Monthly Archives: July 2013

An epidemic

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Saludos a todos!

We are on the last leg of our trip, and have learned so much about chronic kidney disease (CKD) in Nicaragua. The purpose of our project was to survey communities affected by CKD as well as gather data from medical records from an occupational health and research clinic in Leon, Nicaragua to determine the relationship between CKD and occupation. Though we began working on this project months before the trip–reading literature and analyzing mortality data–what we learned from the communities ravaged by this epidemic as well as the doctors working diligently to find the cause has been invaluable in comparison.
Here are some of the both interesting and upsetting things that we’ve learned during our time in Nicaragua:

  • CKD is affecting very young agricultural workers, mainly sugarcane workers, which is the primary occupation for men in the communities we surveyed. Many patients are in their early 20s.
  • Though chronic dehydration is thought to contribute to the development of CKD, some of the residents we surveyed were very aware of the importance of drinking enough water and took care to drink a lot of water throughout the day. However, others relied heavily on soft drinks, coffee, and juices as their main fluid intake, assuming that it is sufficient hydration.
  • Many members of the community are convinced that the water at the sugarcane plantation is contaminated with pesticides and are hesitant to drink the water. However, bottled water is too expensive for most of the community members to buy on a regular basis.
  • The families we interviewed were all so kind and open to strangers asking them health-related questions. We are so grateful for their participation because we learned so much from each family. Hearing the stories of CKD patients was incredibly moving and motivating. We hope to help a group of MS1s continue the project next summer, as there is so much potential for this project to continue and grow.
  • There are many projects in progress within Nicaragua–which is very hopeful–and there is room for students from many disciplines to contribute, as this is clearly more than a health issue. It has become a huge political, social, and public health issue that can benefit from a multidisciplinary solution.

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The mere fact that this is also a sociopolitical issue made us realize that, as future health practitioners, we will be caring for patients who might be in similar situations as those we met in Nicaragua. It is these experiences that will encourage us to approach health care in an interdisciplinary way, and utilize our resources to empower our patients and their communities.

We’ve learned so much on our trip and are extremely grateful to UCI and our PI, Dr. Anton-Culver. If you have any questions for us, please don’t hesitate to ask. We would love to talk about our experiences in Nicaragua.

-Sherry, Cristina, Cynthia, Alejandra, Krystal, and Kyle

Ultrasound Training in Escondido

On Tuesday morning, we set sail to the visit the community of Escondido. The beautiful scenery takes your breath away as you walk though the jungle and watch the little Ngobe kids playing in the rain. The experience is so powerfully moving that you forget you’re walking in the mud almost barefoot with the rain pounding down as you lug heavy equipment and supplies up the steep climb…

We were greeted by one of the town’s parteras, Liliana, who introduced us to the other parteras-in-training and pregnant women. We sat in a classroom and had a long conversation with the parteras about what a typical delivery is like in their community. What do they use for pain control? Does the mother give birth squatting or lying down? If there is an emergency, how accessible is a boat to get her to a nearby hospital?

As all our questions were answered we began to realize these women are much wiser, stronger, and smarter than we could have ever imagined. Single-handedly, they are running their community and serving as mothers, leaders, midwives, teachers, community organizers, and friends. The women took turns using the portable ultrasound on pregnant volunteers and we guided them through operating the machine and interpreting the images. They were taught about the criteria one uses to assess normal development of the fetus such as visible heartbeat, BPD, placenta location, and amniotic fluid volume. By the time we left the classroom, the parteras were well versed in these criteria, and had a basic understanding of how to use an ultrasound machine.

That day, we formed a powerful bond with these women who had welcomed us into their community with open arms. We know that this working relationship is going to continue to flourish as we hopefully send more UCI students to expose the community to ultrasound and lend support in fostering women’s health in the community. Because after all, these women are the backbone, strength, and future of Escondido.

Love,
Shaudee, Esther, and Sarah

Hola from Bocas Del Toro!

Hola from Bocas Del Toro!

We arrived on a rainy afternoon at the tropical island of Bocas del toro. We checked into the Floating Doctors warehouse where we are all staying. In the evening, we had dinner with our volunteer coordinator who showed us the ropes of the island and introduced us to our task for the next few days. While waiting for our colleagues to return from their multi-day clinic at a nearby island, we have been working on the infamous floating doctors sailboat, the Southern Wind, to prepare it for its next adventure on the sea! Not only are we learning about the ins and outs of sailboats, but we’re meeting inspiring people who live at the Marina on their boats and sail the world year round!

During the day, we visit El Asilo, a lovely retirement home community on the Caribbean sea where the residents welcome us with open arms as we walk with them, administer their medication, and work on our Spanish. We’re becoming fast friends and they have graciously invited us to attend Sunday Service with them tomorrow morning!

We’ve also had the opportunity to make house calls to a small community called La Solocion in Bocas where the residents live most humbly yet joyfully. Right now, we’re taking care of a young girl named Wendy, who suffers from Cerebral Palsy and is immobile. Lately, she’s been suffering from blisters and painful mosquito bites on her legs, so we installed a mosquito net above her couch and cleaned her wounds. Seeing the difference a Mosquito net and a few bottles of aloe vera can make has been humbling and eye opening.

We are so excited as we prepare for one of Floating Doctor’s most adventurous trips so far, the jungle of Rio Cana, a place no non-natives have ever gone before! We will keep you posted on the medical clinic that we are going to set up there during our 3 day long trip!

Love,
Sarah, Esther, and Shaudee

Rural Clinical Experience: Day 1

Date: 7/22/2013

Name: Jessamine Faustino

Entry 2: Day 1 of our Rural Clinical Experience!

I hit my snooze button about 4 times this morning. What a great start to a beautiful day! We started the day with “brekky” at around 8am in the MWC dining hall. The chef was very understanding when we told him we had only been given 2 dining cards for the 5 of us. He reassured us that the rest of us would be issued cards and there must have been some sort of mix up when distributing our keys. “No worries,” he said. So we had some breakfast and coffee. I would say each of us averaged 2 coffees each before leaving the dining hall. Little did we know, those coffees would not be the last of the day.

We had about a half hour before Kristy and Adam would be picking us up for drop off to our rural clinical experiences, so we decided to take a walk to a nearby field where kangaroos and deer like to roam around. Luckily, we saw 2 kangaroos hopping about the field! Supposedly, kangaroo kicks are so powerful they can kick your scalp right off or even crush your chest in! After seeing the wild kangaroo, we walked back to the colleges to collect our belongings.

Adam and Dr. Martin greeted us in the parking lot. Dr. Martin stopped by just to see us off. Thanks to him and the rest of the UNE faculty, we were blessed with this shadowing opportunity! Thank you, thank you, thank you!!! Once all of our belongings were packed in the car, we drove to the medical school to pick up Kristy and say hello to Dr. McKeown. We took some photos in front of the medical school and met some of the medical students in passing. Adam took us to a lovely café on campus where most of the faculty goes for coffee. While waiting for our coffees, we learned the differences between a “short black” and “tall black” and a “flat white”. Short and tall black is equivalent to a small and large coffee in the states, while a “flat white” is simply a coffee and milk without foam!

Alas we started our trek to Tenterfield, a small town about 200 km north of Armidale. It took us roughly 2 hours to get there. We stopped at a café for lunch before dropping off Nicole, James, and Chris at Tenterfield community hospital. They would be shadowing Dr. Rachel Harvey, who is the main GP (general practitioner) working at Tenterfield Community Hospital (she lives 3 doors down!). After saying our goodbyes, Tatiana and I headed back to Glenn Innes to drop off our luggage before starting our clinical experience. When we arrived at our accommodation, we could not believe where UNE had booked our stay. They had rented out an enormous 5-bedroom cottage (it was honestly more like a HOUSE) for us to stay in this week. Tatiana and I both chose the rooms with the queen-sized beds, since it would only be the two of us for the first 2 nights. In addition to the beautiful décor, every bed had electric blankets!!

Afterwards, we headed to East Avenue Medical Clinic to meet with Dr. Phillip Correy, one of the local GPs. GPs, or general practitioners, are equivalent to our PCPs in the US. Much like our system, GPs are responsible for referring patients out if they are in need of any specialized care. But unlike our system, GPs take on the role of pediatricians, geriatricians, and family doctors, at least in the rural areas. GPs see everyone! While shadowing Dr. Correy, we saw patients of all ages and a wide range of illnesses and medical conditions.

Tatiana and I arrived at the clinic around mid-afternoon and were able to see 8 patients with Dr. Correy. Of the eight patients, 2 were women in early and late stages of their pregnancy, 2 gentlemen had B12 deficiencies, 1 was in remission for Non-Hodgkin’s lymphoma, 1 gentlemen had a rotator cuff injury, 1 had a history of colon cancer, and the last gentlemen had a history of hemochromatosis but presented to us with a distended belly and diarrhea.

At the end of the clinic day, Dr. Correy took us back to our cottage and we set out for some groceries and food. Tatiana and I found a place to eat nearby called the Crystal Room, it was one of only places open past 7pm in the town. Glenn Innes has a main road with a variety of small shops and cafes that spans a quarter mile long. The town reaches nightfall by 7 or 8pm so we tried to get back to our cottage promptly after dinner.

A little background on Glenn Innes: The population is about 5000. The town is so tiny that it only has one hospital and one clinic to serve the entire population. I noticed that Dr. Correy knew each and every one of his patients as well as their friends and family. The fact that Dr. Correy knew his patients and their individual histories by heart, allowed his appointments to be more focused and brief.

Healthcare in small, tightly knit communities like this one is quite different from the fast-paced nature of healthcare that we are used to back home, but it is just as effective. These doctors have very little resources at their disposal to care for an entire community. It’s quite remarkable what they can do without all of the advanced medical devices we have back at UCIMC. It really puts medicine back into perspective for us young physicians-in-training. Reminds us that there was a time when we couldn’t just get CXRs, CTs, and blood test results STAT and that doctors used to only rely on their senses as diagnostic tools (perhaps not so much the tastebuds…hehe). It has been an incredibly eye-opening experience thus far, and I look forward to what the next day has in store for us.

Welcome to Armidale!

Date: 7/21/2013

Name: Jessamine Faustino

Entry 1: Welcome to Armidale!

I woke up this morning in the bustling city of Sydney and now I find myself in the quaint little town of Armidale, Australia. It was a short taxi ride from my hotel in Sydney to Central Station, Sydney’s main intercity/country train station. I thought it was a bit peculiar that the cost of my taxi totaled 20 AUS and the driver mentioned my fare included a “tip” for him. In the US, most Americans would agree that $20 for a taxi/shuttle to the airport is a steal, however, our country is only of the few places where tips are appreciated or even expected! Prior to my trip, my Australian friends and relatives reminded me time and time again to never, never tip. So with that being said, I’m pretty sure I got ripped off today, but it’s alright because I got to the train station safely and on time for my train. No worries. All part of the traveling experience J

 

After checking in my baggage, I had about an hour before Nikki, Tati, and James would be meeting me (Chris had a small traveling hiccup and would be arriving in Armidale before us all because he had to take a separate flight. More on that later. Haha). I decided to get some work done on computer before they arrived (Thank goodness for free wifi!!!!). After about a half hour of replying to some emails, I looked up from my computer screen and saw my Aussie companions, minus Chris! I was incredibly excited to see some familiar faces, especially since my partner and I had just parted ways that morning (He was going back home to SF and I was staying in Australia). We all hugged and yelled in excitement as if we hadn’t seen each other in years. Most of the excitement came from the fact that this was the first time all of us (minus Chris!) were in Australia together! Once everyone checked in their baggage, we sat and talked about our travels thus far. Unfortunately, due to some unscheduled maintenance, our train was about 30-40 minutes delayed. The 8-hour train ride through the Australian countryside was quite lovely. It was a fantastic way to see the rolling hills and green pastures of New South Wales. We spotted some cows, sheep, horses, and even kangaroos along the way!

 

When we arrived in Armidale around 6:50pm and the sun had already set. It was pitch black outside except for the small amount of light coming from the street lamps surrounding the small, Armidale train station. We were greeted by Dr. McKeown, Kristy, and Chris! They picked up our luggage and we drove to a pub nearby for dinner. We had our first meal in Armidale at the White Bull, a popular local bar that is usually filled with college students. At this time, most students are on winter vacation and won’t be returning for another week or so. On our drive to the pub, Dr.McKeown told us a little about the town and how healthcare works in Australia. Apparently 51% of the population has some form of private insurance and the rest rely on public hospitals funded by federal income taxes. GPs, or general practitioners, are the most common physicians you will see in the “bush” or rural parts of Australia. Specialists are hard to come by in those areas. Most people that need specialty care need to fly all the way out to Sydney!

After dinner, Kristy and Dr. McKeown drove us to where we would be staying, Mary White Colleges (their equivalent of dorms here at UNE). We were so surprised with our accommodations! We each have our own room, equipped with a TV, tea kettle, mini fridge, and a shared bathroom. Once we were checked in, Kristy and Dr. McKeown bid us farewell. After figuring out how to use our chargers and playing with the GoPro camera, we all went to our rooms to get ready for bed. Here I am, unable to sleep probably because I got some rest on the train ride but also because I’m excited for our clinical placements tomorrow morning! Tatiana and I are paired together and I know we are going to learn so much! Gotta force myself to get a bit of shut-eye. Cheers!

Pics from Panama

Pics from Panama

Ngobe Patients

At Floating Doctors clinics you are not presented with your typical American patient in a shiny white hospital room or doctors office. You typically find yourself with an indigenous Panamanian Ngobe under a “rancho” (a typical outdoor patio covered meeting place in these communities) sitting in old wooden school desk chairs. This might be their first encounter with a medical professional.. they might have walked a day or more to be at the clinic… some only speak the traditional “dialecto” of the Ngobe and need a spanish translator. No matter their circumstance or reason for presenting to the clinic they are all extremely grateful for our presence in their community and in search of an answer to what is ailing them.

Over the past few weeks I have encountered some interesting cases. I saw a young child with Leishmeniasis in a remote Panamanian community in the mountains. I performed an ultrasound on an infant who was failing to gain weight in the first few weeks of life for an unknown reason. I saw an older woman with a sixteen year history of hyperthyroidism and severe exopthalmos. I measured a blood pressure of 238/192 in an older gentleman who most likely had an adrenal tumor. I visited a pregnant woman with a history of preeclampsia in her home to do an ultrasound. I saw a child with impetigo and another with Herpes virus that covered the entire right side of his face. I listened to breath sounds of a seven year old with TB. I examined a three year old who most likely had a stroke as an infant and could not use his left foot or left hand or talk.

I learned first hand about the barriers of access to health care for these patients. Some were not able to get medications or make it to the hospital because they lacked the funds. Others would have to walk a day, take a boat for a few hours and then a bus to reach a hospital that might not even be able to treat them. Some distrust the health care system because of a previous bad experience or a story about the hospital that quickly spread through their small community. My time with Floating Doctors thus far has showed me how the health status of the community members in these remote areas directly reflects the prosperity of the community. They deserve access to health care and I am very grateful for the opportunity to be a part of a medical team that reaches out to these isolated Ngobe communities. The patients I have visited with in Panama as a medical student will forever hold a special place in my heart as I continuing my training and career.

Head and Neck Surgery at Mazumdar-Shaw Cancer Hospital

(This post is from Zach Chandy!)

We spent the last two days shadowing the Head and Neck Surgeons at Mazumdar-Shaw Cancer hospital, an enormous hospital on the outskirts of Bangalore city and sister hospital to Narayana Hrudalaya cardiac hospital. I spent the first day in surgery and the second day in the clinic. I choose to write about one surgery and the follow-up, which has made a major imprint on me.

The patient presented with a carcinoma of the anterior 2/3 of tongue that was infiltrating the floor of the mouth. The surgeon and the patient had decided to perform an aggressive surgery to remove the tongue, floor of the mouth, and larynx to extend his life expectancy to one year. By the time we entered the OR at 8:30 am, the surgeon had finished ligating the blood supply and was in the process of pulling the tissue out in one swoop. The scene was quite gruesome with the lower lip pulled off the mandible in an ungodly position. I couldn’t comprehend how the surgeon was going to patch up the wound and make it look somewhat like it did before.

The next steps were to remove a skin/subcutaneous flap from the lateral thigh and place it over the neck to close the wound, fashion a new floor of the mouth, and construct a new tongue that was somewhat mobile. I was amazed at how much care the surgeons put into each stitch and movement considering the surgery was estimated to take 14 hours. By the time we had left the OR at 4 pm, the surgeon had connected the skin flap to the skin of the anterior neck and the pulled it through the floor of the mouth to construct a new floor. He was using a large microscope to reconnect the blood supply to the skin. I knew the surgery would continue for many more hours.

The following day, our group went on rounds with the group of 5 attending surgeons. We saw 15 patients that they had operated on in the last week, but I found it hard to concentrate, because my mind was bustling with anticipation to see what had become of the patient from yesterday. When we approached his bed, I couldn’t believe it was the same patient. His jaw area and anterior neck didn’t look unusual except for the small gash in the lower neck where the surgeon had stitched the skin flap to the neck skin. When I peered inside his mouth, the floor of the mouth and new tongue flap looked expertly done. Only when I looked closely, could I tell the tongue and floor of the mouth were made from skin.

As we left the patient’s bedside, the surgeon mentioned the patient would regain the ability to swallow liquid and minced foods. However, he wouldn’t be able to talk and would have to breathe out of his trachea-tube for the rest of his life.

Although I knew the patient’s life would be much different after the surgery, I couldn’t imagine him getting any better care then he did with the doctors at Mazumdar-Shaw. The experience demonstrated how outstanding surgical care has become, and has inspired me to strongly consider surgery as a specialty down the line.

A cup of tea!

(This entry is from Tiffany Cho!)

We had the privilege of visiting a tea estate in Devala today. We learned that the five Adivasi tribes of Gudalur valley collectively own and manage the tea estate. Although our jeep ride up the mountain was rather perilous at times, we were constantly surrounded by beautifully lush greenery at every turn. When we arrived as far as the jeeps would take us, we met one of the ladies who works as a tea leaf picker and got treated to a glass of tea. Because they boil the water over an open flame, we could really taste the smokiness in the piping hot cup of tea. It was rather delicious. 

We then embarked on a two- to three-mile hike down the mountain to the rendezvous point to have our lunch. The hike was simply breathtaking. Leeches were a minor concern as we walked, but we were forewarned 🙂 I believe our vigilance paid off since most of us only found one or two leeches during our “leech check” at the end of our journey. I must admit though that they were rather tenacious. 

After lunch, we continued our tea education by visiting the Woodbridge tea factory where they process black and green tea. During our short tour, we learned the drying, fermentation, sorting, and packing processes involved with manufacturing the tea we can so easily access at our supermarkets. 

It was a pleasure to experience another aspect of Indian culture and experience, in however small a manner, the daily lives of some of the patients we had the honor of meeting this week. 

Training Parteras in Panama

Some definitions to start….
Floating Doctors- A non-profit medical relief team devoted to providing medical care to remote populations. Right now Floating Doctors is based in Bocas Del Toro (an island off the Caribbean side of Panama) and reaches out to Ngobe communities in the surrounding region.
Ngobe- An indigenous group of Panamanians located in Northwest Panama.
Parteras- Traditional midwives in Latin American and Carribean nations who play the vital role of delivering babies for their respective communities.

Taking a boat to clinic everyday is quite different from being stuck in a typical Southern California rush hour traffic jam hurrying to get to class or the hospital. A typical day with Floating Doctors begins with loading up the boat with clinic supplies, a mobile pharmacy and multiple ultrasound machines. Some clinics are a one day adventure while other are a multi-day experience. There is never a dull moment. As soon as we arrive at a Ngobe community the patients line up to see a physician or get an ultrasound. Our UCI crew typically helps with these clinics or ventures out into the communities to find parteras.

Each community has typically had two to three parteras and several pregnant women. The parteras are very eager to learn the ultrasound training program we have developed for them and the pregnant woman are equally eager to see their babies pop up on the screen. The parteras we have encountered are beautiful and intelligent women. They provide an important service to their community because they feel it is their role or duty to serve. They do not charge for their services and have devoted their lives to delivering the next generation of their communities. The majority speak Spanish, but there are a few older parteras who speak only the traditional “dialecto” of the Ngobe. As we teach the basic skills of obstetric ultrasound we learn their ways as well. They tell us about their culture, role in society and how they handle different emergencies. As we teach them they teach us. It is a developing relationship that has flourished in our short time down here thus far. One partera from a remote Ngobe community in the mountains called Norteno said she delivers about twenty babies a month. Of those twenty she encounters about three to four emergencies a month. The need to identify these emergent situations prior to delivery is definitely evident in these communities. Providing access to ultrasound machines to these women will expand their ability to provide care. The parteras are enthusiastic women, eager to learn. They often surprise us with their level of engagement with our training program. They have proven in the short time we have been down here that they are capable of picking up the skills necessary to utilize ultrasound machines effectively in their communities. With more training in the future a sustainable program is most definitely attainable to provide these women with another tool to expand upon the already incredible services they provide for their communities.