Christine Journal 13

Max and I are in disbelief that this will be our second to last update, but it's been a wonderful past few months and we still have a week left, so we can't get too sad yet.

I had an interesting week in the hospital with Jenn and a social service doctor who is taking over for Dr. Charles as he takes two weeks of vacation time. The new social service doctor is not very communicative, so hasn't been all that helpful with special cases and such, but he's nice enough. It has really emphasized for me how important the Honduran fellow is to provide some kind of continuity and local knowledge to the clinic. Pediatricians coming for a month at a time just really can't do it on their own.

I was happy to see the Global Healing ultrasound put to good use this week. The ultrasound is huge and was donated a couple of months ago. It's been sitting in the corner of the clinic for that time without much use, as no one in the hospital is trained in reading ultrasounds. Additionally, we don't want to move it out of the clinic in case parts (or all) of it get stolen, as happened with the last one, apparently. Howard has been organizing a visit for a couple of radiologists and an ultrasound tech to come down in February and teach local doctors how to use it, which I think will be great. Hopefully then it will be put to good work! Anyway, the surgeon did come by to use it once this week on a woman she believed had gall stones, but she couldn't actually find any in the ultrasound. Jenn also used it twice - once on a boy she wanted to check for an inflamed kidney and another time on a boy's brain.

The second case was pretty interesting. It was a premature baby (born at about 7 months and 1600 grams) who had been in the clinic for weight checks every week since he was born. He was growing very slowly (was 1900 grams this past week), but Jenn was the first doctor to feel his head and realize that his sutures were completely open and his posterior fontanelle was also very large. He presented with a fever of 101.6 degrees, so Jenn wanted to put him on antibiotics and admit him for the fever before we worried about the sutures. She sent him to the ER and went back after about an hour to check on him, only to realize that the ER had not even started the antibiotics because they were "waiting for a bed to free up." She was very angry and frustrated that there seemed to be no thinking outside the box, especially since it should be fairly obvious that the baby needed to be on antibitics asap and could really be put on any surface to do so. Additionally, when the did finally clear out a bed from him, they didn't change the sheets in between patients.

After the antibiotics were administered, we brought the baby back into the clinic and did an ultrasound on the brain. He seems to have pretty severe hydrocephalus, and Jenn was able to send pictures we took of the screen to a neurologist in the US for a consult, which was great. I cannot even imagine how much more difficult international work like this was before the internet...

The hardest part for me of the whole encounter was having to explain to the mom what it was we were doing and that her son would not develop normally, resulting in lower intelligence, decreased motor function, etc. It just all came out of nowhere, since she'd been coming to check-ups with the clinic for a few weeks and no one had caught the hydrocephalus before.

Also this week, I started tutoring a local high school graduate to prepare her for the SAT, as she's hoping to go to the US for college next year. I had taken her to the test in La Ceiba about a month ago, but her scores were not as high as she had hoped, so she'll take it again in January. She's fun to work with and I'm hoping someone else will be able to take over after next week, although I doubt that will be a problem with all the volunteers that come through Peggy's house.

Max Journal 13

Today is the three-month anniversary of our arrival in Roatan and the beginning of our last week here. I have a lot to reflect on, and hopefully I'll be able to put some more of that into words for my last update at the end of the week.

I spent this week working in Peggy's Clinic, alternating between shadowing Dr. Raymond and running the pharmacy. With Raymond I had the opportunity to look in ears, auscultate lungs, listen for heart murmurs, and palpate abdomens. Working with Dr. Raymond is a great learning experience, but unfortunately I did not feel like I could contribute much to his work. I look forward to learning more about medicine in future study, but right now I am more interested in feeling like I am making a difference using the skills that I already have.

Monday brought a surprising number of bad ear infections with at least one ruptured timpanic membrane – a shocking sight. Tuesday seemed to have a lot of eye injuries, with at least two resulting from construction accidents. Eyes are incredible organs, and contemplating the extraction of small splinters from them is a scary prospect. Raymond mentioned that he looked forward to talking to a meeting of construction contractors to address the lack of effective personal protective equipment (specifically glasses/goggles) used by their employees. Occupational safety has never really sparked my interest, but I am inspired by the wholesome approach that Raymond takes to improving healthcare on the island, and I look forward to being able to use my knowledge and experiences as a professional to influence health-related business practices.

Friday brought another large shipment of mattresses and chairs from the Carnival Legend cruise ship. Despite all of the economic complexity that accompanies cruise ship tourism, I am impressed by Carnival's willingness to donate in bulk to Peggy's clinic. The cruise ship is a glaring symbol of the accomplishments of sophisticated modern technology to provide comfort to the wealthy. It's hard to imagine that this several-hundred million dollar luxury ship can dock within a mile of a public hospital providing primary health care to around 50,000 people without a functioning ventilator, ultrasound machine, CT scan, adequately equipped laboratory, or single narcotic drug. Despite all that glaring inequality, I have to say that the 100 mattresses donated in the last two weeks have been well received.

On Thursday and Friday, I returned to Peggy's clinic to do more of the same pharmacy work. It is reassuring to be able to exercise a practiced skill within the clinic to help people get drugs to make their lives more comfortable. The pharmacy seems to be more organized and effective than it was three months ago, and I hope that it continues to move further in that direction as we develop a more consistent inventory system that will hopefully ensure better stocking of necessary drugs. I was happy to hear that Peggy finally placed an order from one of the drug donation companies that Christine and I applied to on the clinic's behalf. The order supposedly contains tens of thousands of dollars of medications for Peggy's clinic and other medical facilities on the island, at a whopping $465 cost to the clinic simply for shipping and handling. I hope the shipment arrives relatively soon and bears as many drugs as promised.

The tutoring program that we ran at Children's Palace Bilingual School came to a close this week. We administered another diagnostic test and saw modest improvement in all of the tutees' test scores. Overall, I was pretty disappointed by the school's disinterest for the tutoring program. It is not the children's fault that they did not want extra math classes outside of school, but I plan on taking better account of community needs in the future. If nothing else, I enjoyed connecting with the students when they did show up, I had a great time getting to know the other tutors, and I like to think that I imparted a bit of knowledge through my two afternoons each week of teaching basic math. I don't think the kids are worse-off after taking the program, and maybe future tutoring projects can use some of the lessons that we've learned to be much more effective.

Yesterday we had a little goodbye party with food and friends at our apartment, and now we have just five short workdays before our return to the United States. I'll give another reflective update before the end, and I hope all is well as usual back home.

Christine Journal 12

I was happy to be back in clinic for the end of next week after my trip to the mainland. We were pretty busy, as Dr. Jackie was not in her clinic, but Drs. Jennifer and Sarah were both comfortable with most things, so it went relatively quickly. We did have a little trouble again with Dr. Charles coming in late, and had to figure out on our own how to deal with a child with a 104 degree fever and possible dengue, malaria, bad viral infection, or early stages of appendicitis. After talking with the staff at the lab, I learned that there is no lab for dengue at the public hospital. I have no idea how expensive or complicated it is to test for, but it seems like something they would probably test for often and I was surprised they did not have the equipment to test for it. We were able to get a malaria smear and CBC, though, but the patient never came back with the results. Hopefully the child will be okay.

Sarah left on Friday and Dr. Charles is taking the next couple of weeks as vacation, so it will be me, Jenn, and a social service doctor in the clinic for a while. I hope it all goes smoothly with the new social service doctor.

As Max mentioned, we helped out at the Concert for the Angels on Thursday afternoon. Peggy had brought a number of patients and their families to the event, so we got to hang out with them, which was fun. It was definitely a different side of the island than I'm used to working with and a little bit ridiculous, but it raised a lot of much needed money!

I helped Peggy and some other volunteers clean out the pharmacy shelves on Saturday, and we were able to send a bunch of meds to a doctor working on the mainland. It still amazes me how much Peggy shares with different people, knowing who will need what and getting it to them.

Max Journal 12

I had a good week full of visitors and business in the clinics. I started the week in Global Healing working with Jen and Charles as Sara wrapped her trip to the mainland. The father of our previous week's ranula patient returned to tell us that his son had been in the Woods Medical Center all weekend being treated with antibiotics. If this is true and the swelling truly went down, then the Global Healing doctor's diagnosis seems unlikely, but we just emphasized the importance of traveling to the mainland for a specialist's attention. I always have to remind myself that some physicians' opinions, put forth with great confidence, are nonetheless wrong.

On Tuesday we had very few patients and I was able to leave the Global Healing clinic early to run some errands. On Tuesday evening Christine returned from a somewhat disappointing trip to the mainland with a patient.

On Wednesday I faced the cruise ship security forces once again to pick up a large donation of used mattresses.

Thursday and Friday I spent in the clinic, doing mostly pharmacy work.

I did my best to coordinate the transportation of three of Peggy's patients to visit an American cardiac brigade in San Pedro Sula. They departed on Saturday morning and I haven't heard from them since they were supposed to have arrived, so I hope that all went well.

On Tuesday afternoon I returned to tutor at the bilingual school and was disappointed that no students came. I was quickly reminded of the uselessness of providing a community service that isn't desired by a community. On Thursday afternoon Christine and I helped set up for a fundraiser in the Roatan airport. The event was a success, and it was humorous to see so many wealthy people putting on fancy shoes in the name of poor islanders' health.

I also dropped an injured bird off at a nature reserve on Peggy's request.

I am getting ready for my departure from this island, and I look forward to a few more quiet days enjoying the scenery before I leave.

Christine Journal 11

Once again, my update schedule was thrown off this week, as I was traveling until Tuesday night.
I had a wonderful trip with my family and was very happy that I got the opportunity to see the mainland with them. We spent a few days in a lodge at Pico Bonito by La Ceiba. The staff there was all Honduran and we had them pretty much to ourselves, as there weren't any other tourists there, and it was really interesting to spend time with them. Our guide was a native of the Mosquito coast and his knowledge of the rainforest was incredible. It was great to learn from him about all different uses of plants and animals. It just really brings to life the importance of conserving lands that are being cut down so rapidly now.
The trip to El Progreso, take two, was once again a let down. I went with Jessica and Neri, the patient and mother I took about a month ago because of her scratched corneas. The clinic had a visiting plastic surgeon who was going to operate on her eyelids so that her eyelashes no longer scratched against the cornea, but the surgery was canceled when she had a cold and thus couldn't undergo general anesthesia. I really wished someone had warned us about that ahead of time, as it was a long trip for the mother and daughter to make. The clinic said we'd have to wait until the next plastic surgeon came, which could be another six months. They normally get two a year, but don't yet have next year's schedule. Since it's such a time-sensitive procedure, though, I'm hoping to find somewhere else she can go to sooner. It's just really important in the future that we get the patients cleared for surgery by the pediatricians here before we send to the mainland, even if we're not sure that they will get operated on. The clinic was going to have us visit a pediatrician there before the surgery for approval before they realized that Jessica had a cold, which could have been complicated, as we didn't know any doctors there.

It was also interesting to see the clinic's way of charging for surgeries. They take the patient into a private room and go through a number of questions to see the economic state of the patient. For example, they asked whether she owned land or a house, whether she had electricity or running water, and how much she spent a week on food. I was with her at the time, and did say that the clinic would be helping with the price of surgery, but other than that all her answers clearly showed that she didn't have much extra money to spend on the care. The price of the surgery still came out at $150 dollars, clearly way out of her price range. I know that the surgeries are incredibly expensive, but I'm wondering about how patients are able to pay for them. The clinic is a non-profit started by Americans to help poor Hondurans with medical care, and I just found it very surprising that they'd still charge someone like the patient I was with 150 dollars. Maybe it was because I was there, but I really hope that other people who can't afford to pay that much don't get turned away.

Max Journal 11

I've had a good week here in Roatan, so I hope you've had a good week back in the States. I began the week showing my girlfriend, Maya, the ropes in Peggy's pharmacy, which was fun as it added a slightly "new dimension" to our relationship. Work in the pharmacy is going well, although I am definitely a lot less inspired when I cannot interact with patients every day. Tuesday was another day of working in the pharmacy, and it brought a rude surprise when I realized that I had been entering data wrongly into the computerized inventory system for the last two months. The inventory system is still very new and lacks a few key features (like a way to view the actual inventory of any given drug), but we have been making an effort to accurately input data from every prescription filled for the last few months. When I realized that use of the inventory was very inconsistent, I became a little frustrated at the effort that we had put into the system. Although we will not be able to calculate the inventory of drugs in the pharmacy at any given time, the data for which drugs have been given out over the course of the last few months should still be fairly accurate, so all is not lost, but this error was a bit of a blow. I am realizing now that Peggy's Clinic is in the middle of a very important phase of its development as it formalizes a lot of the systems that it has depended on in the last seven years. Everything from the pharmacy inventory to the clinic's financial bookkeeping is now more important than ever, and where a lot of "under the table" jobs worked fine up until now, those jobs will have to come into the light of day in very transparent ways for the Clinic to continue to grow. I hope that I can help in some of this transition.

From Wednesday until Friday I greatly enjoyed going back to work in the Global Healing Clinic while Christine took a short vacation with her family. The clinic is a lot busier now than it was when I worked there before. For the last two months the clinic has been staffed by just one or two doctors, so the current staffing of three doctors seems very busy. Coincidentally our patient load seems to have increased, so I'm happy that we have so many doctors attending all of these patients. I have also really enjoyed being able to interpret for Sara because that brings me in a lot closer contact with the medical care that our clinic is actually delivering. While it can be a little stressful sometimes to triage all of the patients and translate for Sara, I am constantly reminded of why I came here to Honduras.

One interesting case of the week was a ~1 year old boy that came into the clinic with a ranula. During triage I weighed the boy and was surprised to see that he weighed only 17 lbs because he looked like a big chubby baby, but then I realized that he was not really fat at all, he just had a drastically swollen head and neck. Dr. Jennifer diagnosed the boy as having a blocked sublingual salivary duct that was causing the saliva to build up in the salivary gland and in the tissue around the boy's neck and jaw. I was surprised that the boy had no difficulty breathing, but he was already unable to eat and needed urgent corrective surgery before the condition worsened to block his airway. We sent him to seek care in San Pedro Sula because the hospital surgeon was not comfortable with such an unusual surgery, but I was confident that the patient would get the care he needed because I knew that his father works for the municipality and therefore has "social security," a form of government health insurance. Although I was disappointed that the public health system that cares for the Honduran poor could not solve this patient's problem, I was quickly reminded of how familiar this situation is to the American medical system. I have to acknowledge that although Honduras has a national health system that aims to protect each person's right to medical care, the Honduran government is not really able to guarantee that right. Alongside that I acknowledge that the United States government officially recognizes very few "rights" concerning medical care, despite the fact that the US has many more resources at its disposal than the Honduran Ministry of Health. Of course I recognize a far bit more complexity in the situation than I mention here, but the situation is nonetheless worth verbally acknowledging.

Max Journal 10

This week has been a bit of a vacation for me as I've had two visitors from the US to entertain. I worked at Peggy's both Monday and Tuesday mostly in the pharmacy filling prescriptions. I'm feeling much more confident in that job as I get to know the organization of the pharmacy and the uses of most of the drugs. I have had a Canadian nurse's aide helping me in the pharmacy, and it has reminded me of how hard it is to utilize short-term unskilled volunteers. She helps me count pills and enter some information in the inventory, but really she mostly just reminds me of how amazing Peggy is to be able to
utilize so many people so graciously when a lot of them really just create more work for her.

On Monday, the psoriasis patient from several weeks ago returned to the clinic looking much better, and I took him down to Peggy's to clean off (this time he was able to shower himself). I was happy to see that he returned when told to and his skin was much better than when I first saw him, but I could tell that he hadn't bathed in days and was probably not going to be able to bathe in the sea as instructed to keep his skin clean, moist, and exfoliated.

I took Wednesday and Thursday off, which worked nicely because Peggy's clinic is always closed on Wednesdays and was closed this Thursday for Thanksgiving. Friday was a pretty normal day filling prescriptions in the pharmacy. I don't think I will ever be a professional pharmacist, but for the time being I do enjoy learning about the drugs.

Outside of clinic hours I have done a few work-related things. On Wednesday I stopped by Los Fuertes with my dad and girlfriend to look for a deaf girl that should receive a hearing aid next week. We had a vague address (above the Adventist Church) and two different names (neither of which was correct) to look for in Los Fuertes, but it ended up being a fun little search. I think especially having my father there helped lend a fresh perspective on the situation; recognizing that tracking someone down in the United States would proceed much differently than here. We found the girl without much trouble and gave her the necessary information, and I felt good about being able to navigate Honduran society to complete at least very
basic messenger tasks.

I have also been chauffeuring a lot of people back and forth around town, which I am happy to do, but I do worry a little bit about the liability involved. I feel comfortable driving on the streets, but I fear that it is just a matter of time before some driver makes a poor decision resulting in an accident. I know that in terms of safety, my driving is probably just as safe as if not more safe than other peoples', but I do feel a slight burden of responsibility being the regular designated driver.

I spent most of my Sunday at Peggy's clinic inventorying new medications that just arrived in a big shipment from the US, which was fun. My girlfriend, Maya , will be taking over for me in Peggy's pharmacy next week as I go back to the Global Healing clinic while Christine visits the mainland, so this afternoon was a good opportunity for Maya to get to know the clinic outside of regular business hours.

Our tutoring project is not going well because the students have not been showing up. Tomorrow we hope to meet with the students and maybe the principal to ask how else we could structure the tutoring to be less of a burden on the students, but I am disappointed that we will not be able to conclude the curricula that we began.

In addition to clinic work this week, I've had a wonderful time hanging out with my visitors and getting to know some of Christine's visitors. We've eaten tasty Indian food, toured Oak Ridge by water taxi, scuba-dived with turtles, had a proper Thanksgiving feast, and fished real "island style." This all makes me realize very clearly how "social tourism" or "voluntourism" can really work to many organizations' advantages, and how non-profits in less picturesque locations have a lot of unique challenges.

Christine Journal 10

Things are going well down here, and we've been having a lot of visitors, which is always fun. Max's dad and girlfriend were here last week, and my mom and sister just came this past weekend. My family will just be here a few days and then is going to the La Ceiba area and Copan ruinas, and I wanted to check with you guys whether it would be okay if I accompanied them a couple of days in Ceiba. I would be out of the clinic on Thursday and Friday of this week, and Peggy has said it's fine if Max leaves her clinic to work in the Global Healing one so there's still an intern there. I'd also be gone the early part of the next week with Jessica and Neri, the patient and mother I took to El Progreso a few weeks ago, to see if we can get Jessica plastic surgery at the clinic in El Progreso. Let me know if it would be okay for me to take those two days to travel a bit with my family, as I completely understand that I have committed to the internship and that it might not be okay to take the time off.

This week was a little crazy in the hospital on Monday and Tuesday, as we saw 23 patients (!) on Monday and quite a few on Tuesday. It then slowed down quite dramatically, as we saw four on Wednesday and about three on Thursday. Friday we were back to about twelve, so it was quite different day-to-day. At the beginning of the week, the social service doctor was still here and kind of in-and-out, so Dr. Normandin was seeing most of the patients and it was fairly overwhelming for her. I've been interpreting too, as she's still learning Spanish, so I'm always busy between interpreting and triaging. I'm loving all the time I get to spend with her and the patients, though! And she's heard me give the same schpeal about viral URIs in Spanish that's she's about ready to give one herself.

Dr. Normandin, Peggy, and I went up to visit a patient in La Colonia on Wednesday that really helped put these hospital visits for URIs in perspective, though. The lengths that some of the patients have to go to in order to get to the hospital (especially when it's rained and the roads have turned to mud) are incredible, so even if the kid really does just have a cold, it's really important to still spend time with the family and give them something (like vitamins) to walk away with. The patient that we were visiting lived at the very top of La Colonia, and we were practically rock climbing up the slope to his house. It was a 9-year-old with an end-stage abdominal tumor with inguinal metastasis who had been through a number of courses of chemo on the mainland. He probably weighed 10-15 kilos and often didn't eat because of the pain. We're going to try to get something to ease his pain, and the family seemed really appreciative that we had come to their house to visit them. It was a pretty emotional visit and was hard to see a family living on nearly nothing who had to care for a dying son.

Dr. Charles came back from his trip to Tegucigalpa applying for a new job, and things are back to normal (or as normal as they get) in the hospital. We had the internal medicine doctor give the lunch time talk this week, and Dr. Normandin will have one prepared for this coming week. A new doctor (Dr. Jennifer Cohen) came in on Saturday, so I cleared up the third examining room (or more like section) for her to use, which was a bit tough with the ultrasound machine we still have waiting for someone to be able to use and move to a place where it will be safe.

The math tutoring project seems to be needing a new direction. We went on Tuesday to, again, find all the students had gone home because they had too much work. After speaking with the school's director about how holiday season was especially hard for students with exams and other projects, we decided that we needed to reassess the tutoring sessions and how to best help the students. I think that it's hard for the students to really see how this directly benefits what they're learning in math, as a lot of what we're teaching really does give them the foundation for what they're doing, but it's not so obvious how it helps them with algebra or geometry homework. So, it was disappointing to see no one there again, but we're hoping to meet with them tomorrow to talk about a direction to go with the tutoring and see how we can best be of help.

Thanksgiving was really nice - we had a fun, eclectic group of people for dinner at Dr. Patrick's house. We did potluck style, too, and had all of the Thanksgiving essentials! Everything was delicious and the company was great - volunteers with Peggy and Global Healing, Dr. Raymond and Dr. Charles, Joe Soloman (the chief of police), etc.

Christine Journal 9

As Max wrote, we have now switched work places, and I'll be in the RVPC for the next few weeks. It's crazy how fast our time is passing, and it's been fun to see so many volunteers come and go. I'm so impressed by Peggy's ability to be so welcoming to each person who comes through when there are so, so many.

I've been enjoying working in the RVPC, although it can be very frustrating and depressing to work in the public hospital due to the politics and lack of resources. Dr. Charles was in Tegucigalpa this week doing job interviews for the jobs he's applying to for next year, so a social service doctor took over for him. The new doctor came in on Sunday, too, so she had a little less orientation than normal, but it is all going well. Even though there were a number of cruise ships this week, the clinic has been pretty busy. The new doctor isn't very comfortable with Spanish, so I've been able to interpret for her this week, which I'm really enjoying. It does make the morning much more hectic, though, since I'm triaging and seeing all the patients with her, but I've been getting there early and trying to triage in any spare time and it's working out.
I've come across a number of interesting medical beliefs while interpreting this week in the clinic, and it's been pretty interesting to hear some of the same beliefs from a number of patients. For example, many people believe that if you sleep with your eyes open you have "bichos," or you get skin infections because of "bad blood." People have been very receptive to the doctor's explanations of disease that go against these beliefs, but it still is an interesting clash of cultures.

We had a few cases this week that highlighted the island's gaps in medical care. One boy's mom claimed that he had to sit very close to the TV and turn it to its highest volume to see and hear well, so we wanted to get him sight and hearing exams, which shouldn't be too difficult. However, according to the social service doctor, there was nowhere to get them in the public hospital.

Another child had a fused sagittal suture, meaning his head was growing front to back, but not expanding on the sides. What was interesting was that the mother never mentioned that in the list of reasons she had come in, so I don't know if she had been told in the past that there was nothing she could do about it or what the history was. Dr. Normandin, the current doctor in the clinic, said that in the US you would just send the baby to the neurologist and probably break up his skull bones to let them set back together correctly, but there aren't any specialists on the island that could do such a procedure. We ended up referring him to the mainland, so hopefully they'll be able to take care of it. It's probably just going to be a cosmetic problem for the baby, but there is a possibility of increased intracranial pressure, and so it's really important to get it checked out by a specialist.

Tutoring went well on Tuesday - we had four students and four tutors, so we were still one-on-one. The girl I'm working with seems really interested and I'm really looking forward to being with her for the next few weeks and seeing her progress. Thursday, though, was quite a let-down. We got the tutors together and were driving over to the school when one tuttee called us (about 10 minutes before we were to start) to tell us she couldn't attend. And then we got a text message from another. However, when we showed up, it turned out that they had all gone home to study for a test they had the next day, so we had made a trip out to French Harbor for nothing. We'll talk with the students on Tuesday and re-assess their interest in the program, but it was pretty frustrating. I think the hard part about it is that it does seem like extra work to them, since we are really working on math concepts that precede what they're learning but that they may not see as really helpful at the moment. We'll see what they say on Tuesday, though, in terms of their commitments and interest, since we're really there to help them.

We have now moved into the apartment under Peggy's house, which is really nice and it's fun to be living downstairs from her.

Max Journal 9

I've had a good first week at Peggy's Clinic now that Christine is working every day at the Global Healing Clinic. I started the week out with Betty in the pharmacy filling drug orders and running some random jobs around town. Betty the pharmacist left for the United States on Wednesday, so since then I have been the official pharmacist for Peggy's clinic. It is a little amazing that I am practicing a profession that requires a graduate degree to practice in the United States. On Wednesday I went into the Global Healing clinic in the morning and bought food for the Wednesday lunch conference before I went to pick up some donations from the Carnival Valor cruise ship. The security precautions at the cruise ship dock are pretty amazing and the cruise ship culture seems very alien to Roatan, but after a few hours of struggling I was able to drive out onto the dock to pick up a few boxes of donated clothing. The cruise ships play such a large role in Roatan's economy that it is almost offensive to suggest that
they should be outlawed, but it is a thought that crosses many visitor's minds. Peggy's clinic has been slower because we have only one volunteer doctor, and Betty is gone so the pharmacy is quiet and a little lonely. This weekend my girlfriend and father arrived from the States for a visit, so I am understandably distracted and will keep this update short. I look forward to getting better at the pharmacy job and learning more about the drugs that we use here.

Max Journal 8

I started out the week by holding down the fort at the Global Healing clinic while Christine was still on the mainland. There was no volunteer physician so I worked alone with Charles until Wednesday when I switched to working at Peggy's. We moved efficiently through a pretty high patient volume, and I was honestly impressed at how many patients Charles could see on his own in such a short amount of time. Charles is applying for jobs for after finishing his second Global Healing Fellowship in December, so he has been frantically preparing a heap of paperwork. I wonder if there is a functional reason why "diplomas" certifying participation in conferences and continuing medical education courses are so important here. It seems like a never-ending occupation of a lot of doctors to get many pieces of paper with the appropriate stamps and signatures to certify and acclaim them for their accomplishments. To a certain extent I think the obsession with "diploms" and "reconicimientos" is cultural (some people just like physical representations of their accomplishments), but I also wonder if there are big problems with forgery of certificates.

Christine got home thoroughly exhausted from her journey on Tuesday, and I was happy to have her company again. I think she made good friends with the mom and baby, met some interesting medical professionals on the mainland, and learned a lot about international medicine in Honduras. On Thursday I worked in the pharmacy at Peggy's and went to the ferry dock to pick up a patient that didn't end up coming. This patient was supposed to come to get an excisional biopsy from an ENT doctor working at Peggy's, which would have been an unusual reversal of the standard shipment of Roatan's patients to the
mainland to receive specialized care.

On Thursday evening Peggy, Christine, Becky (a future Global Healing intern) and I responded to a car accident near Sandy Bay. We were with Peggy when she received a call that one of the carpenters working at her clinic had totaled his car and his wife who was in the passenger seat was unresponsive. By the time we arrived on the scene, the passenger was awake and ready to leave, but we skipped over about every protocol that I ever learned in EMT class and walked her to the passenger seat of our parked pick-up truck. I was amazed that we didn't even have a spine board to provide some degree of immobilization, and I can only imagine how people who are not personal friends with Peggy deal with traumatic emergencies on the island.
Because there were no emergency services (police, fire, nor ambulance) on the scene, traffic continued passing by us on the narrow two-lane road. As we were slowly pulling out into traffic, I committed the cardinal sin of emergency response: I put myself and the other responders in danger by colliding with a passing taxi. Honestly, the cab swerved at me and in an American traffic court I'm sure that I could have reasonably argued my innocence, but in the moment none of that mattered because now there were two accidents and still no formal system for sorting anything out. I didn't even know if there was a tow truck on the island. I sent Peggy, Christine, Becky, and the patient to the clinic in the truck and I stayed behind to sort things out with the cab driver. As it turned out we had hardly collided at all and I had rather miraculously managed to snap his bumper off without denting or scratching it at all, so we talked it out and settled with a small amount of cash and a handshake and without further legal complications. I was very relieved when I got home and learned that the passenger was without serious injury and our hectic night was coming to a close with no more than a few scrapes, bruises, and some property damage.

Friday at the clinic was fun as I showed Becky around the pharmacy and celebrated Betty the pharmacist's birthday. Around 9:15 a.m. I received a phone call from a friend of mine in Coxen Hole who is a middle-aged woman that recently moved to Roatan from the United States to start a spa/beauty salon. She was very upset as she hurriedly told me about a man in her home who had some serious skin problem and needed urgent medical assistance. I managed to ascertain over the phone that it was not really a real emergent problem (no respiratory distress, no impairment of circulation or sensation), and I instructed
her to put him in a cab and send him to the clinic. About an hour later I received another call from my friend stating that there had been no available cabs (cruise ship day!) and asking if I could come pick him up. I drove to her home (cautiously after the previous night's debacle) and arrived to find a 41-year old man in a lot of pain as the skin all over his body appeared to be peeling off. I drove (still cautiously) back to the clinic and learned that he was from Diamond Rock (a Black Islander community on the far east end of Roatan), he had had skin problems for just over a year, and he had come to Coxen Hole the previous day to go to the hospital and had been sent away then and again on Friday morning for unclear reasons. Apparently he knew my friend through a mutual acquaintance and, lacking other recourse, had hobbled all the way across town on badly swollen feet from the hospital to her house and had collapsed on her floor. I arrived at the clinic and asked the patient to remain in the
car as I prepared a treatment room and announced to the doctors his arrival (the clinic has no functioning landline telephone and I was unable to reach anyone via cell phone on the way over, which is a problem in and of itself). By the time I had a room prepared and retrieved the wheelchair to help him in, the security guard had helped him out of the car and onto the clinic porch, so I wheeled him through the clinic in front of a crowd of raised eyes. Some other volunteers rather-inappropriately left their workplaces in the clinic and rushed to take pictures of him while ostensibly "triaging him" and I felt like I had brought him into a very uncomfortable position, but of course at the time this was the price of much-needed urgent medical attention. This feeling touches on a characteristic of American medical care that many people have commented on: the objectification of patients and their diseases. While I cannot imagine taking pictures of a patient without a specific medical excuse (for instance to consult with other doctors regarding the case), I have often appreciated being called in by a doctor to teach me something from a patient's condition. The truth is that as a student of medicine and of public health, I walk a delicate line between learning from and treating patients, and different people have different ideas of what is "appropriate" treatment of a patient.

Anyway, back to the case...the doctor decided that the most immediate treatment necessary would be a warm bath to moisturize and exfoliate the dry peeling skin. The clinic does have a working shower and a water heater, but because the inpatient wards haven't opened yet there is no demand for hot water so the boiler was turned off and no hot water was available. The nearest available shower was at a motel owned by a friend of Peggy's, so I drove the patient over there. I then entered the shower fully clothed with the now naked patient and proceeded to abrade the dead skin off of his entire body for 45 minutes. It can only be described as an unusually intimate encounter between strangers that I have since reflected a lot on. The severe psoriasis that affected him was an extreme auto-immune disease that had only one probable explanation. As I washed every inch of his body and learned more about him than I may have ever wished to, I felt like I was finally doing what I came here to do: helping someone. He felt tremendous relief as his skin regained moisture and after the shower when we applied Vaseline and hydrocortisone to his entire body. As the water dripped down my face and I looked at my soaking wet leather shoes flecked with bits of dead skin, I started to reconsider what it means for me to help another person. There is a little more to this story than I can include here (ask me about some interesting tattoos when we meet someday), but I can say that that 45 minute shower taught me a lot about myself and the meaning of altruism. After that industrial-strength exfoliation, he dressed in some new clothing and left feeling like a whole new person. I gave him cab fare, various creams and soaps, a few medications and vitamins, and strict instructions to bathe twice weekly in the sea and return to the clinic in two weeks. I hope he does come back.

After that overly stimulating Thursday and Friday, I enjoyed a Saturday swimming at West Bay Beach and baking pretzels at home followed by eating Sunday brunch with the new Global Healing resident and scuba diving.

On Tuesday and Thursday afternoons we finally were able to get our much-awaited tutoring program started, which has been a lot of fun. The students we are working with lack some amazingly fundamental math skills, but are really very bright students that I feel we can help a lot. I look forward to continuing this tutoring for the rest of the time that we're here and I hope that the other tutors and students are enjoying it as much as I am. Alright, this seems like plenty of text for now. I hope you had an exciting week too.

Oh, and I'd like to say a big "thank you" for your personal response to my and Christine's journal entries. I can only imagine how busy you both are, but after spending a while going through many of the same trials and tribulations that you both have experienced here, I greatly appreciated reading some of your perspectives on things. I also really enjoyed meeting the new resident from Dartmouth this morning, so I hope that she – as a young female doctor – has an overall good experience with Global Healing. Thanks again and I'll talk at you again next week.

Christine Journal 8

Max and I have reached our halfway point of working by ourselves in each clinic, so we switched places on Thursday. Peggy’s clinic is closed on Wednesdays, so I got to go to the hospital to hear Dr. Dominguez’s talk (part of the weekly lectures Global Healing tries to put on) on developmental displasia of the hip. He was a great speaker and the talk was interesting to hear, so that was fun.

Dr. Welcome had to go to Tegucigalpa to interview for jobs for the coming year, so there is now a social service doctor (Dr. Andres Ordóñez) in his place until he comes back either late next week or the following week. He’s a nice guy and knows the hospital very well, obviously, so I think it will be fine, although the new pediatrician came in today and hopefully he’ll give her a good orientation tomorrow. He does seem to take his time in the morning, though, and especially now that I know how it feels to arrive early in the morning at a clinic and not be seen until the afternoon, I do wish that patients could be seen starting a little earlier. We’ll see what the schedule this week is like.

There weren’t really any unusual cases this week in clinic, but I’m enjoying being in the Global Healing clinic so far, although it can be frustrating working in the public health system. For example, for some reason the lab decided to stop doing stool exams and urine tests this week, and a patient referred there from our clinic came back without anything to help us diagnose his illness, which was frustrating.

Although the tutoring program started on Tuesday, I was in La Ceiba so didn’t start until Thursday. I think it will go really well – we had five students on Thursday with five tutors, so it worked out perfectly. We’re still expecting a few more to join the program, but we might also be able to get a few more tutors, including the new Global Healing resident. The girl I worked with is an honor student, and was very bright and fun to work with. She seemed genuinely interested in learning the material, which makes the tutoring so much more worthwhile.

We had an eventful night on Thursday (see Max’s journal for even more eventfull-ness), as someone who works with Peggy got in a car accident with his wife. There was a large truck stopped in the middle of the road without any lights on it, and by the time he saw it, it was too late to swerve. So he hit it front on, and, luckily, both he and his wife are fine. They called Peggy, though, to come help the wife, who had slammed her head into the dashboard and needed some medical attention. We went to the crash site, where there were no police, ambulances, or anything, something you’d never see in the states. Peggy said that it’s practically useless to call an ambulance, as they can take hours to get there and were even shopping at Eldon’s once when she tried to call them. So, we took the wife up to the clinic and Dr. Patrick examined her. She had no bleeding, but had had a concussion. Dr. Patrick highly doubts that she has any kind of internal bleeding, but it’s impossible to tell on the island without any kind of brain imaging. So, the whole night was a powerful reminder of how limited medicine is on the island and how people can really suffer from it.

Outside of clinic, I’ve gotten to go back and visit Neri, Jessica (the patient I took to the mainland), and the family, and really love being able to spend time with them. I just really hope they don’t get too overwhelmed with all the different medications Jessica has to use, since it is a lot to keep track of (some every six hours, some every 4, etc.). Max and I also finally went on our first SCUBA dive today, which was lots of fun!

Christine Journal 7

I just got back last night from a really interesting trip to La Ceiba and El Progreso, during which I accompanied a Roatan high school student to the SAT test in Ceiba and a mother and one-year-old daughter to an ophthalmologist in Progreso and a dermatologist in Ceiba. The trip as a whole really opened my eyes to how other organizations in Honduras work and provide health care to the country.

I left with Nurian, a recent high school graduate from Roatan, on the ferry on Friday, leaving behind rain on Roatan and heading into it in La Ceiba. She had been to take the test in La Ceiba the May before, so knew the drill pretty well. She'd also been studying for the test in the time leading up to it, receiving private tutoring from Shelli, a volunteer with Peggy who is here for the year. I think she was feeling pretty prepared, which was great. As I dropped her off, I was remembering how nervous I was about the test, as it was something that I had known was important since I was in middle school. It was great to see how calm Nurian was, and how much it was really just her own motivation that had gotten her there, not an expectation that her school, family, friends, etc. had for her since she was younger. She felt really good about how it had gone, so I'm really happy about that. The test was administered at a bilingual school that was opened for the children of the Standard Fruit Company's workers who came from the USA, and apparently is still the best (and most expensive, as they apparently charge in US dollars) school in the city.

I spent Saturday night alone in La Ceiba after Nurian left to go back on the afternoon ferry and before Neri and Jessica came in on Sunday morning, which was relaxing. I went to meet the ferry on Sunday morning and was happy to see that Neri and Jessica arrived safe and sound. I had spent Saturday talking with a few people who work in La Ceiba, and we were able to get a ride with a group from an orphanage who were bringing two boys to get operations at the eye clinic. We were able to wait at Dr. Black's house in the morning before we left for El Progreso after lunch, and it was great to be able to talk with Dr. Black about his experiences and work in Honduras. His observations were really interesting in the context of my experiences throughout the trip, so I?ll reflect on those after I talk about how the doctors? appointments go.

We drove to El Progreso with the ?tio? from the orphanage (the father figure for the kids) and two eleven-year-olds, who were all really fun to travel with. The kids were really curious about everything, asking lots of questions about things we passed and making good conversation, and we took a little detour through Tela, so it was an enjoyable trip. We arrived safe and sound at a house that rents rooms and sells food in front of the eye clinic, and although they had not received our reservations (the clinic was supposed to make them for us), they had a couple of rooms. The woman told us if it was our first time at the clinic, we had to be there at 5 am, so we woke up bright and early and left before breakfast, only to wait until 1 pm to be seen by the doctor. It made me really appreciate the patients that wait so long at the clinic to be seen, and it was also a bit frustrating that they weren?t able to tell us about when we would be seen so we could leave and get something to eat.

The clinic was started by an American ophthalmologist missionary, was in a pretty nice building, and seemed to be staffed mainly by Hondurans. There was a visiting American pediatric ophthalmologist for the week, which is why we were all there, but she seemed to be pretty overwhelmed with all of the patients. When we were finally seen, she didn't ask many questions about the history of Jessica's eye problems, but did tell us pretty quickly that she did not have cataracts. It turns out that her cornea is being scratched by her eyelashes, as her eyelids are pressing too hard against her eyes. She did let us know that they would have a plastic surgeon at the clinic in early December, and also gave some antibiotic drop prescriptions for Jessica since she apparently also had an infection, but it was a little disappointing to go all that way to find out she did not need cataract surgery. It's good to finally know what's wrong, though. All in all, I was not very impressed by the care at the clinic. The American doctor didn't speak very good Spanish, and, as I said before, didn't ask many questions. She left the Honduran doctor to explain to the mother what Jessica had, but he used very complicated medical terms that neither she nor I understood, so I had to tell her what I had picked up as the American doctor was working so that she could know what was going on.

We left there on Monday afternoon by bus, as the two boys from the orphanage were sticking around for surgery on Wednesday. We arrived in La Ceiba at night to pouring rain and flooding streets, but safely made it to Dr. Black?s house, where he sent someone with us to check into a hotel he recommended. It was such a help to have him as a contact in La Ceiba, as well as to have the group from the orphanage with us in El Progreso, and it really showed how helpful and important it is for different NGOs to work together and let each other know about opportunities, etc.

On Monday morning we got a few blood tests done for Jessica that the opthamologist had sent for, and it really made me wish there was a way for us to know what tests she had already gotten. Neri said they had done many tests on her, but couldn?t remember what they were, and we wanted to get them done before coming back to Roatan, as Roatan couldn't doing some of them, so we just went ahead and got them. I think in the future it would be good to make a copy of the patient's file to bring on trips like this one so that there isn't any overlap and the doctors can better see the patient's medical history. I don't know if this is possible, but I'll look into it.

We saw a dermatologist in La Ceiba that Dr. Raymond from Peggy?s had recommended, and he seemed to be really good. He was not able to diagnose a specific skin disease, but did explain very clearly to Neri everything that he was thinking. He said that since it is congenital, he doesn?t really think it will ever go away, but that it may get better as she gets older. He also looked at her eyes and agreed that the cornea was being scratched, but also with just a few questions was able to discover that Jessica slept with her eyes open (her mom usually closed them), so her cornea is probably also getting dried out. He prescribed her lubricating eye drops for that, which he was very surprised the American ophthalmologist had not done. He also explained very clearly how important it was for Neri to use the eye drops, as her eyes need light to enter to develop nerves that will be critical in her sight later on. He prescribed some soap and creams for Jessica's skin, as well.

I think that it was hard for Neri to hear that there wasn't really anything we could do for the skin condition, but she is up to go back in December for the plastic surgeon's visit to hopefully fix the eye problem.

The trip and my previous experiences here have really showed me the importance of talking with patients and trying to spend as much time as possible with them. As I traveled with Neri she told me a lot about the history of Jessica?s skin and eye conditions that I noticed she did not share with doctors unless asked specific questions or given enough time to really give a complete answer. I?ve also noticed while interpreting at Peggy?s clinic that the patients won?t mention something to the doctor when he or she?s asking questions, but when he or she leaves for a minute and I just stay and chat, they?ll bring up other important information. Dr. Black complained that he no longer works with missionary groups because they will try to brag about how many people they saw in one day, when really they?re not giving very quality care to their patients, and I can really see how just spending that extra few minutes with a patient to chat or ask them more questions can make a big difference in the quality of care they receive.

Something else that Dr. Black mentioned that has gotten me thinking is that the Honduran government can use the groups of medical missionaries who come down to perform specialty surgeries or other medical procedures and consults as an excuse to not develop their own medical infrastructure. Since the groups are filling in the gaps that the public system has, the government sees no need to develop in those areas on their own. So, I started thinking about somewhere like Peggy's clinic and how it can fit into this kind of situation. On the one hand, Peggy's clinic is doing great things by trying to provide a quality of care that is not available on the island. On the other hand, the public hospital can use the clinic to get specific medications they may not stock and, as Peggy's grows, may even start sending people over there for operations or in-patient care. However, if Peggy's clinic (or any specialty group who comes down to Honduras) is providing a level of care that the public health didn't seem to be getting close to (or trying to get close to) before she began, does it hurt the public health system? But doesn't it also hurt the people if such brigades or clinics are not started, as they really are filling in a gap that the public health system is not fixing on its own?

I'll be starting my time in the pediatric clinic, and look forward to getting to understand the public health system better!

Max Journal 7

This week I have been working as usual at RVPC and we seem to finally be getting back in the swing of things after the strike. Anita finished her last week here and we saw patients every day. The patient load has been pretty moderate, which keeps things relatively calm in the clinic. The rainy weather and the arrival of lucrative cruise ships keep patients away on any given day.

Probably the most interesting case of the week was a mother that brought in her son with a speech delay. The boy was almost four years old and didn't say anything while I was in the room with him, but apparently mumbled something when he was with Anita. His sister is around two years old and speaks well, so his mother is starting to worry. A few things about this situation were interesting to me. First of all, as far as we know, the mother didn't bring her child to see anyone until now, which seems like a long time to wait. Secondly, the diagnostic tools that Anita used to try to get a hold on the child's condition intrigued me. The mother didn't think the child had any trouble hearing, but she also said that when he did talk it sounded like a "deaf person." We can't do a real hearing test in the clinic, but by saying things when the boy is looking away you can test his reaction to sound, and by asking him to complete simple tasks you can test his hearing and some of his comprehension. The mother also said that he plays normally with the other kids in the neighborhood, which suggests that he is not severely mentally delayed, but rather that he might really just have a speech impediment. Also, during most of the time that the patient was in the clinic, which was most of the morning, Dr. Charles was unavailable to help Anita. Diagnosing a speech impediment is understandably difficult for a non-native speaker. The last thing worth mentioning is what the next step is. The boy needs a hearing test and possibly some sort of more detailed mental exam to evaluate the full extent of his developmental delay. Then he will need some sort of speech therapy, which as far as I know is unavailable on the island. I hope we are able to follow-up with this boy and see that he gets the attention he needs to fulfill his potential for speech.

From a more philosophical perspective, I've been thinking a lot about the relationship between the Roatan Volunteer Pediatric Clinic, the Roatan Hospital administration, and the other sources of medical care on the island. Anita tried for several weeks to participate in rounds at the hospital, but she always received some excuse why she couldn't (they'd already happened, they weren't happening, or they were happening later). This made me think more about whether the hospital really welcomes Global Healing there at all. From one perspective, I can fully understand why anybody would get tired of outsiders continually coming into their workplace and telling them that they are doing everything wrong, and in that sense I think that Global Healing should be careful about delivering criticism to the hospital. And from a completely other perspective, the resistance to change within the hospital is amazing. A certain amount of the problem can be blamed on a large bureaucratic public health system that the hospital must function within, but that cannot be the complete story. The number of small fixable problems in the hospital and the presence of people trying to fix them combined with the lack of fixing going on suggests that there are people *actively resisting* change. It should come as no surprise to me to see corruption in public administration here in Central America, but people fighting real improvement in the hospital nonetheless affects me.

Anyway, on a more upbeat note, I a dropped a patient with congenital cataracts off at the ferry terminal this morning to go to La Ceiba to meet Christine and travel with her to get corrective surgery in El Progreso, a city between here and San Pedro Sula. Christine is doing most of the actual work to make this happen for baby Jessica, but I hope all goes well and I see them soon back here in Roatan. You probably won't hear from Christine for a while because she's on the road, but I'll let you know if anything comes up.

Christine Journal 6

We've survived our first big Roatan storm, which has been a nice, cool change from the hot weather we had been having. On Wednesday morning I woke up to heavy rain out my window and no power (not all that uncommon, but it was out for 14 hours total this time!). Max and I both went into the Global Healing clinic, since Peggy's is closed on Wednesdays, but there was hardly anyone in the hospital. As the rain continued to come down, the entryway to the hospital filled with about 6 inches of water, and many other places were leaking. There were no patients for us to see (I think no one really wanted to travel in such a big rainstorm, especially if they live on dirt roads), so Max and I tried to figure out the Access database that he had found from last year (which seems to do pretty much what our current Excel file does in terms of keeping track of patients). We were hoping that we could get it so that the patients' past medical history could come up when we typed in their ID number, but are still pretty new to the system. Dr. Charles was nice enough to give us a lift home (although the roads were so flooded in Coxen Hole we almost didn't make it!), but it was still pretty early so we went up to Peggy's to see what we could do there. She has a couple of visitors who are working on construction projects, so they put us to work putting in floor tiles. However, there was no electricity still (the whole island seemed to be out) and so it was hard to see and we couldn't cut any more tiles, so we soon ran out of jobs and went home.

Work in Peggy's clinic is still going really well - the staff is all so great and I still learn so much every day. I got to do a lot of interpreting this past week, which I love, as well as work in the pharmacy (also lots of fun). I helped out with triaging some as well, but it gets pretty crowded with two people triaging at once, so I mainly tried to do it when Sherry Kay was busy with something else. Monday and Tuesday were pretty busy, but there were very few patients on Thursday and Friday, since the weather continued to be bad. It was nice to be able to spend more time with patients those days, though. Power was off for another 11 hours on Wednesday night/Thursday morning, which makes it hard to work in the clinic. Hopefully they'll get a generator soon, though!

In the afternoons, I've continued to work on drug donations, as well as help Shelli get ready for the tutoring, which is set to start next week. We'll have a 5-week session, going to the school twice a week and each working with 1-2 students on math. There are a few other community members (American ex-pats living here) who will do it with us, which should be fun. I'm really looking forward to that starting up!

I'm also planning on accompanying a girl to La Ceiba to take the SAT on Saturday morning, as well as going with a patient to El Progreso to visit a cataract surgeon and hopefully a dermatologist in La Ceiba. The patient is about 1-year-old and has an unidentified skin condition as well as congenital cataracts, so hopefully we'll be able to get the cataract surgery done and make some headway on helping her skin condition. That will be from Sunday-Wednesday or Thursday.

Max Journal 6

At the beginning of this week I was pleased to see the ever-present "flag of the syndicate" removed from the entryway of the hospital, signifying the end of a three-and-a-half week strike. It's not clear to me what kind of resolution the workers and administrators came to, but from what I've heard the workers' demands were not completely fulfilled. The hospital seems to be up and running, though, and everyone seems to be in a lot better mood, so my life is a bit simpler now that the strike is over. Patients are being attended to and hopefully the hospital will see a return to some modicum of normalcy in the coming weeks.

Monday and Tuesday were surprisingly slow (only 12-15 patients per day), and I think that's probably because word was still getting around the island that the hospital had reopened. We had one interesting case of a mother coming in for a regular well-child check for her four-year old son (which is pretty much unheard of in our clinic), and she said that she comes in for monthly check-ups because he had had had leukemia. I duly recorded her comment on the chart, and looked back through his medical record for some more detailed history. The child had in fact visited the hospital with some regularity, but never mentioning any history of cancer. We checked the kid out and he seemed fine, and it was certainly possible that he had received effective treatment years ago for cancer, but something in the story seemed a little odd. The mother proceeded to tell us that she also had "cancer of the blood," as did her other baby, at which point we guessed that she was probably talking about sickle-cell anemia. Later in the day I spoke with someone who knew the mother and suggested that she was known for getting baby formula from free clinics to sell on the street, so my "index of suspicion" of the mother's spurious history increased significantly. Fortunately the situation we were in didn't put the child in any danger (except maybe an unnecessary blood draw) and we were able to confidently do what the mother asked (confirm his good health) without wasting many resources, but it certainly exposed our vulnerability to exploitation by our patients. We have to balance our trust and willingness to help the community with a reasonable level of skepticism. The role of this organization is to provide medical care, not to encourage entrepreneurship through black-market drug and baby-formula markets, so from now on I will actively try to keep my eyes open to the exploitation not only of community members, but also of community organizations.

When it started pouring down rain on Wednesday, I had to chuckle as the patients disappeared and the hospital quickly started filling with water. Luckily our clinic seemed safe from serious water damage, but I do not lie when I say that water was coming into the hospital from above, from below, and from all sides. As we drove away through several inches of standing water I saw one hospital worker futilely bailing out the hospital lobby with a small bucket. I think that providing first-rate evidence-based medical care is a fine goal for any public health system, but maybe a solid roof should be one of the hospital's first steps in achieving that goal. It's amazing that we are trying to build so much up on such a weak infrastructural base. Modern medical technology costs a lot more than a leak-free roof, but without an effective roof in place (and clean sanitation, and running water, and proper ventilation), the medical technology will be useless.

Thursday and Friday I was happy to see that the hospital dried out significantly, and we continued seeing patients, although fewer than normal probably because of the persistent rains and the quickly eroding roads.

In the afternoons Christine and I have continued working on drug donations and prepared for the upcoming tutoring session. Hopefully the last few pieces of paperwork will come together and we can see short-dated pharmaceuticals knocking down Peggy's door in no time.

In the meantime Christine and I have been baking a lot, running on the beach when the rain abates, playing Skip-Bo in our dark apartment during the downpours, and enjoying the company of other volunteers. Despite the rain, we've enjoyed a respite from the heat, and we look forward to sunnier skies someday soon (I think right now the wind is finally dying down after five blustery days). We also enjoyed meeting a young Canadian who works with HIV/AIDS testing, counseling, treatment, and prevention in Roatan. The three of us shared our different perspectives on the public health network here, and learned a lot from each others' experiences.

Max Journal 5

Last week was better than the previous, even though the strike persisted. On Monday we unpacked, inventoried, and repacked meds that arrived at Peggy's Clinic from the International Dispensary Association, which was exciting and fun. The drugs have been expected for the last half year, so they were a welcome addition to the pharmacy. Tuesday was back to the strike, but Charles showed up (briefly) and we were able to see patients for most of the week. On Friday the records department stopped handing out patient charts completely (even to the ED), which gave us a little scare, but we decided that if we didn't help out, the patients would just get seen by other doctors without their chart, so we kept functioning as an "urgent care clinic" extension of the ED delivering a lower standard of care than would be expected in the US. Peggy told us to start looking into soliciting drug donations from a number of international relief organizations, so that has kept us somewhat busy in the afternoons. We also spent an afternoon delivering drugs to a small clinic in Diamond Rock that Patrick Connell and the Clinica Esperanza folks helped start, which was an interesting excursion. Yesterday there was a fundraiser for Peggy's clinic in Coxen Hole, and we helped out (a little) and ate snacks (a lot) for much of the afternoon. I am optimistic about soliciting these drug donations and hope that something positive comes out of our work. Also, we spent Saturday morning crunching some demographic data collected by Krista Bruckner about La Colonia, which was interesting and different. Alright, this is a concise journal, but hopefully it's sufficient. And in a special sneak preview of next week: I'll let you know that the hospital strike ended over the weekend.

Christine Journal 5

Things were good in Peggy's clinic last week. I continued interpreting for a doctor who doesn't speak Spanish, and also got to start triaging, which was fun. I also helped Betty out in the pharmacy. On last Monday, the clinic finally received its huge shipment of medications, which was very exciting. We spent the day putting them away and preparing boxes to bring some out to Diamond Rock and to Dr. Black on the mainland. It's great to see how much people collaborate here. We're already running low again on some meds we got in just last week, since the need here is so great for some things.

Max and I have started looking into more long-term donations, soliciting different organizations and drug companies for donations to Peggy's clinic. Hopefully some of those will come through, since as the clinic grows they're really going to need some constant donations.

The clinic was really busy last week since the hospital's been on strike (although it finally ended!).

Max and I have also been doing some work with Shelli on both her tutoring program and a survey that Krista and Dr. Patrick conducted this summer in La Colonia. The tutoring is scheduled to start next week, which is exciting! We have worksheets made up for each tutor to do with their student, based on how they did on the diagnostic test. There has been a lot of interest in tutoring from people living on the island, so hopefully there will be a good group of people.

The survey conducted this summer includes basic personal information, like education level, birthplace, length on the island, etc. as well as medical information. They surveyed about 100 families, and we are in the middle of compiling their data to see the trends. I'm really looking forward to getting a better sense of the community when we get all the numbers together.

Christine Journal 4

I’ve had another enjoyable week in Peggy’s Clinic and doing odd jobs in the afternoons. In clinic, I’ve still been mostly helping out in the pharmacy and doing some interpreting for a doctor who doesn’t speak Spanish. I’m still learning more and more every day, and the work has been really rewarding so far.

One young woman I interpreted for was about 5 months pregnant and wanted to get a pregnancy check-up. When the doctor asked her where she was planning on having the baby and if she was going to breast-feed, she explained that she was on the island without any family and was working full-time, so would go to La Ceiba to have the child, breast-feed for a couple weeks, and then leave the baby with family indefinitely and come back to the island to work. It made me really realize how hard it can be for women here to raise children, especially when they are not near family members.

Another woman came in presenting symptoms that seemed like she probably had kidney stones, but the only way to really tell was to send her to get an ultrasound in La Ceiba, an expensive ferry ride from the island. I’ve come to realize how limiting it is to try to provide high-quality health care on an island that has very limited resources when it comes to testing, etc. Often we can get the people over to the mainland for free or a discounted rate, but they still need to sometimes spend the night there, get transportation to and from medical centers there, etc.

I went in to the Global Healing clinic on Wednesday because Peggy’s is closed, and they are still on strike. Dr. Charles also hadn’t come in, which was stressful for the new attending, as she really wanted to have someone there who knew the system and population better, which is completely understandable. Hopefully the next couple of months will go smoothly.

Max and I have also been taking care of odd jobs for Miss Peggy, including making a poster for a conference they went to in Copan Ruinas, grading diagnostic tests to get ready for the tutoring program, and dealing with special cases. I went to La Colonia on Friday to find a girl with a club foot, as Dr. Raymond wanted her to come into Miss Peggy’s clinic so he could refer her to the surgeon in the public hospital. I found the mom with the help of Irma’s daughter, and she seemed rather disillusioned, since apparently the last time they tried to get the girl to a medical brigade on the mainland, it all fell through and she didn’t really know why. I was happy when she still came in to the clinic on Monday, though, as she’d promised. Hopefully it all works out this time.

Other than that, I’ve been enjoying island life, although we had a big rainstorm all weekend. We did make it out to the east end of the island, which is beautiful and so much different from the more touristy west side.

Max Journal 4

Monday was some sort of holiday from the hospital, although the hospital was closed anyway for the strike, so the Grubers told me to spend the day at Peggy's. I worked in the pharmacy and got to triage a couple of patients. I also took a trip up to La Colonia with Peggy and Irma to track down a child with a congenital skin/eye condition that will (hopefully) visit a pediatric ophthalmologist in El Progresso in the beginning of next month. I am trying to help out with the coordination of that visit as much as possible, and it has been rewarding so far.

Tuesday was the Gruber's last chance to reorganize the clinic a few times, so we did that and saw patients referred from the ED. Anita Kandiar, the new attending, arrived and Howard showed her around the hospital.

I also had the opportunity to try to coordinate transportation of a hydrocephalic baby and her mother and grandmother to Tegucigalpa. The grandmother came to me asking for assistance, and before I really had all of the pertinent information she had dragged me to the mayor's office and the police chief's trying to resolve some personal conflict of hers. I am still trying to assist them in getting to Teguc, but I am a bit more skeptical about taking people's requests at face value.

The strike has also been a point of recent disappointment. At the end of this week more workers decided to at least come sit (or sleep) on benches in front of the hospital to increase their visibility, as opposed to staying at home as they had for the previous week and a half. Every time I ask a striking worker what the demands are, I get a different answer, and every time I ask if any progress is being made, they shake their heads and say that this is a "long-term" strike. I am feeling constrained by a cultural divide, because in the United States I wouldn't hesitate at reprimanding both the union and the hospital management for making so little progress in so much time, but I resign myself to the fact that everyone here comes from a different cultural background and has different standards of what to expect from a public hospital. A couple of children died in the hospital this week for not-completely-clear reasons, and I can't help but think that the disorganization with the strike and some degree of negligence were involved.

I don't mean to sound too negative, but I think many people view this strike as a big setback for public health on Roatan. Anita is great and I am still learning a lot, but I can't quite imagine what the next two months hold for the Global Healing clinic in Roatan.

On a slightly different note, we are now in the midst of rainy season and I happily spent my Saturday watching a movie and baking cinnamon-raisin bread with Christine and another volunteer. The community of volunteers here is great and we are constantly bouncing our impressions of Roatan's health off of each other to learn more

Christine Journal 3

We’ve been here a week now and I am feeling very settled in – we’re already seeing volunteers come and go, and I am so amazed by Miss Peggy’s hospitality for the amazing number of volunteers she takes care of throughout the years.

The highlight of this week was being busy in the afternoons, as we finally got a project for the week. One of Shelli’s friends was visiting for the week to teach an SAT preparation class at a bilingual school in French Harbour. The class had 9-12 graders in it, some of whom wanted to take the SAT and some of whom didn’t want to have double homework the next week (the other option). They were a great class though – always paying attention and very respectful. The class was after school for two hours a day, and I helped out for the five days they had class. I didn’t really know what to expect, but soon discovered how hard it was to teach an SAT prep class to a class of people with such different levels (9th graders who hadn’t seen algebra before to 12th graders who had seen it a few years before) and who didn’t know a lot of the obscure vocabulary the SAT tends to put in the verbal section of the test, as well as all the cultural references that the word problems have. I quickly noticed that the kids were overwhelmed by the test, as they had never taken it before and were not used to the types of questions they asked.

We spent the week giving them practice problems to do alone or in groups, and then went over the answers as a class or in small groups. I soon changed my expectations for how much I could do in the week, and began focusing less on the individual problems we went over and more on just emphasizing the idea of going to college, whether in the US or elsewhere, and in the need to study for the SAT if they were going to take it. They’re going to start individualized tutoring with kids soon, which I think will be much more effective than the larger group.

Clinic has been going really well. I’d been helping out in the pharmacy, but we had two doctors last week who don’t speak Spanish, so I got to do a lot of interpreting, which was really interesting. I loved getting to see the visits with the doctors and see all the steps they take to diagnose different diseases. And I enjoyed getting to chat with the patients as we waited for the doctor to check tests or consult with other doctors. One thing that I found frustrating was the lack of advanced medical care and equipment available on the island, as a lot of patients who need more specialized care have to be referred to the mainland, which is an expensive trip to make. For example, one woman I interpreted for probably had kidney stones, but without an ultrasound, there wasn’t any way to really tell.

We got to meet the Grubers this week, and it was great to spend time with them and hear about the beginnings of the pediatric clinic and how it runs, etc.

This coming week I’ll be in Miss Peggy’s clinic in the morning and have yet to fill my afternoons, so we’ll see what kinds of projects are needed – hopefully I’ll be busy!

Max Journal 3

This was a busier week than the previous few despite the fact that the hospital strike continues and we've seen very few patients in the clinic this week. Having the Grubers around has been a treat, although we have reorganized the same shelves in the clinic several times since they arrived. Alice has kept me busy reorganizing the filing cabinets, the computer, and all of the medications and medical supplies. I also worked on updating her physician orientation guide with current information about the hospital and the island. I have been meeting with technicians from Paradise Computers to try to install some new internet connections in the hospital and repair the old ones that aren't working, and that has given me the opportunity to meet more hospital employees and explore a bit.

The most interesting cases we saw this week were a child with hydrocephaly and a cleft lip and palette and another child with a congenital skin/eye/hair condition that thusfar defies diagnosis. The child with hydrocephaly came to the hospital (referred from Ms. Peggy's) to receive pre-surgery testing because Peggy wanted to send him to the mainland to meet an American surgical brigade to repair his cleft palette. The child came to the clinic to receive an ultrasound (by one of Peggy's volunteers, an ER resident) and then to get all the necessary labs. I spent a full morning walking with the mother and child between offices to get the necessary paperwork and labs, and in the end they did not go to the mainland to get the surgery because of a paperwork hang-up. Dr. Breslin and all the other folks in the clinic have been working hard to resurrect our patient follow-up system (the patient list you sent me was from 2005), and we already have several patients entered into the new database.
The other interesting case was an 11-month old girl with a mysterious icthyosiform erythroderma and congenital cataracts. The doctors sent some photos to a pediatric dermatologist at Boston Children's Hospital and came up with a differential diagnosis, but the patient had already been sent home. A social service doc referred the patient to a dermatologist who was visiting Woods Medical Center on Saturday, so I spent several hours waiting for the dermatologist to try and intercept the patient yesterday. I was doubtful that the patient was going to show, so I spoke with the dermatologist and exchanged contact information with her in case she did see the patient later in the day. I am still hoping to track down the patient to give her mother more information and resources to visit an ophthalmologist on the mainland and possibly get cataract surgery by a medical brigade in November.

In the afternoons Peggy has kept me busy with odd jobs and errands and I spent three days tutoring high schoolers at a bilingual school in French Harbour with one of Peggy's volunteers and Christine. Hopefully this week I'll make it over to the day care and hopefully develop some more regular projects. Also, in a few weeks the tutoring should turn into at least a two-afternoon per week job.

Christine Journal 2

I've been working in Clinica Esperanza this past week, while Max has been in the pediatric clinic (well, most of the time - see his email for the strike update). On Monday and Tuesday, Betty, the normal pharmacist, was out of town, so a nurse and I were in there all day trying to figure out where meds were kept, etc., but we ended up finding everything eventually and got all the meds out. I've also been helping to enter patients into the new database they're making, which includes looking through old charts and just filling out online records. They go back to 2005, so there's a lot of work to do!

On Wednesday, I went in to the public hospital with Max because the clinic is closed, but I woke up with a cold, headache, and nausea, so didn't last long. I did get to go on the morning rounds with Kristen, the current pediatrician, and see her visit two newborn babies and see the rest of the hospital for the first time, which was great. I'd never seen a newborn before, so that was interesting! However, after the rounds I was feeling really sick, and the hospital staff was on strike so there were very few patients, so I got a cab and went home, sleeping for pretty much the rest of the day.

On Thursday and Friday, I was back at the clinic, and helped again in the pharmacy, this time with Betty back. The doctors have been really great about calling me in to see interesting cases, or to help them out a little bit, which has been so rewarding. I listened to a lung crackle with Dr. Charles, and then saw the patient when he came back to get the fluid in his abdomen drained - it filled a bucket that probably held a gallon or more of liquid! I also helped a doctor clean and re-wrap a patient's fingers that he had sliced pretty badly, and saw a boy who had a thyroglosal cyst.

We've still been pretty bored in the afternoons, waiting for either the tutoring to start up, or someone to give us an idea for a project, since we're ready to get going. As I said earlier, Miss Peggy is back now and has given us lots of ideas, but we still need to really sit down with her and decide what would fit our interests, time constraints, and the island's needs the best. I definitely want to make sure whatever we do is sustainable and practical for our skills and time here. It sounds like the tutoring is starting up this week (or at least SAT tutoring is), there are schools at which we could teach English or basic health, among other things. We'll definitely let you know when we decide on something.

That's about it for the week. Everything has been going really well and I think that we're in for a wonderful few months. I'm really looking forward to everything we'll be doing!

Max Journal 2

This week has involved more great learning opportunities for both me and Christine. Monday was a heavy patient load at Global Healing, so I stayed busy all morning triaging and inputting information. On Tuesday I showed up a bit earlier to the clinic, hoping to prevent getting overwhelmed by patients, and we ended up seeing only about six kids. Wednesday I arrived at the hospital to find the Preclinica closed and surprisingly few patients in the clinic. After Kristen and Charles arrived, we ascertained that the hospital workers (or some subset of them) were on strike, so we would be unable to get patient files and see patients. The strike continued until the end of the week and I am still not sure if it will be over tomorrow.

On Wednesday, Kristen gathered the social service doctors together to give a lunchtime lecture on meningitis, which went really well. While she was working on organizing that, I assisted with an American medical brigade called Hearts in Motion that was using the hospital for OB/GYN, dentist, and general internist consults. We let them use our clinic because we weren't using it, and I stayed there helping to translate and deal with patients. Probably the most interesting case that I saw this week was a woman who came to the brigade for a medical report to present to the police after being attacked. We couldn't give her a full medical report without X-rays (there was a possible fracture and radiology was closed due to the strike) and we didn't know what the form should look like, so I just wrote out a semi-official looking letting stating our findings and referred her to Woods Medical Center (on the public attorney's recommendation). I was sorry we couldn't help her more and it definitely made me realize the kind of proaction that is necessary in that sort of situation. We spoke with the woman for a while and gave her antibiotics for a possible infection of the wound site, but I couldn't leave the clinic to accompany her to find an X-ray, which I would have liked to do. Maybe that was the first opportunity I had for case management and I passed it up, but I'll try not to let that happen again.

On Thursday I returned to the clinic to find that the strike was still going on, so Kristen and Charles went to check up on kids in the day care while I did an inventory of soon-to-expire meds.

Each day after I got out of the clinic, I went to Peggy's clinic to help in the pharmacy there, and on Friday I didn't go to the hospital at all, staying at Peggy's clinic instead. Christine and I have also been working on a poster for Clinica Esperanza. It was a good week despite the strike and next week will surely be an adventure too.

This weekend Peggy and the Grubers arrived, so hopefully we will hit the ground running with a public health project before long. We have been trying to figure out where to work in the afternoons, but nothing has realized yet. This evening we will meet Howard and Alice for the first time, so I look forward to them putting us to work.I also spent a number of hours this week trying to track down a dog that bit me on the beach, but I'm not worried about it and I am getting PLENTY of medical advice!

Christine Journal 1

It’s been a week now since we arrived on Roatan, and I’m loving meeting everyone and getting a sense for how things happen here. We were met at the airport by Edwin, the intern before us, and Shelli, who’s working in Miss Peggy’s clinic, and were quickly introduced to all the other people working down here. There’s a really great community feeling among all the volunteers, and I’m excited to learn from everyone who’s working with both clinics (Global Healing and Clinica Esperanza) in different ways.

After moving in to our apartment on Sunday, we were ready to start in the clinic the next morning. We arrived early to find many, many people already waiting outside to see the doctor, and have been told that they arrive around 6 am. I was immediately struck by how different the hospital is from anywhere I’ve been in the United States – no running water was the biggest surprise. I think it will be really interesting to really get to know how things work there over the next three months. Edwin taught us how to triage the patients, where we could find everything, and how to fill out forms at the end of each day. There is an American doctor and a Honduran doctor there right now, and they’ve both been really open to explaining different things to us. It should be a really great learning experience to work so close with them.

I’ve loved all the patient interaction we get as the triagers. It’s been interesting to see the different ways that the kids react to the triaging. Some think it’s fun to stand up on the scale, while some kick and scream and cry when we try to weigh them. I’m looking forward to getting to know people better as time goes on.

Max and I have realized that having two of us at the Global Healing clinic does not really achieve much more than have one of us there, so we both worked at Clinica Esperanza one day last week as well. I went in on Friday, and Alex, a volunteer, helped me learn the ropes of the pharmacy there. That’s probably where Max and I will primarily work when we’re in that clinic. It’s amazing how many donations they receive and how smoothly everything seems to run!

In terms of our public health projects, Max and I are still trying to get a feel for what’s available and needed, especially since Nurse Peggy has been out of town. I’m really looking forward to finding a few projects for the afternoons, though. It seems like there are a lot of tutoring opportunities, and I’m sure there are many other things that Nurse Peggy can tell us about when she’s back.

In our free time, we’ve been enjoying exploring Sandy Bay and other parts of the island, as well as snorkeling, cooking, and getting to know other volunteers and workers at the two clinics.

It should be a really great three months!

Max Journal 1

We started work on Monday with both of us in the clinic with Edwin. He showed us basically what he does each day, and we took turns interviewing patients. On Tuesday all three of us went to the clinic again and did essentially the same thing.

On Wednesday Edwin left for El Salvador so Christine and I both went to Global Healing to make sure we remembered how to do everything before we left each other alone in the clinic. Dr. Breslin gave me a very short tour of the hospital and I was very grateful to get a little more of the "big picture" of how the different departments there interact. I would still love a more complete tour by Dr. Charles or anyone else, but that will probably come when I need to get something done and I'll just figure it out for myself.

On Thursday I went to work in Clinica Esperanza because the pre-med volunteer there was taking a day off and I wanted to see the place. I spent the day in the pharmacy with Betty mostly doing data entry and learning how the clinic works. I assume that once I work there a few days I will be able to help measure out prescriptions and possibly translate for the nurses and doctors, which will be interesting. It was also enlightening to see how the clinic takes in large quantities of donated medications and incorporates them into their pharmacy. I noticed that the clinic there will take peoples' personally prescribed medication, which is different from Global Healing but seems to make sense. For both the Global Healing clinic and Clinica Esperanza I am slightly amazed by how they keep consistently providing quality services with what seem like inconsistent supplies of medications, equipment, and volunteers. For most of the non-profits that I've worked with in the states, "turn-over" a very sore point and constant reason for concern, but here these clinics seem to be built around an acceptance of extremely high turnover with volunteers coming and going every month, and they seem to function alright. Also, with the medical supplies that seem to come in randomly (except for the few things that the clinic buys outright), somehow prescriptions manage to get filled one way or another. It's like stability out of chaos. Very cool, and not at all easy to pull off, but I look forward to learning more how it all works.

On Friday I went to the Global Healing Clinic and Christine went to work in Clinica Esperanza. We had almost 20 patients so we stayed quite busy. I am enjoying practicing and improving my Spanish and haven't run into any insurmountable barriers, although my Spanish is definitely a long way from being as fluent as Christine's. I look forward to practicing and improving more over the next few months, and I hope that I can be effective if I am put into the position of translator. I was expecting one patient whose chart had a number of notes from previous Global Healing clinic interns, but the patient never came to the clinic. The boy had some sort of seizure/muscle spasm disorder for which a previous intern considered coordinating an expensive surgery in San Pedro Sula, but the charts say he is responding well to seizure medication. Although I never saw this patient, it reminded me of the "case manager" portion of the orientation packet.

Christine and I decided that we will work most effectively if we each have a large chunk of time at each clinic, so for the next month and a half I will work in the Global Healing clinic each morning and Christine will work in Clinica Esperanza each morning except Wednesday (when they're closed), and then we will trade places. I think this will provide the most continuity for each clinic and will allow us to get to know each place well.

In the afternoons we have mostly been getting to know the area and swimming a lot. Because Peggy has been out of town, I feel like our "public health project" questions haven't been getting very straight answers. I know it is up to us to arrange something, so we will keep asking around and exploring possibilities, but it may take a little while for us to find a project even though I think we both would like something to keep us busy in the afternoons. It seems that Edwin was playing/coaching basketball with Dr. Raymond's team in the afternoons, but we got rained out while he was here and now I don't know where the courts are and I'm honestly not much of a basketball player. Shelli (the long-term volunteer living in Peggy's downstairs apartment) has mentioned several times a tutoring project she is starting up, but I don't know when that will come to fruition. Also Peggy mentioned via email the possibility of us teaching a health class, but she's not here now and I haven't heard anything about it from anyone else. We will keep asking around and I hope that by the end of the week we'll have a better idea of how we can contribute to the health of the island with our afternoons. For the time being we are learning a lot about how things work here and enjoying some fabulous snorkeling (swam amongst a pod of ~30 dolphins this morning, including at least 4 babies!).

The White Diamond Luxury Apartment is very luxurious and probably the nicest place I'll live in the next decade. It's a little more than Christine and I were expecting to pay, but the landlord is nice and we'll just have to have a lot of guests. The clinic seems to be in generally good shape and I am looking forward to meeting the Gruber's and Nurse Peggy soon.

Tonight we are having several volunteers over for dinner, so we've got some cooking to do, but if I left out any pertinent information or used a completely inappropriate format for this email journal entry, please let me know and I'll change it. I imagine that in the future I will present more case studies and reports on my projects outside of the clinic, but for the time being I'm still just getting my bearings.