Sunday, October 28, 2007

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.

Monday, October 22, 2007

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.

Monday, October 15, 2007

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

Sunday, October 07, 2007

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.