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.