Sunday, July 29, 2007

Vanessa Journal 1

It’s the end of my first week here in Roatan, and I’ve already made lasting memories. I’ve grown accustomed to many things that are part of daily life on the island: random power outages, putting on mosquito repellent before stepping outside, the sound of barking dogs early in the mornings, bargaining with the taxi drivers for the best fare. Sarah has been showing me around the island, giving me her best advice and recommendations, as well as training me at the clinic. We’ve been seeing about 20 patients a day at the clinic, and the most common conditions so far have been diarrhea, scabies, viral syndrome, and fever. I’ve noticed that most of the mothers request for the doctors to check their child for parasites, as well as for vitamins because they believe their child is underweight. In several instances this week, the child has actually been in a healthy weight range for his/her age. Therefore, Sarah and I have filled out the growth chart in front of the mothers and explained what it means. At times, the mothers seem to be in disbelief, so we’ve explained that their child does not have to appear chubby in order to be healthy.

Dr. Welcome and Dr. Rhee have been very helpful and welcoming. They take the time to answer any questions and explain the medical conditions that are presented. Dr. Welcome has been courteous enough to help me translate certain medical terms into Spanish. Dr. Rhee has particularly explained about fever in babies and infants. He explained the differences between treating a baby that has a fever in the United States and here on the island. In the States, he explained, parents have easy access to a thermometer and know right away if their child has a fever. Here on the island, however, parents may not have access to a thermometer and usually rely on the fact that their child feels very hot, as most of the parents have told us here at the clinic this week. Dr. Rhee also explained that with the limited resources here, doctors must ask for a blood test and stool test here, which is different from the more advanced treatment in the States.

We’ve also started on Sarah’s research project this week at clinic. Sarah thought of an idea to see how well parents understand the doctor, as well as their child’s condition and meds. We’ve been questioning a few patients a day. We’ve found that getting to the clinic a little earlier gives us more time to triage and survey after the patients see the doctors. From the surveys so far, we’ve noticed that some mothers do not know what condition or prescription they were given. Instead, they’ve simply shown us or pointed at the paper with the name of the medicine on it. However, there have also been mothers who show to have a clear understanding. These mothers have used terms such as “virus” and have been able to tell us exactly when and how to give the meds. I’m going to continue doing surveys in the next couple of weeks to gather more research.

Aside from time at the clinic, Sarah introduced me to everyone at the daycare she has been volunteering at. I’ll be helping out here as long as they need me – they are expecting a family of volunteers to arrive sometime in August. Sarah has also introduced me to Moises, who I will begin tutoring this week. I’m also going to start teaching English to Maria Cristina. She is heading to the States because her daughter is having surgery, and Peggy explained to me that she wants to know at least some basic English to help her get around.

We’ve also had time to relax and enjoy the island this week. We rented a car and drove to the East End of the island to an isolated beach. From there we had dinner at a resort nearby – there were no other guests there – and our table was on a deck overlooking the water and the sunset. We have been going to dinner in West End frequently (so far, our favorite has been the Creole Chicken Rotisserie). We’ve gone to West Bay Beach and swam off the dock by Peggy’s. We’ve also spent quality time with the locals, who have all been so nice and welcoming. Sarah and I bought baleadas and spent time with Nereyda and Tania just talking. We’ve also spent time with the local boys. One day, we spent a few hours with them on the dock. They told us they would help us with our Spanish if we started teaching them English. They began to quiz us on our Spanish: they pointed at things (the moon, sky, water, dock) and asked us to say the word in Spanish. They also asked us to pronounce words with double R’s (apparently we have difficulty rolling the R’s in Spanish). We then began to teach them simple words in English. They’ve been asking me when our first official English class is going to be, so I’ll probably start with them this week. I just need to coordinate a time – half of the children say they end school at noon and the other half say 5.

We dropped Sarah off at the airport yesterday and now she has officially passed the torch to me. I’ll keep you updated on everything that happens within the next couple of weeks. Now I’m off to relax and read some more of the book Peggy recommended – Mountains Beyond Mountains.

Thursday, July 26, 2007

Sarah Journal 3

Last weekend, we sadly said our goodbyes to Dr. Gruber, Mrs. Gruber, Dr. Toledo, and Natalie, all of whom have been with us for many weeks. But with this farewell came the arrival of our new attending from New York, Dr. David Rhee. He has been a wonderful addition to the clinic, and things have been running smoothly since his arrival. After working in the clinic for three weeks, I’ve begun to notice certain trends in the different illnesses we treat – scabies, respiratory viral infections, impetigo, and intestinal parasites are among the most common – and I’ve learned to recognize different skin conditions after seeing so many cases. One of the most exciting aspects of my work in the clinic here has been working with Dr. Rhee as he explains the children’s’ conditions to their mothers. I often get a chance to help explain Dr. Rhee’s diagnosis to the child’s mother and how exactly mom should give the prescribed medicine to her child. It’s been extremely fulfilling getting to be the one who reassures mom that her child is healthy, or that he will feel much better in a week after taking the medicine we prescribe. Just yesterday, for instance, a mother brought her children in for a follow-up visit to make sure they no longer had intestinal parasites. When I told her that her two baby boys were perfectly healthy and that their residual stomach pain would pass within a matter of days, her face relaxed into a smile. Then we laughed, talking about how silly her two boys were, and Dr. Rhee and I sent her on her way with a month’s supply of Flintstone chewable vitamins and some stuffed animal toys. Even simple cases like these can be rewarding, making every day in clinic a fulfilling experience.

Through my experience I’ve found that sometimes when I explain a child’s diagnosis to his mother, mom simply nods her head to signal that she’s understood, when in fact she doesn’t quite understand how to properly give her child his medicines. So I’ve learned that the most effective way to make sure mom understands everything is to ask her to explain back to me the doctor’s advice and how she is going to use the medicines when she goes home – only then can I rest assured that she understands everything I’ve told her. Working with moms who sometimes don’t understand everything when it’s first explained has made me realize that it would be a good idea to find out just how well the patients in general are understanding the doctors and their directions. So I began brainstorming with Dr. Rhee about a good way to assess this level of understanding, and we agreed that a great way to do so would be to conduct a quick interview with patients after they finish seeing the doctor, to learn how well they understand their child’s condition and to ask them to explain to us how they will be taking their medicines. From there, we can use the surveys to provide the doctors with feedback about the things they are doing well and those they can work on. Hopefully, this little project will be a good way to help our clinic continue to improve and to ensure that we are providing our patients with exceptional care.

Wednesday, July 18, 2007

Sarah Journal 2

I’ve been here two weeks now, and I finally feel like I’ve fallen into a good routine in clinic: triaging patients, shadowing the doctors, entering patient information into the computer. Earlier this week, I was able to accompany the doctors to see the newborns, and I got a chance to hold a day-old baby girl: she was wearing a little red dress and was so adorable! Seeing these mothers and children, I realized that I had never seen a live birth. After meeting and speaking with one of the ER docs, Dr. Avila, he let me know that I could accompany him to see a birth if I wanted to. So, on Thursday afternoon when he was on call, I shadowed him while he delivered a baby! It was quite an exhilarating experience – watching a birth for the first time. I have to admit, it was very different from what I had envisioned. I watched as the mother pushed and pushed; she was exhausted and in a tremendous amount of pain. In fact, here in Honduras they don’t give these mothers anesthesia; the birth is completely natural. I was pretty shocked when I learned this; later I asked Dr. Avila and learned that the mothers cannot receive painkillers because there are not enough anesthesiologists available. As I watched the birth, I was amazed at how quickly the baby delivered – it was the mom’s second child, so the baby came out pretty easily. After the baby came the long umbilical cord, white and tough. The nurse clamped the cord and quickly cleared the baby’s small mouth and nostrils so that he could take his first breath. I went over to the baby, letting him wrap his teeny fingers around my pinky: he was so small and adorable. Next, the doctor delivered the placenta, a large, bloody mass. Finally, the doctor sutured up the small vaginal tear that the mother had suffered during the birth. The doctor hummed happily as he sewed up the tear. It was amazing to me how routine the birth seemed to the doctor, and how new and almost foreign it had been to me. Here I was, still in a little shock after the entire process, and the doctor singing to himself as if the whole procedure was as simple as tying one’s shoe. At the end of it all, I felt extremely lucky that I was able to sit in and watch something so amazing. I think this experience is a perfect demonstration of how generous and accommodating some of the doctors in this hospital are; if you are curious about something, just simply ask and you might be able to sit in on an exciting procedure or learn something interesting you never knew before.

In my free time, I’ve continued to volunteer at the Daycare Center in Coxen Hole; this week we set up little easels outside, and had the kids paint with tempera paint. It was a joy to see the little kids in their oversized smocks so intently concentrating on the painting in front of them. When they were finished, they were each so proud of their own paintings and eagerly asked me to help them write their names on each of their pieces of work. After the daycare, I return to my apartment to teach Moises English. This week I began teaching him how to conjugate simple verbs like “to run,” “to see,” and “to swim.” It constantly amazes me how quickly he learns and how excited he gets when he is able to form a sentence in English on his own. He is a very bright kid, and I am lucky to be able to work with him.

Sunday, July 15, 2007

Natalie Journal 2

I’m sitting on my porch enjoying my last morning in Roatan. We had a big storm last night, so today is humid but painfully beautiful as the skies are once again their inviting light blue. I can’t believe how fast these two weeks flew by and, although I’m excited for what’s next, I am sad to be leaving this peaceful, natural paradise.

I’ve become a little complacent about the DEET recently and have been rewarded with my fair share of bug bites, conveniently located on my joints for increased discomfort. So I suppose I’m taking a little piece of Roatan home with me (though hopefully not a lot of Roatan home with me in the form of dengue or malaria). I’m happy to report that my GI problems finally resolved, just in time for me to leave. I think my body has adjusted to life in Roatan just in time for my mind to re-adjust to a bustling life in the States.

My two weeks here have been simply amazing. Being surrounded by passionate health care workers, both locals and foreign volunteers, has reinforced my desire to become a physician and given me incredible insight into future career paths in international health. The physicians I’ve worked with give so much of themselves to the community, not just doing everything possible for the children coming into the clinic, but dedicating their extra time to community projects - teaching at the public schools, doing health screenings at the daycare, teaching English in the community. Even during off hours, it seems that all we talk about is improvements to the hospital, teaching efforts, community projects, acquiring meds for a specific patients.

In working with the leaders of Global Healing for the past two weeks, I have learned invaluable lessons about nonprofit work in the developing world. It is not simply enough to have the desire and the financial means to effect change; an organization must understand the existing system in precise detail and embrace the personalities and politics that it contains in order to make sustainable changes. Global Healing does just that by collaborating with hospital directors and leading teaching efforts in various hospital departments. Last weekend’s Surgical and Trauma Conference at Anthony’s Key Resort was a huge success, and the weekly Grand Rounds continue to be well-attended by hospital staff.

I feel very fortunate to be part of the Global Healing team, and I am so thankful for the opportunity to keep working in such a passionate and professional group. Returning to the RVPC as a medical student, I feel the same enthusiasm and hope I felt as an undergraduate. It has truly been a refreshing and inspiring two weeks. I wish I could stay longer, but I know I will be back again in the not-too-distant future and can take these lessons back with me in the meantime.

Wednesday, July 11, 2007

Sarah Journal 1

It is almost the end of my second week here, and I am happy to say that I finally feel settled in. Work at the clinic has been an eye-opening experience, and it has been a joy to speak with the mothers and children who visit our clinic. Usually our clinic is pretty busy, with about 30 patients coming in to see us each morning, but this week that number has dropped to about 15. With fewer patients to see today, I had the opportunity to make a difference in one mother’s experience when she walked through our door this morning. She wasn’t our patient, but she was confused and needed help. Her daughter had been seen at another clinic in the hospital for dehydration and vomiting and mom was carrying an array of medicines prescribed to her by her doctor. But after speaking with her for a few minutes, I could see that she didn’t understand her doctor’s instructions. She didn’t know what each of the medicines were used for or how much or how often to give them to her child. The pharmacist had written the dosages on each of the bottles, but the mother was illiterate and couldn’t read the instructions. Like many other patients who visit the hospital, the mother was too quiet to speak up and let her doctor know that she didn’t understand and that she couldn’t read. So in order to help her as best I could, I pulled the mother aside into one of our exam rooms and attempted to explain to her how to use the medicines she was given. I showed her how to prepare the electrolyte solution that her doctor prescribed for the child’s dehydration. To help her remember which medicines corresponded to specific dosages, I color-coded the bottles with markers and different shapes. The technique sounds silly, but when a mother is illiterate and color-coding the bottles is the only alternative you have to helping her recall the instructions you explain, it’s practical.

I think the most difficult part about helping this woman (and patients like her) was making sure my advice was well received. I needed to make sure that she trusted me as a person before she would listen to what I was saying. And I needed to be conscious that I wasn’t disrespecting her by seeming superior or condescending in my effort to help. In the end, I felt great about being able to personally help someone like her receive better healthcare. I felt like I had actually made a difference. And that is what I love about working with the Global Healing clinic. Patients are constantly popping their heads in with questions, and I am the one who gets to help them. Sometimes that means walking down the hall with a patient to track down her medical file when the hospital says it’s lost, or speaking up for a mother at the pharmacy when she is too timid to do so herself, or (as in this case) helping a mother understand the medicines and dosages she has been given.

After clinic closes, I make my way down the street to the daycare in Coxen Hole that cares for children whose mothers are busy working and earning a living. At the daycare, I lead arts and crafts projects for the kids to help them explore their creative sides. When I first began working at the daycare, I was impressed with the collection of donated crayons, markers, paint, construction paper, easels, stickers, and glue – all the supplies the kids need in order to develop their creativity and have fun. The kids are all so cute and very fun to play with and have warmed up to me very quickly. In fact, yesterday was only my second time going to the center, and as soon as I walked in the door, the kids were so excited to see me again and screamed “yay” all in unison.

In between these two volunteer jobs, I tutor Moises in English and spend quality time with the volunteers that work at Peggy’s clinic. I’m constantly trying to find new opportunities to make a difference – right now I’m looking to get involved in the local HIV clinic that counsels HIV-positive patients on the island. On the weekends there is also time for relaxation. I go snorkeling in the reef right off of Peggy’s dock and spend time at the beautiful beach in West Bay.

After my experience today helping the illiterate mother in clinic, I began to think that lots of mothers – not just her – must end up in similar situations, unclear about their medications and confused about their doctor’s instructions. In fact, I’ve heard from several other volunteers that this situation is all too common for patients on the island. Not that this is the doctors’ fault – often doctors must work quickly to see all of their patients, and patients often are too shy to tell their doctor they do not understand. It seems the hospital needs a better way to serve its illiterate patients, making sure they understand how to take their medicines. Perhaps the pharmacist could use a straight-forward color-coding system to indicate different dosages to illiterate patients or provide a slip of paper with pictures of breakfast, lunch, and dinner that are circled in order to indicate the time of day and frequency with which the medicines should be taken – anything at all to help lessen the number of confused patients who go home with medications they don’t know how to use. In my remaining few weeks, I hope to create a practical solution for the hospital and help implement it so that more patients receive effective healthcare.

Friday, July 06, 2007

Natalie Journal 1

Watching the sunlight skip off the gentle ripples of the Caribbean from my hammock, it’s hard to believe I am already a week into my two-week journey to Roatan. This is my third trip to Roatan and my first as a medical student. I spent one week here last year, but it was more of a Spring Break adventure in the jungle in La Ceiba and less of a clinical experience at the Roatan Volunteer Pediatric Clinic (RVPC) in the Hospital Público de Roatán. In the spring of 2005, I lived here for three months, working as the first student intern at Global Healing’s RVPC. Inevitably, being back here gazing at the same waves calls for some reflection.

First off, I am struck by how different it is to be a first year medical student than an undergraduate in a clinical environment. Sure, as a Stanford undergrad you think you know everything. Sure, as a first year medical student, I still know absolutely nothing about medicine. But is that entirely true? I feel like I held my own this week when asked to list common abscess culprits (staph aureus+Group A strep), perform a neuro exam (thank you, long painful neuro exam workshop), compare red reflexes to check for retinoblastoma in a newborn, and define the boundaries of cranial sutures. Meanwhile, it was an optimal learning environment for someone like me who loves to learn in a clinical setting. I learned how to hear pneumonia in an infant’s lower lobe, use an otoscope in the tiniest of ears, and make a baby poop huge amounts while taking a rectal temp. All without making anyone cry (Dr. Gruber says we fail if we make anyone cry!). It turns out that I have learned a little something in the last year. More importantly, it turns out that I truly love this profession and love to learn. And since we’re talking about scary, how frightening is it that I really love kids?

This week was certainly not all fun or pleasure or mindless excitement. We saw several tragic cases in clinic, and I can’t help but feel conflicted when I see a child with a condition that is so easily prevented or treated in the States. It’s certainly not the parents’ fault, and to think so is blatantly naïve. Attributing blame to anyone specific is inaccurate, but every case like this provides, in my opinion, empiric evidence for increased global aid by countries that have so much and contribute so little. There are an infinite number of cases that could be discussed, but it seems to be the ones with shock value that stick in your mind. On Wednesday, we saw a one-year-old boy with severe hydrocephalus and an array of other congenital deformities, including cleft lip and cleft palate. The child had limited feeding function due to his worsening condition and had become dangerously dehydrated. Suffice to say, this was a difficult case to observe as a medical student, for the child looked much like a slide from Neurosciences Pathology, and there was limited medical care to be provided at this point in time. Apparently, a brain shunt had been proposed in the past but not carried out for a variety of reasons. He was re-hydrated by our incredibly patient, compassionate physicians and treated for probable infections.

We also had a great number of successes this week due to the tireless efforts of Dr. Welcome, the Honduran/RVPC Fellow, Dr. Toledo from CHOP, and the Grubers, Global Healing extraordinaires. We saw over 120 kids in clinic this week, a huge increase from the time I worked in the clinic two years ago. Drs. Welcome, Toledo, and Gruber each taught me a great amount – after misdiagnosing my first scabies case as chicken pox, Dr. Welcome taught me the various presentations of scabies in kids of different ages and varying degrees of infection. Dr. Toledo taught me the art of a gentle pediatric otoscope exam and showed me classic ringworm presentation, among many other things. He was also very patient with me as I learned to take a blood pressure on a toddler (don’t laugh – it’s pretty challenging on a tiny arm). Dr. Gruber spent hours and hours explaining pediatric physical exams and diagnoses, while I taught him Spanish vocabulary and interpreted instructions for killing “bichos” (“bugs”) and “lombrices” (“GI worms”). I still can’t believe how fast a newborn heart beats, but I’m getting better at hearing the murmurs.

Outside of clinic, I have spent most of my free-time reading This Side of Paradise and reflecting introspectively as the afternoon sun rays reflect off the Caribbean back at me. A fellow med student from SC and I spent last weekend touring the island on a scooter (of which the scooter part I do not recommend to any future intern). We also met some powerful investors that invited us to dinner on the eastern side of the island, and this experience gave us a glimpse into the “other side” of Roatan, the one I do not see in the public clinic. The tourist culture of West End, where I am living, is the same as I remembered it – tanned bodies with foreign accents, mostly Canadian and Western European and Southern, drinking too much cheap, tasty Honduran beer and cheap, disgusting tequila. If I lived here for a longer period of time, I would surely live in Sandy Bay with the other interns, but West End will do for two weeks since USC is generously paying for my accommodations through a Travel Grant. As always, I am drawn to the Creole Rotisserie Chicken restaurant, and we’ve decided that it makes sense that the chicken here is the best in the world since there are robust chickens meandering on every road just waiting to be roasted for our culinary delight. I guess my days of Berkeley-Hollywood pseudo-vegetarianism have ended, for now.

I’m off to catch the last hour of sunshine with the kids at the pool, a “Coca-Cola light”, and my faithful Fitzgerald protagonist Amory Blaine. Thanks for reading - More to come next week.