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.

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.   

Carol

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
patricia.spross@gmail.com

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
patricia.spross@gmail.com

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
patricia.spross@gmail.com

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
patricia.spross@gmail.com

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
patricia.spross@gmail.com

PINCC team in Leon Nicaragua June 2, 2013

Saturday, 6/1/13

It's rainy season in Nicaragua, and the air is heavy with humidity.   Managua is quite sad, except for a park along the lake full of colorful restaurants and playgrounds.  A few 2-wheeled horse-drawn carts navigate among the cars.   Vendors move through the neighborhoods singing out their wares.  The cathedral has not been repaired since the devastating earthquake of 1972. 

 

Sunday, 6/2/13

This morning the PINCC group moved from rainy Managua.  We are now staying at the charming Hotel Real in Leon.    Sitting in rockers on the patio, we gathered around Carol as she explained the work we will be doing.  The clinicians broke off and spoke together while we support folks and interpreters reviewed the medical questionnaire.   Carol assigned a team of 2 to each of the medical suitcases.  We will be responsible for their contents, and safe return of the costly instruments and medicines.   Carol is well organized and very calm.  She reminded us that if anything goes wrong, it's her fault.   I feel very safe around her.

We broke for dinner after our training session.    We are a group of 16.  About half are in their 20's while most of the rest have passed our 40^th birthdays, some quite a while ago.   Dr. Pam's children are with us, charming us with their games and drawings.

We will turn in early tonight, so we can be fresh for tomorrow's adventure. 

--
Patricia Spross
patricia.spross@gmail.com

The PINCC Team with trainees, last day at Kiambu District Hospital.

Final day in Kiambu

What a difference a few days make.  After a rocky start the PINCC team dug in. With four improvised exam rooms in full swing, Anne Daly, Eva Bryer, Deborah Crabbe and Art Levit took on a constantly changing group of trainees ranging from MDs to Nurses to Clinical Officers (sort of like our physicians assistants).  Some had never done an a pelvic exam, others were quite experienced.  By the end of the week the group had more or less stabilized and enthusiasm and commitment grew.  Carol, Laurie Jones and myself manned the desk and as word got out about the free screening, people poured in.  Predictably, chaos ensued as we struggled to register, interview, screen patients, and restock supplies in some sort of coherent manner.  By Friday the desk was a well oiled machine (relative to Monday). 

And miracles do happen-- a malfunctioning cryo tip was replaced the same day by the company supplier in Nairobi.

By Friday afternoon, thanks to the finely honed diplomacy skills of Carol and Art,  the hospital higher ups were on board and eager for another visit and more training with the hopes of setting up Cryo and LEEP treatment centers.  What a difference a few days make.