, and she talked again with Dr. Sharry to ask a few more questions before taking the bus back home.

Around 2:30, Carol brought us all together, instructing us to blow up two balloons and tie them around our ankles.  Really?  Some of us were better at inflation and others at tying, and eventually we were all set for her ice breaker.  Amidst squeals and laughter, we tried to pop each others balloons, until there were only two left standing:  Jaya and the trainee, Inez.  It was a great way to release the stress of the week and come together as a group again.  Each of member of the PINCC group shared what they had learned/loved on the trip and about Nicaragua. Sally translated for those that didn't speak Spanish and the consensus was that it was a very valuable week of learning and listening.  Many of the Nicaraguan trainees wanted to share also - expressing their gratitude and looking forward to our return in November.  PINCC will return to Pearl Lagoon every six months to check on the trainees and continue educating them in these life saving techniques.  Each visit they are progressively moved forward until they are able to perform all of the available treatments independently.  This process usually takes about 3 years and there are always new trainees with each visit, so everyone progresses at their own pace.

The rain continued to fall as we headed our separate ways, filled with appreciation, and wiser for having experienced this amazing week together.

The Good, the Bad, and the Hopeful

The Good, the Bad, and the Hopeful

by Sallie Weissinger

Each morning the PINCC clinicians train the local doctors and nurses while non-medical volunteers interview the day's 45 patients, noting their medical histories and highlighting details that might be of interest to the clinicians (previous PAP or biopsy results that turned out positive, for example).  Then we log  the sheets and pass them on to the PINCC nurses and doctors and the local trainees for their breast exams, pelvic exams, and visual inspections.  

On Thursday Mary Johnson came to the clinic for a PINCC exam.  A stylish, poised, articulate divorced woman in her late thirties, Mary is a school teacher with three daughters.  When the interviewer asked when she had her last PAP test, Mary said it had been more than five years.  She said she'd been too busy teaching her students and taking care of her daughters.  The interviewer - that was me - said the best way for her to take care of her students and her daughters was to have a regular PAP test.  She said she knew that and would make sure to have her PAPs in the future.  We talked at some length about the importance of regular check-ups.  

I also asked whether she currently had a husband or partner.  She said she didn't want to be with a man because she didn't trust one to not abuse her daughters.  She said that her children were her major concern - they were pre-teens and teenagers, and she would not put them at risk.  I wished her well, she promised me again she would take care of herself, and I assumed her exam would turn out well.

Thursday night, as is often the case, the entire group got together before dinner to socialize.  Program Coordinator Carol Cruickshank, whose energy, dedication, and kindness simply never flag, asked us to share our impressions about what we had seen this week. She specifically asked us to focus on the pain we had experienced and asked us to share coping strategies.  As part of the gathering, the doctors and nurses opened up about their patients.  I learned that two of our doctors had seen Mary and that it didn't look good.  Because her cervix wasn't entirely visible, they had to do a rectal exam and felt a bulky area that was suspicious for cancer.  They ordered a biopsy, with results to come back from Managua in two months, and a PAP smear.  The PAP came back as normal, but her situation is still concerning.  Both doctors are hoping for a possible non-cancerous diagnosis - extremely bad endometriosis? post-menopausal atrophy (although Mary isn't post-menopausal)? - the outcome isn't promising, but they hold a glimmer of hope.  

How do the PINCC doctors and nurses deal with the reality of a likely devastating outcome for Mary?  Both Pamela Lotke, our medical director, and gynecologist Sharry Kreitlow say they usually are able to focus on the many patients they can help rather than on the occasional patient with certain or almost-certain cancer.  The good results far outweigh the bad.  But Pam's misted-over eyes and Sharry's serious tone of voice showed that they can't always focus only on the good side of their work.  We all were silent after they spoke, silently hoping for the unlikely: a good outcome for Mary, her children, and her students.  

Plain Talk in Pearl Lagoon

Plain Talk in Pearl Lagoon

by Sallie Weissinger

Several of the volunteers and doctors speak fluent Spanish; many more, while not fluent, speak Spanish well enough to interview patients in Nicaragua, picking up key details of their medical histories.  We thought before coming here that in the Pearl Lagoon area many of the people spoke English, but weren't prepared for the fact that their English and our English weren't the same.  Here the prevailing language is Creole, English spiced with its own Caribbean flavor.

Our patients' names sound English:  we've seen women named Brenda, Joyce, Ellen, Jenny, and Mary.  Their surnames are Fox, McCoy, Williams, and Temple, names that sound like those of friends back home.  But, in the beginning of the week, when they began talking with us during the PINCC intake process, the challenge began.  It's been even more daunting with women of indigenous Miskito origin.

As the week has progressed, we've improved in asking questions and understanding the women's answers.  And when we've faltered, we've been able to enlist local clinic staff to interpret for us.  

First, we don't ask for an address.  We ask the village and the barrio (sector).  Sometimes a woman gives a description: two miles from village X, next to the church or across the street from the hardware store.  If we want to know her phone number, we don't ask about her phone (that means landline); she will say "I no have phone." You ask for her cellular number.  Sometimes she has one, sometimes she doesn't.  

Asking about a woman's medical history has gotten easier, as we have learned, in our various ways, how to frame questions.  The hardest thing for me to ask about was total number of pregnancies, including miscarriages.  It got easier once I began asking "How much baby born alive?  How much childs alive now? How much baby born to blood (miscarriages)?" and then have summarized for understanding, asking, " Five times pregnant?  One baby die in blood?  One baby die age two?  You have three children live now?"

Another potential misunderstanding was cleared up after a patient told me she'd been pregnant four times and had five children.  I asked her to repeat her comment.  She said, "One appear at two baby." I said, "twins?" and she didn't understand.  So I said "gemelos", Spanish for twins, and she said yes.

We also want to know how they delivered their children - vaginally or by C-section.  For a vaginal delivery, they say "normal" and flush the back of their hand down their laps, between their legs.  For a C-section they simply say "cut."  (For tubal ligation, or "ligadura de trompas," they say "cut to not have baby" and then there's "cut out womb", or hysterectomy.  For the few women we've seen who have had hysterectomies, we ask the reason they had the operation.  If it was because of a cancerous tumor, we will examine them.  If it was because of fibroids or some other reason, we don't examine them because they don't run a risk of cervical or related cancer.)

There are other translations we've learned:  diabetes is "sugar problem"; they often say "sick" instead of menstrual period.  And so on....

By the end of the week, I've found myself talking my version of Creole 'Crenglish?"), asking "How much childs you have?" without putting "did" and "do" in front of my verbs.  I've been dropping the definite article "the" and the occasional preposition and talking primarily in present tense.  I wonder how I sound to the warm, welcoming people of this area.  They listen to my questions and answer them as fully as they can, at times squinting to show me I need to repeat, using different words.  They can't know that I would love to be able to replicate the musical lilt of their Jamaican-sounding (to me) accent.  To me, it's what a smile would sound like, if smiles had sounds.  

Thursday, June 13, 2013

Brenda is #1

On Thursday the woman holding hand-written ticket #1 was Brenda Joyce Jimenez, of Miskito origin, who has worked as a cleaner at the Pearl Lagoon clinic for 10 years.  Her mother, Joyce Corina Jimenez, held ticket #2.  

Brenda is 28 years old and has two children; she wants one just one more child and stopped taking Depo Provera in February.  She told her interviewer that she was worried that she hasn't gotten pregnant, but her PINCC doctor assured her nothing is wrong - after years of being on the  injection for birth control, it can take up to one year for menstrual periods to resume.  

Family planning is something that was not available to Brenda's mother, 62-year old Joyce.  Mrs. Jimenez had 14 children, six of whom died before age seven, primarily of diarrhea and dehydration  The eight remaining children all live in the Pearl Lagoon area, where we are working this week.  Brenda's father died of cholera - at first she called it diarrhea and vomiting- when she was eight.  Her mother washed people's dirty clothes to keep the family alive.  Brenda's mother told me, "Some people helped me, some didn't.  I worked hard for them.  I worked for food and I worked for money."  

Brenda went to school until age 14, coming to class only when the dory stopped to pick her up.  She stopped school to help her mother, as did her siblings.  They are proud that once they were working, they were able to support their mom so she could stay at home.

Brenda's inspection was "inadequate" - meaning the nurse and doctor could not see the entire cervical area to determine if there are lesions.  She had a PAP smear done and will get the results in two days.  Her mother showed vaginal atrophy and the speculum exam was uncomfortable, so she also had a PAP test.  Brenda will get those results at the same time she gets her own.  

Creole, Mestizo, or Miskito? by Tina Romenesko

Creole, Mestizo, or Miskito? by Tina Romenesko

Carol opened our PINCC group meeting by exclaiming " This is the dampest PINCC first days we have ever experienced!"  The rain here comes and goes - one minute the sun is shining and the next the sky has opened up and it is raining gatos y perros.  We were without electricity for a full clinic day and for parts of the other three days which means no fans, no air conditioning, no lights, no computer back up.  You don't realize how much you depend on electricity until you don't have it!  

"Because this is a first visit - we all walked in completely cold," Carol reminded us.  We didn't have any idea what conditions would be, how the rooms would be set up, or even how much support the clinic could offer us.  The consensus is that it has been a very good couple of first days.  The trainees are beginning at ground zero as VIAA is a completely new technique to this area - so they are brand new to the idea, as are the patients.  PINCC's main mission is to train these doctors and nurses to replace the need for return visits, which usually takes a few years and lots of training and patience from the U.S. clinicians.  The day starts and ends with classroom time - combining study (lecture, slides, etc)  and hands-on experience.  VIAA, or Visual Inspection with Acetic Acid (or vinegar)  and immediate removal of lesions with cryo (freezing) or LEEP (electrical current) allows women to be evaluated and treated in the same day, a big advantage when patients travel long distances to be seen.  On day three, women traveled from the neighboring communities of Orinoco and Tasbapounie, spending one to two hours by panga (boat) through driving rain, to get treatment.  Most spoke predominantly Creole, a few spoke only Spanish, and we BOTH had a hard time understanding each other in interviews!!  

The support team spends a lot of time educating women in hallways and private rooms to help them understand the procedure they will be receiving, what we can evaluate, and what we cannnot do.

This part of Nicaragua was never conquered by the Spanish and therefore is unique in its ethnic and racial composition.  The population is mostly Creole, but also includes the indigenous ethnic group Miskito (nothing to do with the Spanish word "mosquito" which comes from "mosca") as well as the ubiquitous Mestizos that are a combination of many races, colors, and creeds and speak predominantly Spanish.  This diversity makes communication challenging here on many levels.  

I begin each intake asking the patient her name, figuring out how to say it correctly, and then holding her hand as I share my name and a smile.  I emphasize that clear communication is key and that it is important for us to be sure the answers are accurate.  Smiles and gestures are always helpful, like the one that seems to be universal for vaginal births - a sweeping energy with the back of the hand, down and out of the pelvic bowl!  I continue to do orientations with women that have a history of abuse and am keeping a running journal of the case histories, including only their age, ethnicity, and story.  No names.  Confidentiality is a big deal here.  Carol wants me to keep a data sheet so the director of the clinic can make a case for the need for support groups and psychological counseling for women that have been victims of rape, physical abuse, and sexual abuse.  I stress how important it is for women to support women.  "Find a good girlfriend,"  I counseled a young 20 year old mother who was feeling alone and disempowered.  "Changing your life alone is really difficult - but with the support of friends, it's always more hopeful."  This young woman found me as she was leaving - her VIAA was clear, and she and her one year old son gave me big hugs before they left.  " Girlfriends," I whispered in her ear.  She kissed me on the cheek and said she'd try.  

A troubling percentage of women admitted to being victims of domestic violence, sexual assault, or rape.  One admitted that she will not get into another relationship because she has 4 daughters and doesn't trust men, and based on her experience; she wants to protect their safety.

Each clinic day is dedicated to a different area, plus overflow from Pearl Lagoon and Haulover, the main pueblos in the area.  Day four included women from Kukra Hill, of which many were Spanish speakers, or Mestizos.  They seemed very relieved when we offered them the option of English or Spanish.  When the bus showed up - it was a sea of women that seemed overwhelming until we realized that half of them were here for ultrasounds and the other half for VIAA.  Whew.  

Tomorrow is dedicated to the Miskito women from Raitipura which is only about 10 minutes from Pearl Lagoon and will offer its own challenges in language and culture.  It will also be the day to see any local women that we were unable to see during the week and employees of the clinic.

Tuesday, June 11, 2013

Happy Birthday Reva - PINCC's MPH Summer Intern!

Today is PINCC's MPH Summer Intern's 26th birthday!  
Happy Birthday Reva Grimball!  
by Tina Romenesko

Can you think of a better way to spend your birthday than on the Caribbean coast of Nicaragua, sitting in a damp hallway, interviewing women about their knowledge and practices concerning cervical cancer?  PINCC's summer intern, Reva Grimball. is doing just that!  Her summer project will be analyzing the data she collects to help PINCC inform others of the need for their services in areas just like Laguna de Perla.  

Reva has an undergrad degree from St Edwards University in Austin with a Major in Biology and a Minor in Spanish.  She just completed her first year in Berkely's Graduate Master's in Public Health program, with an emphasis on Infectious disease and vaccinology.  I quizzed her about the safety and efficacy of vaccines to which she replied that she is 100% pro-vaccine.  Her enthusiasm includes, whole heartedly, the new vaccine for the Human papillomavirus, or HPV, which is the cause of cervical cancer.  " Cervical cancer can be prevented and is eradicable because it has no animal reservoir.  In Australia, the HPV vaccination is mandatory."  She also emphasized the importance of vaccinating both young women and young men, as the virus is passed between the sexes with sexual contact.  Even though it is best to vaccinate before the onset of sexual activity, young people can be vaccinated up until the age of 26.  "We were able to eradicate smallpox with vaccines.  It's time to do the same with HPV."  

Reva said she was attracted to PINCC because of their ties with infectious disease (HPV) and women's issues, as well as their emphasis on sustainable programs that focus on education and treatment.

We are all looking forward to Reva's birthday cake tonight with dinner.  :)

PS:  Cake was delicious - from the PINK BAKERY.  Chelsea had tried to order the cake the day before, from our favorite local baker, and they informed her that it was dependent on the electricity (absolutely necessary for baking a cake) and the temperature (cakes cool slowly here!)  I am happy to report that the cake was enjoyed by all - with a nice round of Happy Birthday To YOU!!!!


SOFIA JARKING LOPEZ by Sallie Weissinger

Most of today's patients came from Laguna de Perlas, right here where we are working in the clinic, or from towns nearby.  But not Sofia Jarking, a 62-year old midwife ("partera") whose home in El Cedro is not a hop, skip, and a jump away.  Sofia's trip took her ten hours - two by horseback and eight by boat - and part of that boat ride was in torrential rains.  She spent last night at a "casa materna" (a maternity waiting home, where pregnant women from distant villages come to stay in anticipation of childbirth) and will spend tonight there as well.  Tomorrow she will head back home, again by boat and horseback.

Sofia's visual inspection with vinegar was "inadequate", which means that the clinicians were not able to see the entire area that would tell them if there was any suspicious activity (low or high grade lesions) that could lead to cervical cancer.  So they did a PAP smear to be sure they got the full story.  Sofia said she has had many PAP smears in the past, but has never gotten her results.  She has called the various clinics and labs to follow up, but has never been able to find out the results.  This time, however, was going to be different.  In Laguna de Perlas PINCC brought along a cyto-technologist, Fatima Figueroa, to provide quick turnaround results.  We didn't have electricity at the clinic all day yesterday, but today we did.  So the microscope went at full speed today, making up for lost time.  By mid-afternoon we had her results - the results of the PAP smear were negative and all was fine - and two PINCC volunteers walked over to the casa materna to give her a copy of her results.  Tomorrow she will head home on her ten-hour trip, her mission accomplished.  



Of the 45 women we saw today, the oldest was 71-year old Emma Fox.  She learned independence and resourcefulness at any early age- she was four when her mother died and she went to live with an aunt.  

Emma and her husband worked hard to support their eight children, all of whom have lived to adulthood.  "He was a good man," she said, "but he is gone now."   To keep the family going, she "did a little bit of everything. I bought coal and lumber and sold it for more money.  I dried shrimp and sold it." And she raised her children, proudly noting that three of her daughters are nurses.

Talking comfortably during the PINCC interview, Emma provided full information about her medical history.  The interview questionnaire asks sensitive questions to help the clinicians assess a woman's risk of developing dysplasia that can lead to cervical cancer.  Sample questions include "How old were you when you had sexual relations for the first time?" and "How many sexual partners have you had?"  Many women wince as we ask these questions, but not Emma.  She said, "You have to tell the truth to keep your health.  If you lie, they can't help."

But when I asked her the final question, Emma lost her confidence and her eyes teared.  I told her that she'd be having a breast and pelvic exam and that she'd be in stirrups for the cervical exam with vinegar.  I explained that a local doctor or nurse would be giving her the exam, and U.S. nurses or gynecologists would be training them.  I asked if she would sign the release form, but she didn't want to because she thought only U.S. doctors would be doing the exam.  She didn't want people from Laguna de Perlas, people she knows, attending her.  We offered to let her choose her own local nurse, she thought about it, signed the form, and then sat down to wait her turn.  WHEW!

Monday, June 10, 2013

Clinic Day One in Laguna de Perla, Nicaragua

JUNE 10, 2013 - Clinic Day One in Laguna de Perla, Nicaragua

PINCC Blog post by Tina Romenesko

The torrential rains during the night had left us without power, but the gas stove was humming as I entered the cozy kitchen of the Green Lodge.  Arlene and Wesley, our hosts,  were busy serving breakfast to the PINCC volunteers, six at a time.  Coffee, scrambled eggs with tomato and pepper, gallo pinto (of course), bread, guayaba jelly, and some of the most delicious pineapple I have ever tasted.  We were all done, and fully coffeed,  by 7:00 sharp and headed for the Clinic, where the patients were already lining the soggy and overcrowded hallways.  Some volunteers began setting up rooms while others began the interview process.  Fifty numbers had been distributed to patients, which meant we had a very full day ahead.  Many of them had come by panga (boat) from neighboring communities and represented at least 3 different ethnic groups that comprise the Pearl Lagoon region.  We weren't sure if the interviews would be done in Spanish or English.  The people in this area speak both languages, as well as many ethnic dialects.  Our intake forms were in Spanish, but most of the interviews today were in a combination of the two.  It took me awhile to get the gist of the accent - in English.  I asked them to be patient with me as I tried to listen and spell their names and towns over the rattle of the continuing rain on the roof.  Most of us were standing in puddles or underneath roof leaks, but everyone pursued and communicated the important facts surrounding each woman's reproductive health issues.  

We have brought Cytotechnician, Dr. Fatima Figueroa from Leon with us, which allows clinicians to perform a PAP test if the clinician feels that the view of the cervix is inadequate or incomplete.  This option gives patients the most accurate result, if there is any questionable tissue in the viewable area.  It usually takes weeks to receive PAP results - and follow through can be formidable as slides are often read off site, or even sent out of the region.  The problem today is the lack of electricity.  The microscope lights won't be illuminating any slides until we have power.  Fatima and Sara, a medical student and pathology intern, stained 16 slides today, and hope to examine them tomorrow, but time will tell.  The power outage originated in El Rama - the regional capital - so it is impossiible to guess when we'll be sending emails, enjoying air conditioning, or even powering microscopes.  If you see this BLOG ENTRY, we are back in business.  

I am always impressed by the volunteers willingness to do ANYTHING - and I mean ANYTHING.  No job is too menial when the team is in need.  Today I found myself doing interviews, educating clients in the hallway, donning rubber kitchen gloves and assisting Becca and Sallie in sterilizing instruments, and eventually was called upon to follow-up with clients that had been victims of abuse.  It is estimated that around 25% of women with HPV - the cause of cervical cancer - have been sexually abused before the age of 16.  The incidence of HPV rises with the age of onset of sexual activity, numbers of partners, and also the amount of stress the women endure throughout their lives.  For these reasons, our intakes include very personal and important questions that can raise difficult emotions and memories.  My role was simply to inquire, listen, and offer support and safety for them, however they needed it.  It is an honor to hold these women's stories in confidentiality and with deep compassion.  

Seven hours later, when we break for lunch, we have seen 45 patients, performed a handful of cryos, and scheduled about half a dozen LEEPs for the end of the week when we HOPE to have power to perform them.  We have also given many women the good news that there were no abnormal cells in their cervix!  So many women came to the clinic with the C word, front and center.  They leave relieved, better educated, and empowered to improve their sexual health practices - physically and emotionally.  

PS:  Just got power!  Blog going UP!!!

Sunday, June 9, 2013

Meet Jenny - from Laguna de Perlas

(Contribution from Sallie Weissinger)

Meet  Jenny – from Laguna de Perlas 

We got to Laguna de Perlas, a first-time trip for PINCC, Saturday evening shortly after sundown.  The last third of the 13-hour bus ride was on unpaved roads.  At times the bus driver would come to a turn in the road, looking up to see which direction had more electrical wires going its way, and choose the route with the greater number of wires.  We let out a sigh of relief when we arrived at 7 pm.  It had been a long day, but we were here, gracias a Dios.  

And why Laguna de Perlas, a place our coordinator Carol Cruickshank calls the most remote place PINCC has ever gone, including Africa?  It's because Jenny Williams, PINCC's Leon connection with the Ministry of Health, was born and raised in Laguna.  It has been her long-standing hope to bring more health resources to her region.  

Jenny was one of ten children – five boys, five girls – born in "Pearl Lagoon" on the northern Atlantic coast of Nicaragua, where the Atlantic and the Caribbean merge.  Laguna de Perlas was part of a British protectorate, and the people, of mixed indigenous and African heritage, speak English and  Creole, as well as Spanish; the town seems more Jamaican than Nicaraguan, and we're in culture shock, trying to remember to say "good morning"  and "thank you" in lieu of "buenos dias"  and "gracias."

When asked why she became a nurse, Jenny offers two main reasons- her father and mother.  When Jenny was 14, her father died at age 50 of pancreatic cancer without adequate medical care.  Her mother had to raise the 10 children on her own; Jenny doesn't know how she managed it, although she recalls several aunts in Panama helping out.  There was no family planning in those days, and her mother ended up raising many more children than she would have chosen to have.  Jenny talked movingly of a miscarriage her mother had.  Oarsmen rowed her mother, bleeding and wrapped in sheets, in a canoe to the clinic in Bluefields for 18 hours, hoping in vain to get help. 

Jenny went to a school in her village run by Moravian evangelists, but for high school had to go to another town where she lived with family members.  For three years she pursued nursing training in a town called Bilwaskarma, near the Honduran border.  To complete her degree she went to Managua for mandatory public health and psychiatry courses, a move that ultimately led her to her work in Leon, where she has remained since 1975.  Had employment opportunities been available in Laguna de Perlas, however, she would have chosen to go home to work.  Following her nursing program, Jenny worked as an assistant surgical nurse and then as chief of nursing at a Leon health center.   In 1991 she returned to nursing school for two additional years to become a licensed nurse, una enfermera licenciada.  With that milestone under her nursing belt, she went the administrator route and is currently Leon's Coordinator of Women's Health for the Ministry of Health.   

Jenny's interest in the medical field is matched by several of her family members:  her older sister also became a nurse, and her nephew Dr. Wesley is a pediatrician here in Laguna and sub-director of the clinic where PINCC will spend the week working.  (Dr. Wesley's father, Jenny's brother Wesley, is a trained high school teacher and runs the lodge where we are staying.)  And Jenny's children?  Her older daughter is a lawyer, and her younger daughter has just finished her medical training to be a gynecologist.  

Busy, capable, big-hearted Jenny is married to a lawyer in Leon, who shares her with an expanding family of Nicaraguan women whose lives she can alter in a way that wasn't possible in her mother's time.  Brava!

Overcoming Challenges: Superando Dificultades in Leon, Nicaragua

(contribution from Sallie Weissinger)

Overcoming Challenges:  Superando Dificultades in Leon, Nicaragua

One of the challenges the PINCC clinicians face is learning how the local health care system works as we train the local doctors and nurses to perform visual inspections with acetic acid (VIA), cryotherapy, and the Loop Electrical Excision Therapy (LEEP) on their patients, in their country, with their resources.  While we bring with us, in beaten-up suitcases tagged with pink bandanas, all the necessary equipment and supplies for training, we rely on the local hospital here in Leon, Nicaragua, to analyze PAP smears and biopsies whenever they are necessary.  On this trip an estimated 30% of the women have required one or the other lab procedure, so we can be sure we aren't missing anything that could lead, down the road, to cervical cancer.

We started out unfamiliar with the administrative and lab procedures at HEODRA, the local hospital where we set up our training and exam rooms.  Most baffling, to be sure, is the protocol for getting lab work done.  Patients have to walk the slides with their own PAP smears or little bottles with their biopsy samples to the pathology lab.  The nurses wrap the slides in paper and label the biopsy bottles with the patients' names written on masking tape.  Patients are told when to call or return for their results.  The wait is typically 6-8 weeks, and, even then, they may not be ready.  Once they do get the results, patients need to make arrangements to see their doctors to discuss the results.  

Pathology results are not always reliable -our teams use a cytobrush, which in Nicaragua is generally not the case (here clinicians use regular cotton swabs unless the patient brings or pays for a cytobrush). Sometimes samples are mixed up and results don't get tracked back to the right patient; it's easy for patients to "get lost in the system" or simply to fail to follow up, for whatever reason.  

To the extent we can, we train local providers to perform "one-stop" medical treatment – with  a positive VIA diagnosis, when a lesion is detected with the two-minute protocole of applying vinegar to the cervix, we are able to remove low and high grade lesions without further testing – there's no need for the patient to wait weeks or months for the next step.  We can remove the tissue then and there, provide her with counseling for follow-up, and prevent for the time  being her chances of getting cervical cancer.

But it isn't always that easy.  Sometimes there are parts of a patient's cervix we can't entirely see or associated  risks and concerns, indicating further lab testing is needed.  Understanding  the system the trainee doctors and nurses work in helps us help them and their patients. In a country whose resources are, at best, limited and overburdened and whose equipment doesn't always work, we want to make it as easy as possible for the doctors and nurses to keep their patients healthy and long-lived.

Friday, June 7, 2013

Leon, Nicaragua, 6/7/13

Friday, 6/7/13

Contribution from Sallie Weissinger

When you meet PINCC trainee Maria Antonia Aviles Castillo, or Antonia as we call her, you want her to be your own nurse back home.  She is warm, reassuring, down-to-earth, and knowledgeable. Her outgoing, competent manner makes you wish you could see her for your regular OB/GYM exams. She makes you feel you're going to be fine.

 Now in her early 50s, Antonia has been a nurse for 31 years.  She has no plans to retire because she loves what she does.  "I'm going to work as long as I can.  I love everything that has to do with women's care," she says.  "I am a nurse at work, in the street, and in my home - women come to ask for my help."

 Starting out as a nurse's helper and then becoming a medical aide, Antonia studied hard to become a professional nurse, obtaining her nurse's credential in 1995.  In 2007 she was licensed in obstetrics and perinatology.  Her hard work over the years is matched by her friendly smile and dedication to her patients - and her patients-to-be.

 Antonia's goal is to bring PINCC's work to her hospital in her home town of Sauce, 90 kilometers (56 miles) from the Leon hospital training site.  This week, she has been getting up at 4 am and getting back to her village at 8 pm.  The bus ride, with endless stops, takes three hours each way. That doesn't deter her - she is committed to developing her skills and establishing a special center at her hospital to spread PINCC's work in her region.  She sees no reason she can't make it happen.

 When asked what she does for fun in her spare time, Antonia responds, "I have no spare time.  I have three children and five grandchildren ranging from 2 months to 11 years old.  When I was younger, I didn't have enough time with my family.  Now I dedicate any time I have to them because I finally can.  My weekends I spend with them."

 But this week she's been with us, so she can serve the women of Nicaragua.

 PHOTO:  Antonia (seated) counsels a patient she has just examined how to minimize her chances of contracting HPV (the human papilloma virus) and how to take steps to prevent cervical cancer.  Patient education is of paramount significance in reducing this preventible disease.

Thank you, Sallie!

Our last day in Leon

Today was one of our busiest.  There were many patients who arrived in an ambulance and minibus from a village outside of Leon.    A lot of effort went into organizing the trip, ensuring that the patients who needed extra care gathered from their respective homes, some by horse or foot, and took the long drive to Leon.   In addition to this group, women continued to arrive over the course of the morning.    The large group presented an opportunity to teach the women about cervical cancer and explain to them the VIAA procedure.    They were surprised to learn that the practitioners were using plain old vinegar to identify abnormal cells.

The last patient arrived with her little girl.  Chelsea interviewed the mom, then entertained the daughter with crayons and paper.   Meanwhile, Leah faithfully entered data into the computer, while Rebecca washed speculums (again).    Then, we interrupted the repacking of the suitcases to participate in the closing ceremony.   There were many grateful words for PINCC 's efforts on behalf of the women of Nicaragua.   Dr. Pam thanked the Nicaraguan trainees for their hard work and patience over the course of the week.   

We ended the week with a celebratory dinner, and a wonderful musical performance by local artists.   


Since this is my last blog entry, I want to say a special thank you to Carol.   She is tireless and selfless, treating everyone with great kindness and respect.  Despite the scarcity of medical resources, difficult conditions, and numerous workarounds to be engineered, Carol never seems flustered.  She is everywhere, answering hundreds of questions, and ensuring that our work gets done.    Many, many thanks, Carol!  

Patricia Spross

Thursday, June 6, 2013

Leon, Nicaragua blog 6/6/13

Thursday, 6/6/13

Contribution from Sallie Weissinger

Like Mother, Like Daughter

Chelsea Kreitlow and Rebecca Rich share a lot in common.  Both are college students planning on a likely career in medicine; both love to travel and have a passion for doing humanitarian work; and both are accompanying their gynecologist mothers on PINCC's Nicaragua trip.  They spend their days working together in the hospital, doing patient interviews, entering patient data into the PINCC computer, helping clean equipment, and doing whatever it takes to keep the process moving.  When necessary, they run out to a pharmacy to buy pregnancy tests, hold anxious patients' hands in the exam rooms. and answer a variety of questions about supplies, charts, and people's whereabouts.  They're amazing!

Chelsea, 22, comes from Wisconsin and is in her final semester of college at the University of Minnesota, where she's majoring in Kinesiology and minoring in Spanish.  She says growing up with a doctor mom meant she always got honest, straight-forward answers about the human body.  She remembers being very young and asking her mother where babies came from.  Hearing the facts of life she immediately said, "Mom, you're lying."  She laughs about it now, and is intensely proud of her mother's work.  Chelsea enjoys the culture and language in Nicaragua and most of all the chance to share this trip with her mother.  "It's very rewarding to get to help the women here.   And it makes me happy to see my mother being so happy doing this – she's such a giving person."

Rebecca, 20, has just finished her second year at Occidental College.  Born and raised in San Francisco, she's majoring in Urban Studies with an emphasis in Public Health and is taking pre-med coursework.  Becca recalls being a child and loving to tell her friends that her mom, Laurie Miller, was a doctor and delivered babies. She also  remembers being frustrated at times that her mom couldn't come to all her soccer games or pick her up after school, but "it taught me independence and how to balance work and family.  It's awesome to be here.  I'm so proud of her taking her skills around the world. I get to see her in action and see how good she is at her work."

Both young women talk fondly of having spent time at their moms' workplace – the hospital – when they were younger.  They got cookies and chocolate from the cafeteria and candy and stickers from the nurses "if they were good."  They both rememer how the smell of the hospital made them feel comfortable, very much at home.  That sense of comfort will take them far - it's already brought these two impressive young women to Nicaragua with PINCC... and they're just starting out.

Thank you, Sallie!


Bounce necklace

Sallie has developed a prototype Bounce necklace featured in our photo.  Here is a description: - pink / PINCC necklace with three pink plastic keys attached with three rustic ivory strips of Bounce.  Orders are starting to pile up, so ACT NOW to get yours in time for the summer mosquito season!!

Leon City tour with Julio

A group of us enjoyed a city tour featuring an Art Museum with paintings ranging from the 1600's to contemporary works by Central American artists.  We also visited San Francisco church, and took a photo of our group in the doorway.   Our tour guide, Julio, made Nicaragua's recent history come alive. Imprisoned as a teen by Somoza, Julio became a Sandinista guerilla in the mountains, studied in Cuba and St. Petersburg Russia, endured a failed attempt to migrate to the US, and finally found his calling as a learned and entertaining tour guide here in Leon.   Julio will travel with us to Laguna de Perla, and we expect to learn more about the difficult history of this fascinating country.

Our day in the hospital

The photos speak for themselves.  Mary's photo of the hospital entrance speaks to both the poverty and color of this tropical city.  It was a busy, fulfilling day.  Once the clinicians and their trainees had seen all of the patients that had been referred to the hospital for treatment, the team was able to do screening for a number of hospital employees. 

Patricia Spross

Wednesday, June 5, 2013

Nicaragua blog 6/5/13

Wednesday, 6/5/13
Today there were only about 20 patients waiting to be treated by the PINCC team.    So the practitioners in training were able to devote more time to practicing biopsies on papayas, and LEEPs on raw cuts of meat.   Meanwhile, the support people had to visit the pharmacy to stock up on home pregnancy tests.   The teaching hospital in Leon does not have such tests, and our medical team will not risk performing a procedure on a woman who may be pregnant.  So far, about four pregnancy tests have been administered, with one positive result for a woman who had had a tubal ligation.   The other 3 women were able to be treated by the PINCC team. 
Although many things about the US healthcare system can be improved, the basics that we take for granted are not easily available to the Nicaraguans.   The teaching hospital in a major city seems to have no budget for pregnancy tests.  Dr. Pam learned that women need to pay $1.25 to purchase a cytobrush if they want a more effective Pap test.  The "free" test uses older technology, but is less effective in obtaining cells from inside the cervix.  For these poor women, the price of a cytobrush can be daunting.  Women have also told us that they have not been able to afford medicine to treat an infection.  Sometimes these medicines are available at no cost through the government-subsidized hospital, but if supplies are depleted, the women will have to pay.
Since the support staff had fewer patients to interview, we had the chance to teach a small group of women about cervical cancer and how to prevent it.   This group of 3 women shared their stories about the distance they need to travel to obtain medical care, and the limited number of facilities and practitioners available to provide it.   These women were grateful for our fact sheet about cervical cancer.  Though two of the women were unable to read, which is not uncommon among older women,  they were happy to take them home so a family member could read it for them. 
Today's lighter workload allowed us to accept the invitation from the owner of the Hotel Real, where we are staying, to visit his family's beach house.  The Pacific is about 30 minutes from Leon, and we enjoyed a breezy drive through the countryside to the beach town, Poneloya.  The Pacific was very rough, and the sand very dark from the high content of lava ash.  But the lagoon where we bathed was warm, and the current strong.   After our swim, we enjoyed pizza at the beach house.

Patricia Spross

Tuesday, June 4, 2013

Nicaragua blog 6/4/13


Tuesday, 6/4/13

Today we had a good laugh at breakfast when someone finally had the courage to ask Sallie about the bits of fabric that she had peeking from the neckline of her shirt and tied onto her shoes and watch.   Sallie informed us that these were pieces of Bounce fabric softener sheets (scented only!!)  A friend of Sallie swears that this is an effective mosquito deterrent, and perhaps less toxic than creams designed for that purpose.    Cheryl, good scientist that she is, wants to subject them to rigorous testing.  But Sallie is determined to embark on a business venture to produce jewelry woven with Bounce for the fashion-conscience Tropics-traveller.   All proceeds to g to PINCC, of course.   Stay tuned for the product rollout!!

Things were a bit less hectic on day 2 at the hospital.   The clinicians saw about 40 patients and performed 2 LEEPs and 7 cryos, which made for an interesting and busy day.   Unfortunately, one patient was diagnosed with cervical cancer, and will need more advanced care than our team can provide.   These instances of cervical cancer will hopefully become increasingly rare as VIAA becomes more widely available in developing countries through programs like PINCC's.   By way of comparison, clinicians Cheryl and Sharry, who identified the cancer, report that seeing 2-3 cases in 20 years of practice would be the average in the US.   

In the photos of our teams at work, the level of concentration is apparent, as the clinicians use their Black Diamond headlamps to examine the patient's cervix.  Cheryl, Jenny and Maraeling were so focused that they did not realize their photo was being taken.    In another photo, Alexandra speaks to the patient while her students perform VIAA.   After the examination, the patient Silvia is surrounded by Alexandra, Cristela and Brenda.

It was a fulfilling day in Leon.   While we were all saddened by the patient with cervical cancer, the day had many good moments as the clinicians were able to treat 9 patients with lesions.   Using VIAA, the clinicians were able to give good news to many more women whose abnormal pap results had prompted their referral to the hospital.         

Patricia Spross

Monday, June 3, 2013

Leon blog 6/3/13

Monday, 6/3/13

Today was our first day at HEODRA, the teaching hospital in Leon.   The doctors examined and treated about 38 patients, out of the 40 or so that we interviewed.  Most of the patients had been referred from their local health centers because of an abnormal pap result.    The patients waited quietly in the heat to be interviewed, and then had to wait again for their examination.   Thankfully, some of the exam rooms were air conditioned.  The PINCC nerve center also was also air conditioned.  There, the volunteers  attached the intake forms to the patients' charts, and input the information into the computer.   Data input involved lots of data cleansing, i.e. running around asking the doctors for missing information, or  interpretation of handwritten notes.    

Some patients bore the signs of their difficult lives, with faces aged beyond their years.   Many women have four children, but those whom I met stopped at four with a tubal ligation.  The interviews identified a number of women who had been abused sexually or physically.    The patient Reina returned to see Carol.   Dr. Pam performed a LEEP on Reina two years ago.  Reina has since given birth to her third child, a girl seven months old.   Miguel, Reina's 5 year old, accompanied her to the hospital.     

All in all, it was a long day.   We waited until all the patients had been seen until we had the lunch that had been delivered in takeout containers.

At Carol's late afternoon meeting, the reports were of a very satisfying and successful first day.  There were a few tough moments, but overall the job got done.  The doctors who are being trained in IVAA, cryo, and LEEP, have some experience and performed well.  Yet, they seem reluctant to ask questions.  Maybe we are more intimidating than we realize. 

After a dinner of veggie lasagna at the local restaurant, we will turn in early to prepare for another day of hard work, and hopefully the satisfaction of helping the doctors of Leon prevent cervical cancer among the local women.    

Patricia Spross