Category Archives: Nicaragua 2012

La Isla Foundation health fair to screen for CKD

Got up at 4AM, loaded the trucks, arrived at Chichigalpa for our Chronic Kidney Disease screening health fair with UNAN-Leon, La Isla Foundation and Mt. Sinai School of Medicine, ultrasounded almost 100 kidneys, now back at our hostel, exhausted…getting ready for day 2 tomorrow. Pictures to come–but for now, buenas noches.

Time to watch a cholecystectomy

Today was my first opportunity to stand in on an operation, a cholecystectomy. After an hasty run-through in proper scrubbing technique, I was standing next to the lead surgeon and watched as an inflammed gall bladder was identified and excised. Apart from some grilling of the resident and student by the surgeon, the atmosphere was casual, with Alejandro Fernandez playing in the background and the staff making occasional jokes. 

The procedure went smoothly and the pressure let off even more when the resident, student and I were left to suture. As we chatted, the feeling of lowly second year medical student disappeared. What little autonomy I felt assisting in the operating room strengthened that boundless motivation I had when I came into school. Leaving the hospital after a long day motivated the four of us to keep advocating for our patients and become the most well-learned, competent physicians for whomever we see. We may only have one year of training under our belts, but with our skill set we have already made many positive connections with patients; and our trip is not done yet.

“We just don’t have those resources in Nicaragua”

Today we received a tour of the hospital at UNAN, Leon in Nicaragua.  The hospital is pretty standard for Central America, with all the different divisions spread over 4 floors and doctors walking throughout the hallways at the usual brisk pace.  During our tour we walked into the pediatric unit, where we were greeted by an American physician.  Ellie is a third year pediatric resident at Duke who is performing an away rotation in Nicaragua as part of an exchange program.  She invited us into the pediatric unit, where 2 patients were stationed.  Ellie is a very competent physician, who cares very much for her patients.  However, working at a hospital in Nicaragua has demonstrated many challenges for her.  The hospital does not have a CT or MRI machine.  The closest machines are in Managua, 2 hours away, and are too expensive for most patients.  The perfect example is our first patient.

Priscilla is a young girl, about 2 years in age, who is suffering from a suspected interventricular septal defect and down syndrome.  Upon auscultation of her heart, the murmur could not have been missed.  Ellie told us that the diagnosis of Down Syndrome has simply been assigned to her, but no genetic testing or chromosome studies can be performed because of the lack of resources.  In the US, genetic testing would have been performed on a young patient with a septal defect and neurological symptoms, but not here.  The interventricular septal defect was also diagnosed solely through physical examination by Ellie.  We decided this would be a perfect time to inform her that we had an ultrasound machine with us, and we’re eager to help Priscilla and her family with the diagnosis.

Ellie was surprised that we had an ultrasound, as the hospital doesn’t even own a portable ultrasound.  We brought Priscilla into another room for an ultrasound, hoping to solidify the diagnosis.  Upon imaging, there was no doubt that she has a ventricular septal defect, but also an atrial septal defect.  The doctors, all surrounding our ultrasound machine, stared at the image for a few seconds before I asked Ellie when Priscilla would be able to get surgery.   Unfortunately, Ellie will not be receiving surgery.  The resources just aren’t available.  Ellie gave a prognosis of 2 years before Priscilla would pass away. I couldn’t help but imagine how different Priscilla’s life could have been if we were back in California.

It seems that sad stories about lack of resources are plentiful here.  Our second patient, 19 months old, looked the age of a typical 6 month old baby.  He was very malnourished, and Ellie informed us that instead of feeding him solid food, her mother was forced to continue breast feeding because food is too expensive for the family.  The baby was diagnosed with Kwashiorkor, a protein deficiency that is rarely seen in the US.  The baby was put on a steady diet and has been improving, however the baby had an open wound on his neck as a result from a “cut down” procedure that was performed at a different hospital.  When the baby was brought to Ellie, he not only had severe Kwashiorkor, but also had the open wound on his neck.  Ellie was told to close the wound with stitches, and was unable to give any pain medication.  When we asked if the baby was in pain, she replied, “Of course.  But that is just how things run down here. It breaks my heart.”  

Today was a harsh learning experience for me.  It may sound cliché, but i learned a lot about the differences between first world problems and third world problems.  Resources make a huge difference in the care that patients receive.  No genetic testing available for Priscilla.  no surgery available for priscilla.  No  help available for our Kwoshiorkor patient.  It was hard knowing the pathophysiology of our patients today, and not being able to do a single thing about it.  But as Ellie told us, “That’s just how things run around here.”


To add to Andrew’s earlier post “Sorry, iPad,” we’ve discovered yet another use for our iPads–entertaining patients in the waiting room!

This morning, as one of our little patients waited for her ultrasound examination, we thought we’d keep her and her brother entertained with games on our iPads. One was DancePad, an iPad version of Dance Dance Revolution for your fingers which the brother absolutely loved, and the other app was Draw Free, which Michelle used to draw with the little girl. It was a fun 10-minutes before the actual exam–filled with giggles and “alto cinco’s.”

For many, the waiting room is an uncomfortable place–it’s completely natural for patients to feel scared and anxious. Things are probably even worse for the younger patients. Today, the iPad helped us bond with the patient, despite the slight language barrier, and I believe our time with her before the examination helped put her at ease during the ultrasound.

Thinking further into the future, I wonder what I can do to improve my future patients’ waiting experience. Of course, the ideal experience is one in which my patients spend the least amount of time in the waiting room, or one in which I can play or get to know them before the actual exam, but these may not always be possible. Instead, maybe providing the right kind of toys in the waiting room may be enough to upgrade the experience? Activity tables, interactive workshops, and even iPads filled with educational resources and kid-friendly games that teaches about health could all help alleviate the anxiety, while being educational at the same time.

Ultrasound Education in Nica

This gallery contains 9 photos.

The past two weeks we had the opportunity to work with UNAN-Leon medical faculty and students through ultrasound education. We were impressed with their eagerness in learning to use ultrasound and how receptive they were to using it in their … Continue reading

Sorry, iPad

Admittedly, I was not a heavy iPad user throughout the school year.  Other than using it to read some textbooks or glance at the occasional anatomy flashcard, I hardly ever used it.  I found that a laptop accomplished nearly every task more efficiently.  Even when starting this trip I expected that it would mostly be used for Facebook, Angry Birds and, when I fell asleep in my hammock doing either of those two things, it could pass for a sun visor.

I have to say I owe iPad an apology.
Yesterday morning we found out somewhat unexpectedly that doctors from the community were coming to learn ultrasound techniques from us.  We panicked a little from the news, because, other than Michelle, our Spanish isn’t that great and we questioned whether our knowledge of ultrasound would even be useful for physicians in rural Nicaragua.
This is when iPad stepped in to the rescue.  Using screenshots of Dr. Fox’s podcasts and other images of ultrasound pathology, we created an impromptu powerpoint presentation on the iPads.  On one of the iPads we even added slides in between with text in Spanish that would serve as a script for the three of us gringos  (Jon, Alvin and me).   If there was anything we didn’t know how to say, we could simply open the google translate app, speak the word in English, and have it translated to Spanish for us immediately.
We were able to hand the physicians our iPads to follow along and look at the slides as we gave our presentation.  When it was their turn to operate the ultrasound we could show them a smaple image that they could try to replicate.  This style of presentation worked amazingly well!

My Second Day

The first day of work started promptly at 8am, and following a meeting with our advisor in Nicaragua, we start seeing patients (see Jon’s post). Afterward we planned our ultrasound curriculum for physicians and students, but the highlight of the day came when we returned to our hostel.

Vanessa works at the hostel and is about six months pregnant. She had never been ultrasounded and did know the gender of the baby. Before I arrived to Nicaragua, the plan was to try our best to perform a fetal ultrasound to see the baby.

We briefly reviewed basic fetal ultrasound techniques before starting. With our recently acquired equipment, we first explained our limited experience but our desire to provide our best effort for Vanessa.

The four of us worked as a team, each piecing together the various planes we visualized into a more complete image. Our first eureka moment came when we found a small, pulsating, four-chambered organ, which quickly became our reference point. Glimpses of other parts were also accompanied by the smiles and gasps of an excited mother watching the ultrasound screen.

That didn’t compare to our reactions when the correct sagittal plane was found to reveal a head sucking a thumb, legs crossed, at times kicking and kicking. We found him.. or her.

While the gender of the baby was not officially determined, for the patient, it was the first opportunity to see her child in a new way: feet moving, fingers curled and body rested and comfortable, ready to meet mom.



During our last week, we’ve gotten to know some really great people here. The first person is Huguette, the sister of the owner of the hostel we are currently staying at. She gave us our first tour of Nicaragua, introducing … Continue reading

Our first patient – Diagnosed with terminal kidney disease at 27

Today we saw our first patient with Chronic Kidney Disease.  We performed an ultrasound and found that the size of the kidneys were diminished (7 cm renal length compared to a normal value of 11 cm).  The patient was not in any pain at the time of the examination, but we later learned that he is currently in stage 5 terminal kidney disease.  The patient is only 27 years old, which demonstrates how devastating the effects of Chronic Kidney Disease are on the farm workers of Central America.  His current creatinine levels is 4.2, which compares to a normal level of approximately 0.5 – 1.5. We will continue seeing around 2 patients every morning and teaching ultrasound to the medical students and staff of the clinic in the afternoon.

Where are our manners…

Where are our manners, we forgot to formally introduce you to Nicaragua and its people. Nicaragua is a Central American country bordered by Honduras to the north and Costa Rica to the south. Most recent memories of the people of Nicaragua  start with some reference to the armed Sandinista uprising starting in 1972 and peaking in 1979 in civil war. From 1936-1979, Nicaragua was controlled by the powerful Somoza family and supported by the US government. The Somoza family governed Nicaragua as a dictatorship and rigged elections to gain power. Those political and military figures aligned with the dictatorship enjoyed the benefits of complete political and commercial control of Nicaragua. The opposition in Nicaragua was the Frente Sandinista de Liberación Nacional (FSLN) a political and guerrilla group of revolutionaries founded in Costa Rica and came to be known as Sandinistas. Fixed elections, increased proverty, and torture and assassination of political enemies increased tension between the opposing parties. The breaking point came in 1978 with the assignation of Pedro Chamorro, journalist and activist who exposed Somoza’s use of torture against political opponents.  In 1978, civil war broke out throughout the country as the soviet and cuban backed Sandinistas attempted to take over Nicaragua. One of the Sandinista commanders was Daniel Ortega who eventually came to full control of Nicaragua from 1985-1990. Much of Nicaragua’s infrastructure was destroyed in the civil war and many Nicaraguans fled to Florida or California including my (Edsel) parents. Between 1980-1986 the Sandinista government battled against CIA-backed Somocistas in an episode the US knows as the Iran-Contra affair (US gov’t sold Iran weapons and used those funds to fund the Somocistas or Contras). In 1990 Nicaragua ended Ortega’s control by electing Violeta Chamorro, wife of the late Pedro Chamorro and member of the Partido Liberal Constitucionalista (PLC).

But Nicaragua’s history is more than war and struggle. Nicaragua is the home of many cultures and ethnicities. Spain originally colonized Nicaragua and mixed with the indigenous to create a mixed population. Much of the culture comes from the traditions carried from the Spanish, which included traditional Catholic celebrations. Nicaragua is also the home to the father of moderismo literature, Rubén Darío. Born in Matagalpa, spent his life reviving Spanish literture and traveling Latin America. Rubén Darío  is entombed in the church of Leon and is honored in all of Latin America. Take some time to read some of his poetry found here.

In the early 20th century, Nicaragua became the home of many emigrant populations such as Palestinians, Lebanese, Chinese (specifically Guangdong province), and Western European nations. These populations integrated into Nicaragua and became vital to many cultural and political movements of modern Nicaragua. For example, Dr. Moises Hassan was a FSLN revolutionary  and is  of Palestinian decent.

Today, Nicaragua is a growing nation attracting tourists to its Spanish colonial cities, untouched jungles, and virgin beaches. In 2011, Nicaragua experienced a GDP real growth rate of 4.0% (US State Department) and continues to expand its manufacturing businesses. It’s wonderful food, mixed culture, and amazing ecotourism is one of the many reasons why Nicaragua is a great place to visit. Still, Nicaragua continues to advance its academics to meet the needs of its people. The dean of the medical school here at UNAN-Leon was very enthusiastic to work with us in getting us to use ultrasound on the sugarcane farmers suffering from CKD. We hope that we can make a difference and that we can begin the process of ending CKD in Nicaragua.