We just finished our third day in Cacaopera. Many patients have traveled for miles to visit us for treatment. There have been numerous LEEP's and cryo's which have enabled our doctors to train the local medical team. The trainees need to observe many cases of diseased tissue in order to recognize it in their practices.
The local public health employees have done a great job to improve the health of their communities. One group arrived today with their doctor, their nurse practitioner, and their psychologist! The doctor, like many here in El Salvador, was trained in Cuba.
Yesterday, we had a patient who had been deported from the US. She preferred to speak in English, and overflowed with stories of her troubled life and the difficult living conditions in El Salvador. The young woman seems to have no place in this world. She has no documents for the US, and none which allow her to work in El Salvador. This lost soul spent time talking with us while waiting for her cryotherapy. She seemed grateful to have someone listen to her.
Today, the services of the PINCC support team, i.e. non-medical volunteers, expanded to include child care. One young mom came with her 2 year old who sobbed pitifully during her exam in the ante-room. His body was tense with fear, and nothing could soothe him. He finally calmed down when his mother rejoined him after her exam. But his young mother was very nervous at the prospect of the cryo treatment that the doctors had recommended. Another PINCC volunteer supported the mother until her turn for treatment came. During her cryotherapy, the little boy sat quietly in the waiting room watching the scene. People delivered lunches in huge baskets. Stray dogs smelled the food and roamed the hall until shooed away. Doctors and nurses rushed to treatment rooms discussing their cases. Patients chatted while waiting their turns. Most entertaining were the young children who drew with the colored pencils that one of the PINCC volunteers had brought. Sitting next to my young charge, I also enjoyed the bustle of the clinic at midday.
Off to a smooth start on our first day in Cacaopera, El Salvador! The town is in the poorest region of El Salvador, and the region most impacted by El Salvador's war. The clinic's team was well- prepared for us, and the trainees eager to learn. Veterans of 7 PINCC trips, Carol and Cheryl, were very impressed with how well organized everything was. We saw 20 patients, which allowed us to unpack the PINCC suitcases and sort things out without pressure. Salina, a medical student on our team, had the time to teach the patients some anatomy. Although the patients were quiet during the talk, Salina had an impact because several women approached her afterwards with questions.
As always, the patients were lovely, and grateful for the care. Among the older women there were harrowing stories of war experiences. One woman delivered her baby two months early when a bomb detonated a few yards from her home. The baby survived, but the mother was left deaf for several years. Another woman had worked as a nurse for wounded guerillas. Another woman had beautiful green eyes, a rarity in this country, but not in her village. There must have been a European ancestor who brought those genes to this remote region. It is an honor and a wonder to hear these women's stories during the patient interview.
It is rainy season here. We need to be vigilant about using the stinky mosquito cream. Our hotel is high in the mountains, surrounded by clouds in the late afternoon. What a joy to be here with such a wonderful team of women, in this forest full of colorful birds and tropical vegetation. Tomorrow is another day of adventure; we expect to see 40 patients, so there will be lots of stories to share.
Today began with the news that one of our nurses' cousins had died in Managua. She was in her 30s and had been diagnosed a year ago on the first PINCC visit to Laguna de Perla. She left 4 children motherless. This sad news reminded us of the significance of our mission. 300,000 women are diagnosed annually with preventable cervical cancer worldwide. In my 35 year career in the U.S. I have diagnosed only 4-5 women. It is rare because we practice prevention.
The clinic and patients from a village, Orinoco, who came by panga today for cervical cancer screening.
Photographs of Nurse Elcia and Doctor Maria Inez, that I worked with today.
A truck parked outside the clinic.
The cryo therapy unit was successfully repaired today so we treated 2 women with pre cancer.
First day at work—7:30 til 4—curried shrimp and rice for lunch. Lots of bottled water. Hot sunny day outside. Inside AC when electricity was on. I worked with a Spanish speaking family practice doc—25 wks pregnant—Cuban trained. There are 4 docs here who went to Cuba at age 18 and trained for 10-15 years before coming home to Nicaragua.
Well, the last day has now officially come…Friday. What happened to the time, the two weeks of the trip? This time here has FLEW by!!
The work here have been long days; some with sunshine and heat, others are humid along with down-pours. Regardless of the weather, every day our group has strived to work hard; to teach the clinicians in Pearl Lagoon to maintain cervical cancer screening without PINCC returning; educating members of the society about cervical cancer; working in rooms filled with many women with limited air conditioning; keeping up with all the paperwork, computer work and medical records; cleaning and stocking each room. Everything in the past 2 weeks has made the experience here be a total thrill!!
The local 'Pearl Lagoon' folk, the PINCC crew and the staff at each hospital have been totally amazing! I will miss each and every person…it brings tears to my eyes to think that tomorrow I will fall asleep in a hotel room all alone somewhere in Houston awaiting a flight back home to Wyoming. I have become so close with everyone here that it will be heartbreaking to leave.
The simplicity of the lifestyle here in Nicaragua is one thing that I will miss more than I can say. People tend to walk slower taking in the beautiful day, sunshine and life in general. Once the locals get to know you, they will smile as you pass with a simple greeting. Children are riding their bikes, playing baseball, and running around their houses with friends. One thing that I have noticed is that children here seem very happy and content. The mothers are very attentive and the older siblings are second hands to help tend to the youngsters.
On a regular day I have noticed that horses wander down the dirt roads. Cows wander in the fields. Chickens roam around each house. Dogs lay in the sidewalks. Hummingbirds feast on the beautiful flowers growing all over. The 'farm lifestyle' is one thing I will miss the most. Children walk to school each day in groups, dressed in classy uniforms. White shirts, green bottoms, skirts for the girls and pants for the boys. All carrying backpacks…smiles greet us each day.
Our day ends with our group separating prior to dinner. Some go back to the room to rest, others socialize. We all reconvene for dinner at a local restaurant…changes each night. The late night walks back to the hotel have been exhilarating. Cool breeze and calm…a perfect way to end each day. The power has only gone out a few times this week, but overall we have been sleeping in air conditioned rooms throughout the nights.
Even though it is a goodbye for some of us, the rest of the crew will be continuing on to El Salvador next week. I have heard so many great things about El Salvador and in some way…I'm slightly jealous I'm not going!! I can't wait to hear all of the stories of next week. It will be a great adventure and I wish everyone safe travels! Thank you again PINCC for a great learning and travel experience. One I will never forget!!
By Shana Wetzler, RN ICU/ER, Jackson Wyoming
"Welcome to Pearl Lagoon!" was the first thing that I heard stepping off the boat onto a deck full of men handing out their hands to offer assistance. All I could think of is…"where am I? This place is magical" I was a little nervous at first flying into Nicaragua, the first time since I've been out of the country in 3 years. Although, Carol, our leader, who has spent many years in this country, fluent in Spanish, yes pretty much a saint, reassured me this place was safe. That still didn't convince me and I definitely had worries coming from a small town in Wyoming.
I felt like I was walking aimlessly around the streets looking at all the greenery, palms trees, run-down buildings, brick roads and not to mention the natives staring at you with no smiles on their faces. When I offered a smile to them and said "hello" their facial expression immediately changed to a smile and offered a "hello" back.
We got to our hotel called the "Green Lodge" which was a gated little area. Professor Wesley was the first to greet us with open arms and a smile on his face.
"WELCOME TO OUR HOME. Thank you so much for coming". Bottled water was in our hands within seconds with a key to our rooms. What a welcoming gift, although I didn't realize I was dripping with sweat and cold water was heaven in my eyes. As we entered our rooms, the air-conditioning was the first to greet our tired and hot faces.
All I could think of is "This is WAY better than what I was expecting! Air conditioned rooms with beds, fresh water every morning, homemade breakfast from Wesley's wife. OK sweet, I do this for 2 weeks, no problem!" But there are definitely some things that we have taken for granted in the US such as; sunscreen to buy, internet access, consistent electricity and running water, a cold beverage with ice or fresh veggies (Carol has make it VERY clear not to drink the water here or eat fresh veggies). Mangos and pineapple on the other hand…are safe! YUM!
Sunday was our adventure day. We hopped onto a boat filled with the 15 of us from our PINCC group and a random extra engine lying on the floor of the boat. We headed out to the "Keys Islands", and within about 15min the boat stopped. Our boat driver was frantically working hard to 'fix' the broken engine. Within minutes he was asking to hand him the 'random extra engine'. Little did we know…this extra engine was not as strong as the first…so our quick boat ride ended up turning into a 2 hour boat ride to the Keys. He stopped at the first 'tiny' island because it was the closest and our crew was getting pretty anxious to get out of the boat at this point. This 'tiny' island may have had about 26 palm trees total…each one finding it battling to stay alive with the small amount of space given. The white sandy beaches and warm water calmed all our nerves the minute was stepped onto the island. Swimsuits were on and people were instantly in the water swimming. What a wonderful way to spend our first 'leisure' day in Central America.
Meanwhile…while our group was basking in the sun, eating fresh papaya and coconut, swimming…Carol, was hard at work in Kukrahill. Meeting with the hospital staff for our visit, setting up transportation for the week, making sure we were going to have lunch each day…hard at work. She greeted us back in Pearl Lagoon with a huge smile on her face saying "I have such great news". What a comforting thing to hear after spending a total of 4 hours on a boat, a few people getting seasick, and many of us with sunburns.
Instead of having to take a bus ride for 1 ½ hours, she set up a boat ride that would only take us 20 minutes. I laughed internally thinking…we just spent 4 hours on a boat, I'm sure some of the crew is not so thrilled about more boat adventures. Although, I was over excited! Not having to be on a bus for 1 ½ hours in the hot and humid weather…done and DONE! Thank you Carol!!
Each night Carol set up a spot to eat at a different restaurant. "I do this to help out the community, our business will feed their families for weeks" Carol would say. I will have to mention…this woman, Carol, whom I just met a few days ago…is one of the most positive, inspiring, organized and giving person I have ever met in my life. A smile on her face at all times and a reassuring statement to make any worried person feel at ease.
Monday, May 26
First day of clinicals in Kukrahill. We arrived on the boat to a dock in Kukrahill filled with beautiful colors painted all over. What a welcoming place! The ambulance was there to greet us and pack our large suitcases filled with equipment to the clinic. We arrived at the hospital around 8am. The waiting room was packed with women of all ages, children running around and men standing outside. I had no expectations walking into the hospital, but this was sure overwhelming. We all started scrambling to set up each exam room. Carol assigned 2 of us to each room to set up. I remember thinking as I was setting up the room…I have no idea what I'm doing! I hope I don't put something in the wrong place…I don't want to forget something…and what the heck is the VINEGAR for?! I could see Carol and Sarah running around knowing what to do and where to go. Meanwhile, Christian, Lang and I were kind of dumbfounded. The physicians were all in the back room giving a lecture and class to the 'new trainees' about the procedures, instruments, etc.…
While the physicians are training, the rest of us volunteers and nurses from Kukrahill will interview all of the women. Questions range from; age, date of birth, medical history, history of family cancer, how many children they have, when was their last menstrual period, when they first had their menstrual period, if they have ever been abused physically or sexually, and many more questions. Once we get a nice stack of women interviewed, we will start placing the women in each exam room with one MD from PINCC with one or two trainees. The PINCC MDs will explain and instruct the cervical cancer screenings. Within a few patients, the trainees will then take over and have the MDs supervise.
It was a pretty hectic day with a lot of cervical cancer screenings being performed. Not only that, but myself and a few others felt extremely overwhelmed due to the massive amounts of 'Spanish speaking only' women here. It was a struggle because every time someone came up to the front desk to ask a question, I had no idea what they were asking. I then had to go find one of our bilingual volunteers to help me interpret. That was pretty frustrating, I sure wish I knew more Spanish!! We were expecting to start with 20 patients…that was until Carol came to us to let each of us know that there was a bus filled with 16 women from a different town who needed to be first priority to leave by 1 o'clock that day. Of course she had a smile on her face with no fear at all, how impressive. So we scrambled to get all the women seen by our lovely physicians before one o'clock that day.
At the end of each day the physicians take the trainees into the back room to for more teaching, also reviewing their day. The rest of us cleaned each room, entered patient data into the computer, cleaned up paper charts and organized for the next days to come. Whew! What a crazy day…and we all left the clinic smiling and happy to be in the sunshine. I personally was looking forward to the cool breeze on the 20 minute boat ride back to Pearl Lagoon.
There were a few things I remember Carol telling us before I came to Nicaragua:
"It may rain every single day so be prepared"
"The women here speak both English and Spanish"
"Don't bring a suitcase heavier than 25 pounds".
So far…the sun has been shining almost every day, with a few rain spouts here and there to cool things off. The women in Kukrahill mostly speak Spanish. AND my backpack only weighed 15 pounds!!
The nights here have been very relaxing. We all usually meet around 6pm to head to dinner. That gives us a few hours to cool off and separate from the group for a bit. A few nights some of us will relax on the patio looking out into the Bay and watching locals fish. Others go for walks or catch up with their children and family to hear about all of their adventures during the day.
So far this adventure has been wonderful! I came with zero expectations and…well my expectations have been exceeded. The local people here are extremely friendly; the land here is absolutely beautiful with lush greenery everywhere; the water is warm and clean to swim in; the food here is delicious-ranging from shrimp, white fish, chicken, plantains, beans, rice, and cooked veggies (mainly carrots and squash); and most of all, our group is FABULUOUS! We all get along and work together really well and to top it off, Carol is a wonderful leader. I am going to miss the crew that was here the first week, but also can't wait to meet the new crew coming next week! Thank you PINCC for letting me take this adventure to an amazing country with amazing people!!
When I had returned from my last trip a mutual friend of Carol Cruickshank and mine gave me a card. It had PINCC in large letters and had Carol’s name and contact information. I had not seen Carol for many years and had only heard about her briefly through our friend so I had no idea what she was up to and certainly had never heard of PINCC before. So I did what we all do these days and got on line to investigate.
I was intrigued by the idea of working with an organization supported and coordinated by someone like Carol. I had always known her to be a compassionate and unselfish person who had spent much of her life in the service of others. I was also excited about the idea of working specifically with African women. As amazing and beautiful as East Africa is it is the people that draw me. My internet search lead me to a U tube video of women singing out their gratitude to PINCC as they stood waiting in line to be screened. That was the all it took and I decided that I would contact Carol right away to investigate becoming a volunteer.
Approximately 1 year later I met with my first PINCC group in Bungoma, Kenya. I had already been traveling for several weeks in Uganda visiting Hospice and seeing friends. I arrived a couple days early so had a chance to check out the town. Like many East African towns Bungoma was bustling with street life. Cars, matatus, boda bodas and what I call boda bikes (transport of people on a padded seat on the back of a bicycle). Window shopping is easy in East Africa because the clothing shops display their cloths on wire hangers that express the cultural appreciation for women being well rounded from the waste down.
Our hotel was peaceful with a friendly staff. I was touched when it was time to go that they genuinely seemed sorry to see us leave. And despite a few kinks in the plumbing, a few holes in the mosquito netting and that toilet paper was hard to come by, it was a pleasant place to stay.
But of course the highlight was what we all came for, saving women’s lives with cervical cancer screening. One of the things that attracted me to PINCC in particular was the fact that it isn't just a group that comes in, rescues Africans and then departs leaving them with a vague memory of the experience and no ongoing skills. PINCC teaches the screening itself, even providing supplies and sometimes expensive equipment such as cryotherapy and LEEP machines. I was also so impressed with the other volunteers. Doctors, nurses and support people who have not only spent the time and money to be here but do their work with grace and compassion. I watched the doctors patiently and gently teaching the many different personalities that made up the doctors, nurses and medical officers from each site who are all so eager to learn how to make cervical cancer screening available to the women in their country.
Our second site was Kibera, one of the largest slums in East Africa. Each morning we would trade our shoes for rubber boots to make the 20 minute or so walk to the clinic. It had been raining (and a downpour in Kenya is very impressive) which made the narrow passageways through the slum more difficult, as the last thing anyone wanted to do was slip and fall into the mud here. We also had to be mindful of our heads as low metal roof overhangs were abundant. But the walk and the emotional experience of Kibera itself were all worth it when we encountered the enthusiastic group of healthcare providers waiting for us.
I have to say, that as I had thought, it was the women themselves who impressed me the most. Many of them had never seen a health care provider before and certainly most of them had never undergone a pelvic exam. Many of them were truly frightened but they overcame their fears and came in numbers. My favorite job while volunteering was when I had the opportunity to teach about cervical cancer. Generally this was done with an interpreter. Often a woman herself waiting to be screened who spoke English. I also found it very rewarding to explain to a woman what to expect from the process of screening itself in hope of easing her fear. But despite everyone’s best effort at preparation there was still some fear and in this case a hand to hold and a soothing voice became the necessity of the moment.
Gently, firmly with humility and much grace, Carol, our fearless leader kept us all on track. It was such a great experience getting to work with this amazing woman. She was truly the conductor of the orchestra and there would have been no music without her.
Volunteering with PINCC will always be a highlight, not only in my career as a nurse, but my life in general. It was a profound and rewarding experience and I am forever grateful to all the courageous, compassionate PINCC volunteers that I worked with. It was a true honor to be counted among you. AND I will see you again!
PINCC volunteers arrived on the outskirts of Kibera at the offices of Carolina for Kibera on Monday morning, albeit later than expected because of the ever-unpredictable Nairobi traffic, ready to get to work. For some volunteers this was to be their first experience entering the slum they had only heard about in the various forms of popular media. Apprehension, excitement, curiosity, determination and many shades of emotions in between were apparent on the faces of the volunteers as we prepared to make our way through the narrow paths that would lead us to Tabitha Clinic. Along with donning our rubber boots we carefully forced straight and stoic faces while mentally preparing for what we had only heard about. The residents of Kibera were already in the midst of their day, easily traversing the somewhat treacherous terrain which we nervously (and very slowly) tread. I am happy to report there were no slips during our week of walking in and back out from the clinic despite the heavy rains that made this trek all the more daunting.
Upon arrival to Tabitha Clinic, most of us were struck by the large concrete structure. How they managed to construct this massive building in the midst of small tin-roofed homes, open ditch sewage, millions of residents and muddy streets is a feat I will not even begin to contemplate. We were, as per usual, greeted with enthusiasm and hospitality that far exceeded our expectations. All the staff went well out of their way to be accommodating for the duration of the week, and yet every day I was amazed that this seemed effortlessly to be the case. We walk in and disrupt their routines and their staff roles, and they couldn’t be more welcoming to this ordered chaos. After a brief introduction of the team we would be working with throughout the week, we realized how much assistance we would have available. Community and peer health workers were in abundance and more than prepared to encourage the residents of Kibera to come in and be screened by the PINCC trainees. As we took a tour of this clinic it was a bit jarring to look around and see how well supplied it was. Tabitha Clinic is a CDC site and is also made possible by Carolina for Kibera. Therefore, it is resourced fairly adequately, particularly in comparison to some of the other sites PINCC visits. Since this was the second visit to Tabitha, we were going to try to use the supplies provided by the clinic as they were available. The clinic had their own cryotherapy equipment, but PINCC supplied the LEEP equipment in order to have this service available to clients throughout the week.
For the majority of the trainees this was their first experience working with PINCC. We were all impressed by how quickly they learned and the enthusiasm in which they undertook the training. Many had never performed a speculum exam, and I can personally attest to the fact that by the middle of the second day they were patiently and competently teaching me. The learning that took place within this group was exceptional. Dually noted was the warmth and kindness that radiated from everyone in the clinic. From the clinical officer to the maintenance staff, every person I encountered was contentedly working towards helping this startlingly underserved community. The energy of that goal was palpable from the time we stepped foot in the clinic to the time we took our last steps out. I have not a shadow of a doubt that this is the attitude even when there are no witnesses. What a humbling and honorable experience to have the opportunity to work alongside this dedicated group of men and women.
I couldn’t help but compare the experience at Tabitha Clinic with the experience from the previous week at Bungoma District Hospital. When first walking in Tabitha, it feels a bit closed off compared to the open and spread out layout we experienced in Bungoma. Our “nursing station” was a desk in the middle of the crowded waiting room. Among large numbers of waiting clients and screaming children getting their vaccinations, we began. Despite the lack of personal space and the crowded nature of this room, the volunteers and health workers tried to provide as much privacy as possible while interviewing clients. It was a difficult realization that the simple concept of privacy in these situations is somewhat futile. Asking personal questions and performing cervical examinations are usually tasks that are kept as dignified and as private as possible. However, our idea of patient privacy and confidentiality does not quite align with realistic possibility in Kenyan clinics. Still, we worked with what was available and tried to preserve patient privacy as much as was feasible. It’s just one aspect of the great learning curve we had the privilege of experiencing every day. We had five exam rooms; one of which served as a cryotherapy room and one that was used for LEEPs as needed. The rooms inside the clinic are about the size of a closet and have no source of light except for the natural light peeking through the windows. Conditions were tight, but everyone made the best of it and worked past the small discomforts with ease. Even when, on the first day, the skies opened up and the clinic was under several inches of water, everyone simply slipped on their boots without complaint and carried on with the tasks that needed to be completed before we were able to leave for the day.
The patients we saw during the week spoke a variety of languages, primarily Kiswahili, Luo and English. We had printed materials in all three languages and the community health workers were able to assist with patients that had limited English. Despite the language barrier, the gratitude emanating from every client and staff member was palpable. I suppose some things traverse language, and spoken words become inadequate. Again, such an incredibly humbling and honorable week from start to finish. The patient population coming in for screening tended to be younger than I personally had anticipated. Typically, PINCC recommends screening only for women older than age 25. However, during our week at Tabitha we amended this standard. Because the majority of women are sexually active at an earlier age and a high percentage are HIV positive, the risk of cervical cancer is significant even for women in their late teens or early twenties. Education for these clients was vital and it was encouraging to see such proactive young women coming in to be screened. Despite the fact that the average life expectancy in Kibera is only mid-30’s, alongside the younger population there were also middle-aged women coming in to be screened for the first time. We detected varying degrees of dysplasia and were able to successfully treat many women of all ages.
We had several cases throughout the week where we would have to turn women away for one heartbreaking reason or another. Once cervical cancer is detected, the services PINCC has the ability to provide become insufficient and the woman is encouraged to seek medical attention elsewhere. Sadly, the waiting lists are endless, resources few and financial assistance unavailable. Many women also come to the clinic in the hopes of finding an answer for their breast cancer or their neighbor’s progressing cervical cancer. Not looking for money, but simply for an answer. A pleading look, a desperate grasping of hands and the inevitable walk back out the door into the harsh reality. There is nothing. That is something I hope to never become accustomed to.
Throughout the week we saw anywhere from 30-55 patients a day, and performed several cryotherapies and LEEPs. As the trainees grew in their knowledge base and experience, our confidence in them increased exponentially. By the end of the week we were able to certify two trainees and both were present at PINCC’s first visit. The small number of certifications awarded is due to the fact that PINCC likes to have each learner perform a large number of exams in order to confidently certify someone in VIA. Needless to say this usually does not happen during the trainee’s first experience with PINCC. We encouraged all the trainees present during this visit to return upon PINCC’s third, and perhaps final, visit in September. Based on the skill level and educational development of the trainees, there is sure to be many more certifications earned upon PINCC’s next visit. As we prepared to leave, we were surprised by an impromptu performance by both the Kenyan Boys Choir and the Kenyan Girls Choir. They were incredible and it seemed a very fitting way to end our last day. As we put on our rubber boots to make our way out of Kibera slum for the last time, the energy among PINCC volunteers, Tabitha employees and Kibera residents was tangible. The Friday afternoon activities were in full swing: children out of school, food being prepared along the narrow streets, people going about their business as we inconspicuously left Tabitha, and Kibera, behind. It almost seemed as though nothing had changed since our arrival, and yet, for me, everything had.