Sunday, June 9, 2013

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.

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