It’s on, floor tiles!

I am in a personal war with the main hospital hallway. There is a loose tile along the middle of the hallway leading up to the nurses’ station. This tile happens to be directly across from the bathroom with plumbing problems. Every day this tile lies in wait for me…

I probably should explain a little more about plumbing and sanitation here. The hospital has had plumbing for many decades, but it is a rarity here in Ahuas. The majority of the people in the village have no running water, no indoor toilet, and clean water only after boiling it.  In some more rural villages there is also a prevailing lack of education on germs and the dangers of unboiled river water. If it looks clear why wouldn’t you drink it? The more advanced houses in the village have a wooden outhouse building built over a large hole. The people go to the river every day to carry water back up to the house. Washing of dishes, clothes, and bathing is all done in the river. In fact, the main water hole under the bridge is known as a general “meeting place” where women go to wash and catch up on the daily happenings in Ahuas. All of this added together means that the general population here is not very familiar with indoor plumbing.

This lack of familiarity leads to many problems at the hospital. Many times we find water taps left wide open, draining precious water out onto the floor. When the toilets overflow, they too feed dirty water out into the hallway. Although we are not in a drought right now, it does take electricity to run the pumps that feed the water tanks, and on a cloudy day (when the solar panels aren’t taking in much power) we tend to run low. Another problem is that people don’t understand just what is appropriate to flush down the toilet. One time our handyman took an overflowing toilet apart only to discover an entire bar of soap had been flushed down. Many times the people are without toilet paper (there are thieves who constantly take the newly furnished rolls from the bathroom) and after using leaves or some cardboard to wipe, they flush that down as well. So the toilet off the main hallway is almost constantly overflowing. I have also seen a patient’s mother take the bedpan her daughter had just used, walk out into the hallway, and dump it right there. Appalled, I asked why on earth she would think that was an appropriate place. She explained that the toilet had overflowed out into the hallway and so she was only adding to what was already there. When I asked if she would please empty it outside were this to be the case she rolled her eyes and explained (what should have been immediately obvious to me) that it was dark and she did not want to meet any spirits. She was not necessarily a good picture of our patient population, but you begin to get the picture.

So, the hallway stinks. Every morning our cleaning ladies wash, scrub, and mop the area and return it to a semblance of cleanliness, and then almost every night it descends to filth again. The sala de labor y parto is also along this hallway so many times there is also a trail of blood from where a woman whose water just broke was carried or walked along to the labor room. The chickens and dogs that run through the halls occasionally add their own little gifts to the murk. Our nurses do have some awareness of cleaning, but many times there are 15 – 20 patients for one nurse and she (or he) is simply too busy to clean.

I loathe walking up this hallway to get to report in the morning. I lift my scrub pants and tiptoe through the fetid puddles attempting the least amount of contact possible with the disease ridden liquid. The hallway sensed my loathing. It went on the attack. Last week as I tiptoed through the swamp one of the tiles shifted under my foot and shot putrid liquid up the length of my pant leg. I gagged and attempted to hold the cloth away from my flesh. I resolved to walk on the opposite side of the hallway, but it managed to get me twice more when I was rushing to do some important task and forgot. Today, I automatically navigated off to the side, only to get splashed once, twice, more with scum water. There were a total of 6 tiles now loose from the constant water drainage. It was war. I approached Dr. Rudy with the issue and he said we can consider buying new tiles and grout only after we buy the monthly inventory of medications. I approached our maintenance men and they promised to fix them as soon as we have supplies. I gave the nurses a long talk on keeping the hallway clean whenever possible and they referred again to lack of education in the patient population, and the fact that they, too, would love a clean bathroom that was not constantly overflowing with filth. I glared in hatred at the floor tiles, and they said nothing at all.  But I could feel them waiting to spray me once again. This is not over floor tiles. I will conquer you.

A challenge to myself

Looking forward

It is now less than two months until I shall be homeward bound.  I begin to think in anticipation of seeing family and dear friends again, of meeting sweet little babies that had not been born when I left, and oh so many things!

I have been asked what I am most looking forward to when I return.  Kristian asked me, what is the first thing you’re going to do when you get home? Mental lists of delights began scrolling through my imagination.

1. Getting to choose what I will eat!  Along with this comes, getting to eat large quantities of vegetables!  The food I have been given here daily is quite delicious and filling.  I have never been hungry.  Lesvia the cook does amazing things with a very small list of ingredients, but I cannot wait to get home and make a huge Thai or Indian stir fry.  One morning I was listening in on Dr. Rudy, Peter, and Hazel having Bible Study and discussing free will and choice.  Dr. Rudy asked the kids what “choice” entailed and Hazel answered “choice is having more than one type of cereal for breakfast.”  It’s true – after eating cornflakes almost every breakfast for 5 months I will be excited to have some choice!
2. Getting to toss my dirty clothes in a wash machine, add some soap, turn the dial, and walk away.  Washing clothes by hand is hard work – as any of the women here could tell you.  Your back hurts, your hands get dry and cracked, and you begin to resent your socks.  Socks are so annoying, they are tiny and must each be individually washed.  They get dirtier than most other articles of clothing (especially in this muddy weather), and there are so many of them every week!  They seem to multiply as they are pulled one by one from the water and scrubbed on the washboard.  Oh, the joys of a wash machine!
3. Walking to the beach.  I love the savannah here.  There is a majestic beauty in the rolling fields that stretch endlessly to the horizon.  But I have always lived near the water.  I miss the crashing surf and the glory that is walking West Cliff Drive in Santa Cruz.  I cannot wait to see the Pacific.
4. How lovely it will be to have a glass of wine with dinner and not have to worry about offending anyone!  Drinking alcohol is more than frowned upon in Miskito culture; good people do not even consider imbibing wine.  So I am looking forward to ending a 5 month period of almost total teetotalism.  Not to any excess of course, but the thought of a glass of wine after a hard day brings a smile.
5. I am greatly looking forward to having time all to myself.  To walk away from my job (when I get one) and not have to think about it for the rest of the day.  Living on the hospital grounds provides many benefits, and I learn so much from every experience, but I cannot wait to have free time with no chance of it being taken away!
6. But most of all I want to hold onto how blessed I will be to have these things.  I don’t want to immediately get sucked back into “normal” life and forget to be thankful for these simple things.  When I have a hot shower, I want to remember that many people do not have running water.  When I have a hard day and want to complain about my boss, or my difficult work schedule, I want to remember the millions of people are laboring desperately every day to make less than a dollar an hour (in some cases less than a dollar a day) – struggling just to feed their families.  When I feel the “need” to go shopping or splurge on a new expensive phone, I want to remember how easy it is to live simply.  I do plan on enjoying the luxuries of home when I get there, guilt free, but I want to remember.  I want Honduras not just to be an anecdotal amazing interlude in my life, but something that leads me to live differently.

Dr. Ovelio

When Dr. Rudy left on his two week trip to the States I was quite nervous.  I did not know how my Spanish would hold up with no other English speakers around to help out with the occasional translation.  I did not know if I trusted the medical decisions of the new doctor.  I was uncertain how well we would work together.

The week did not start out auspiciously.  We were overwhelmed with staff sick calls – including our administrator (who had to fly out to La Ceiba because he got so sick)-  the surgical cases kept piling up, there were staffing conflicts, Dr. Ovelio and I disagreed on several decisions on patient care, and I was desperately counting down the days until Dr. Rudy returned.

I admit to feeling some mistrust of Dr. Ovelio’s ability.  I knew that he was a relatively new doctor.  He went to medical school and was trained in Cuba, and then did some of his practicum in Venezuela, but had to leave before finishing the full course of study.  I know he is lacking the surgical experience that Dr. Rudy has, after 17 years operating on the wide variety of issues that come through our door.  Just before Dr. Rudy left he took me aside and reminded me I needed to have patience.  Reminded me that everyone is new at one time or another, we can’t start something with an automatic upload of experience and skill (oh Matrix…), it has to be learned over time.  Yet I quickly forgot his words.

I was irritated when Dr. Ovelio did not write his orders as legibly as Dr. Rudy (you think doctors’ handwriting is bad?  Try reading it in another language…), I was irritated when he changed the wound care orders that I was supposed to be tending to, I was irritated when he asked me to redo the staffing schedule I had spent two days creating.  Nothing was the same, nothing was under my control, and I’m sure I snapped a couple times and responded tersely when he asked a favor.  Yet Dr. Ovelio was always kind, calm, and smiling – even after spending all night delivering a baby or tending to an emergency.

I dreaded going to surgery, so of course there was one surgical case after another.  Two tendon repairs in the first few days, a gangrenous foot to be debrided and toes amputated, then a child with burns over 45% of his body, and finally a femur fracture needing traction.  I know that every surgeon has to perform each surgery for the first time at some point in his career, but I was so nervous.  Would there be complications?  If the patient started crumping, would I have the resources to run the code?  This was not my perfectly controlled ICU environment.  Before each surgery I nervously set out the medications I might need: succinylcholine for emergency intubations, ephedrine, epinephrine, and atropine for code situations, labetalol for high blood pressure.  When we began the surgery I checked each dosage of anesthesia that he ordered and monitored everything closely.  I waited for the mistakes that I was certain would occur, and then was surprised!  Surprised at the grace with which each surgery was completed.  Each movement was meticulous and well planned.   With each complex surgery everything went well!  Even days afterwards, the patients continued to recover.  There were no post-op infections or fevers, no inexplicable bleeding, no complaints of overwhelming pain.  The placement of the traction pin actually made the procedure look easy.  I was humbled.  My lack of trust, and lack of understanding were failures indeed, and I had certainly made them known.  Yet Dr. Ovelio continued to thank me for assisting in each surgery, and to work diligently every day with a good attitude and a smile for everyone.

I am excited that Dr. Rudy returns tomorrow, but I am also glad that I have two months to continue learning from both Dr. Ovelio and Dr. Rudy before I go home.  Perhaps the next time I encounter a new doctor, or someone beginning at anything, I will not be so quick to judge.

Images

December and January were such busy months (with all of our visitors and teams) I never got around to posting many pictures.  The internet connectivity issues may have had something to do with that as well.  So here are some recent pictures for your viewing pleasure

Sunset walk on the savannah with Taly

Taly was certain that she had a secret talent as a “horse whisperer.” This was not true

Glorious sunset on the savannah

Little bits of beauty littering the path

Taly again attempting, unsuccessfully, to sneak up on a horse

Stephen and Uri spent many hours helping build this schoolhouse at the JUCUM base

Stephen, Uri and the Hofstad boys

Taly and I went to visit the boys at the base, and to take random pictures

Kristian and Jarle working hard

Ben and Tobias Hofstad

There was also a team of North Carolinians volunteering to build the new airplane hanger

While Taly and I worked in the clinic we got to visit the attic – and all the local bats – to find supplies

Pensively analyzing some chest xrays

The loyal workhorse of the Ahuas airfield – the Cessna

The traditional Moravian church in Ahuas

Lesvia preparing dinner

Sosimo and Karixa – our lab techs

Helping in preclinica

Uri pretty much ran preclinica during our busy specialist week

Carmen, the preclinica nurse, finding patient charts

My youngest brother Micah and George

Mom drinking coconut water on Sunday after church in Paptalaya

Fresh coconut water is delicious

Miskito wedding in Paptalaya

Peter was one of the groomsmen in the wedding

The pastor entering the church

Kristian, Uri, Micah, and me

Mom and Adela – the woman who cooked for Mom’s family and carried my Mom and Aunt around while they were babies

Adela and her family

Oh, poop

Yesterday, while pulling the gurney from the operating room/building over to the main hospital, I almost trod upon a poisonous serpent.  I heard the other nurse say something about “culebra” and almost pulled a muscle trying to simultaneously stop the heavy gurney from backing over me (we were on a decline) and jump up into the a nearby tree to escape.  Everyone around me found my reaction quite amusing, but I think it is quite logical to fear something that can kill me with one bite, and painfully at that.  I suppose if I were to get bitten this would be a good place, since we actually stock the anti-venom and MOST people live after receiving the shots.  They puff up to twice their size first, and might get rhabdomyolysis, but usually live.  All in all I was quite happy when one of the passing yucca farmers killed it with a stick.  It was a feisty little thing, and managed to strike the stick (and nearly the man) over ten times before dying.  I am no longer walking around at night sans flashlight.

I am sleeping in the main house while Dr. Rudy and family are away, and my sleep has become less than adequate.  One of the soccer boys told me that some of the rebellious youths in the village were talking about breaking in to the house, and I lay awake at night imagining footsteps.  Two nights ago I was awakened by a fearful clattering from the bathroom.  Imagining that someone was attempting to clamber in through the window I rushed in and flipped on the light preparing to scream… only to see two baby mice who had managed to get caught in the bathtub.  I had no idea that beings so small could create such a racket.

Today I was putting away supplies in the basement bodega (where a large family of rodents and amphibians also create a home) only to get defecated on by a bat.  I sighed, and remembered that the correct term for the smelly liquid creamily coating my arm was guano.  When I was a child, and found all things having to do with feces amusing, my brothers and I knew quite a list of official words for poop.  It is possible that I still find stories about excrement amusing, but I wouldn’t want to admit that in a public forum.  Guano, scat, dung, … I can’t remember the rest.

Other words for poop describe how I feel about this week.  This is an excrementy week.  Nothing is within my comfort zone, my favorite doctor is gone, and things are done differently without him, I am left with no safety net (and other such clichés), half our staff is sick (and therefore calling out sick), our administrator was so sick he shipped out to La Ceiba, someone yelled at me yesterday for not speaking Miskito and told me I in no way lived up to my Grandfather and Uncle, we have had an emergency surgery every day since Dr. Rudy left, and I just want a glass of wine, and to get away from it all…

So such is the excremental aspect of life right now, but on the other side of things there are quite a few positives this week.  All of this surgical experience had led me to realize how comfortable I am giving anesthesia and dealing with emergencies in the OR.  Perhaps I shall look for a surgical job when I return.  I am getting to practice my Spanish more.  I have a chance to work on gaining patience and being joyful (or just ok) when I am not in control of everything. Best of all, I get to eat lunch and dinner with the Norwegian missionary family every day.  Jarle (one of our pilots), his wife Yngvald, and their three children have extended wonderful hospitality welcoming me into their house everyday to eat.  They actually eat vegetables on a daily basis!  After dinner we play games like Rummy-Q, or watch a movie together.  Last night Camilla (the 7 year old daughter) and I put together a Disney princess puzzle.  They are a lovely family, and so much fun to relax with after a stressful day.

It seems there is always good somewhere in the day, even if you have to dig through some excrement to find it.

Kingbaowla

6 de Febrero, 2012

Hoy es un dia duro, y estoy cansada  ya.  Dr. Rudy is gone, and the hospital does not function as smoothly without him.  My job is also much less defined without him here, and I feel frustrated by knowing there are things to do, but not knowing what they are – or at least not knowing how to fix them.  I am realizing just how far from fluent my Spanish falls, or fails.  Half of the hospital staff are sick with malaria right now, including our administrator who normally looks after a good many details while Dr. Rudy is gone.  Two of the nurses were very angry that I would not let them exchange shifts with the student nurses, but the students are not yet experienced enough to work alone.

Alongside all of these actually important issues, is the irritation of the massive collection of chigger bites I have gained this week.  I had just been mentioning to someone that I hadn’t had any bug bites for some time when the chiggers mounted their attack.  I think they must have secret planning meetings where they discuss the perfect amount of time to lull the human into thinking they are no longer a consideration (and thus cease in the daily application of bug repellent) before sending out a full scale invasion.  They are evil.  Both of my ankles are swollen into cankles, there are huge red bites behind each knee… and of course they managed to find their way into other, more personal areas where one would not like to be seen itching in public.  It is amazing how much simple bug bites can raise one’s irritation level to a constant simmer.

All that being said, today was a good day for a run.  We have been having some late-season thunder storms, but the rain retreated back into the clouds by early afternoon.  As I made my way out into the savanna, legs increasing spattered in a Jackson Pollack cacophony of mud colors, my irritation (and my bug bites) slowly dulled.  The sky was glorious – the clouds curving up from the far reaching grasslands to form a sort of fishbowl with a perfect circle of blue in the center – right above me.  In every direction rain could be seen sheeting down from the clouds, but the blue skies lingered over me as I ran.  I couldn’t tell if I was running to or from the rain, since it encompassed me so, but the beauty was enveloping.  Along the way my feet brushed the kingbaowla plant and I stopped for a moment to revel in the simple beauty of nature.  The kingbaowla plant is a groundcover plant with small pink flowers.  The delecate leaves curl and “bow” or fold in on themselves whenever they are touched.   Thus the name in Miskito – Kingbaowla – the King is coming!  The plant bows down in reverence before the King.

Not that I have a superiority complex, but it is fun to run a hand or foot along the plant and watch as the leaves all curl under… and then wait to see them peek out again in time.

The week has only just begun.  We continue forward, siempre en la lucha

Ispara ai klakan

“Ispara ai klakan, doctor, latwan, doctor, latwan!”  The machete cut me doctor, it hurts, it hurts!  This week was quite busy.  Not as insanely busy as the preceding week, when we had our pediatric surgical team here, but certainly not the week of rest I had been hoping for.  I’m not certain why our clinic numbers have increased so dramatically, but we have doubled (and sometimes tripled) our normal daily dosage of clinic patients.  With both Dr. Rudy, and the new doctor, Dr. Ovelio, seeing patients this wouldn’t normally be a problem.  In an ideal day we would finish report and rounds at the hospital before 9am, get all the clinic patients registered during that time, and then allow both doctors to see patients throughout the morning and early afternoon in an orderly fashion.  Of course, this rarely happens.  Usually there is a pregnant woman, or two, in labor who take some of the doctors’ time.  Or an emergencia arrives, and time must be taken to suture the wound, or do the EKG, or push the sedative that the emergency patient requires – all while the less emergent clinic patients wait, and attempt to impress on me that they are also in dire need of medical attention – RIGHT NOW.

This situation is further exacerbated when there is an emergency surgery required. When we can schedule surgeries we like to work them in around late afternoon, when the clinic traffic has slowed or stopped completely, and where one doctor can manage the clinic and the other see to the surgery.  Of course if the surgery is an emergency, and both doctors are required (since the new doctor is trying to learn everything possible before the more experienced doctor leaves), and you don’t want to leave a child NPO for hours – then you go right ahead and have surgery in prime clinic time in the morning.

This week we had three people come in with serious tendon damage from machete wounds.  Machetes (or ispara – as they are called here) are the tool of choice for any manly work.  Farming, cutting grass, harvesting yucca, splitting open a coconut – everything is done with the machete.  Boys of barely 4 years of age are already wielding these giant knives to cut grass.  Our first case was indeed 4 years old.   The machete had sliced through his palm and severed his 4th and 5th fingers.  The pinkie finger was only barely attached to the ring finger.  The ring finger had been amputated completely through the bone, but a flexor tendon was still attached and there was some blood flow to the digit.  Somewhat miraculously the pinkie finger also had capillary refill, although we could not see how.  Dr. Rudy gave spinal anesthesia, both doctors scrubbed in, and I monitored and administered ketamine as needed.  While watching them prep the skin I actually got a little dizzy seeing the detached fingers flop around.  It was the first time something has affected like that since nursing school.  I reasserted my interest in watching, and conquered the slight dizziness quickly, and was amazed yet again at the skill Dr. Rudy possesses with tendon repair.  Each finger had multiple points of reattachment, and sometimes the tendons were not readily obvious and had to be sought out from where they had retracted into the tissue.  It took three hours, but at the end both fingers were attached and pink.  Vamos a ver, but the prognosis is promising!

Then it was out to see the irritable mass of people who had been waiting all morning just to see the doctor.  Dr. Rudy didn’t leave the clinic until 8pm that night. The next day we started off clinic, thankful that there were no scheduled surgeries, only to have another young boy brought in with his Achilles tendon cut through.  The next day it was another hand – this time a young man – sliced through across the knuckles.  That day we also had an elderly woman who had managed to insert a sewing machine needle down through her fingernail and into the bone.  It is never boring here.

Despite the general grumblings and heavy work schedule I was happy we had so many surgical cases.  The more time Dr. Ovelio and Dr. Rudy get to spend in the OR, the better off Dr. Ovelio will be when Dr. Rudy leaves.  Even though I didn’t get to scrub in to any of the cases this week, I still get to see many things of interest from my perch at the head of the bed (where the anesthesia person always sits) and I am always thankful for more learning opportunities.

Dr. Rudy and family left for a two week trip to the States yesterday.  It will be a good trial run for Dr. Ovelio to see all the challenges inherant in running the hospital and clinic solo.   He is a very good doctor, and a good man, and I have no doubts in his abilities.  I do think it shall be a very interesting couple of weeks for me as I will have no English speaking translator readily available as my safety net.  I will need to keep up on all the crazy multi-tasking that Dr. Rudy always has under control.  Keep the pumps running, check the batteries daily, don’t let the clinic run out of water, make sure someone is aware of gasoline levels so we can run the generator whenever we need the big autoclave for sterilizing, make sure the dressing changes on our four post-op patients are being done daily (and correctly), check all the daily vitals and inform the doctor of any issues… keep an eye on the nursing students… I know there must be more… I need to start writing more lists… Let the fun begin!

Dr. Samuel Marx

It has been a year since my Grandfather died.  When I was a child, falling asleep at night, I would beg my mother to tell me a bedtime story about Honduras.  There was the time Grandpa chopped a huge snake in two with his machete – when he found it inside the crib with his infant daughter (my mother).  The cedar chest with the deep machete scar still exists today.  There were stories of danger, of family, of joyous games, and of many surgeries and time spent working to heal those in sickness.  My Grandparents were, and are, my heroes.

I only wish that Grandpa was alive today – now that I am here living and walking where he walked for 35 years.  I wish I could go hear him tell stories of times past, and ask his advice when times are hard.

Since it is his 1 year memorial (january 28th, 2011) I thought I would post the obituary and some of the wonderful pictures my cousin Elly gathered for the funeral last year.  Memory Eternal Grandpa Marx!

Samuel Benno Marx: Nov. 25, 1918–Jan. 28, 2011 Dr. Sam,” as fondly known to thousands in North Carolina, Washington state, Honduras, and Nicaragua, lived a full life of compassion and service to others. He went to be with the Lord at age 92 while at home at Salemtowne (Winston-Salem). Born to missionary parents working among Tibetans in northern India, he grew up in Pennsylvania, eventually going to Moravian Seminary. He pastored a German-speaking congregation in Vancouver, Canada, in 1940. Sharing his faith that summer at Camp Van Es in Alberta, he met stunning and talented Grace Hoppe. Challenged by his brother Werner to medical needs overseas, he attended McGill University, graduating with a medical degree in 1948. He and Grace were married in 1945. After a medical internship, they left directly in 1949 for mission hospital work in eastern Nicaragua with the Moravian Church. Thus began Sam and Grace’s 35 years of service among the Miskito and Creole peoples of Nicaragua and Honduras–living the love of Jesus by word and deed, pastoring and doing medicine and surgery. They gradually built up the hospital in Ahuas, Honduras, and raised their children there. Sam and Grace were blessed with five children: Rick, Steve, Benno, Cathie, and Julie, all of whom grew up and learned the ways and language of the Miskito; more importantly they were taught the pathway of the Lord and introduced to the person of Jesus. Before Sam and Grace returned to the Winston area, they lived several years in Wapato, Washington in the 1970s; Dr. Sam working at the Wapato Medical Center. They returned to Honduras for six more years. By 1985, they had returned to Winston-Salem, where Dr. Sam worked in Yadkinville in private medical practice for a few years. He assisted other pastors at Christ Moravian Church where he, until recently, also helped teach a Sunday School class. He often volunteered at Sunnyside Ministry and enjoyed growing vegetables for himself and to share with others. Sam and Grace always enjoyed conducting weekly Bible studies, which he did until November 2010. Surviving Dr. Sam are his wife, Grace of 65 years; children: Richard (and Vicki) of Winston-Salem, NC, Stephen (and Ann) of Nampa, ID, Benno (and Teresa) of Grandview, WA, Catherine (and Joseph) of Ben Lomond, CA, and Julie (and John) of Kendrick, ID; grandchildren: Elizabeth, Jonathan, Brian, Grace, Hannah, Samuel, Laura, Eileen, Stephen, Marie, Luke, Cristi, Micah, Ryan; and great-grandchildren, Levi, Ethan, and Zoe. Summarizing anyone’s life is impossible; to try with Dr. Sam, as husband, dad, granddad, pastor, missionary doctor and surgeon, teacher, hunter, and carpenter, one begins to touch his character as warrior of the faith, a man of integrity, a humble man. Dr. Sam always tried to follow the footsteps of Jesus. And so he left an indelible print among many especially among the Miskito of Central America. Many, drawn by his example and message, have discovered for themselves the satisfying answer for “the eternity in their hearts” (Ecclesiastes 3) that has eluded so many others.

You can see the joy and love

Dugout canoes

Pushing a patient from the operating room to the main hospital

Dr. Sam was a doctor and a preacher

The family house

Grandpa was well traveled

Communication in those days was only through HAM radio

Kicking off the futbol game

Grandpa as a young man

Grandparents and Grandchildren (some of them)

Grandpa and Uncle Roy on horseback

What is normal?

29 de Enero, 2012

After months living in the new country that which was at first surprising, and perhaps distressing, now becomes routine.  I no longer blink in surprise when a stray dog – ribs starkly outlined – wanders into the clinic and gets in the way.  It seems normal to shoo them away from the nurses’ station while we are giving report in the morning.  They wander into the church as well.  Usually there is a man stationed near the door to keep them out, but sometimes one manages to sneak in and then we are granted the vision of a little Miskito grandmother hiking up her skirt and brandishing her umbrella to chase the dog back out where it belongs.

This week a chicken flew into the house to lay an egg.  Just like that.  For the last four days a chicken appeared, flew up to the second story window where there is a tear in the screen, came into the TV room and laid an egg in the closet.  Friday there was a momentary disturbance when the chicken arrived, not to an empty room, but a group of Peter’s soccer buddies watching a movie.  There was much squawking and some errant feathers flying through the air, but she still returned the next day to gift us again.

Dr. Rudy tells how there was a small possum living in the pantry for several weeks  eating eggs (these ones purchased from the local chicken owners) and whatever else he could get his paws on.  He managed to go unnoticed (his thefts probably being blamed on Peter) until Dr. Rudy was up late one night on-call.  He (the doctor) heard a scrabbling sound coming from the pantry and went to investigate and saw the tiny intruder retreating to his lair behind the freezer.  The night nurse was called from the hospital to fetch his machete and have it out with the possum. Despite his small size he put up quite a fight against two grown men, but eventually he was ousted.

Then there are the barking geckos.  I remember in Nicaragua they are called something like little dog (in Spanish), because they frequently “bark” or chirp their strange call to the world.  They are lithe, beautiful little creatures.  They have tan, somewhat creamy skin that is almost opaque.  They crawl all over the walls – inside and outside the houses.  At first I was rather nonplussed to see a lizard at face level one night while brushing my teeth, but I rather like them now.  Their call echoes through the house at all hours, and is my nightly lullaby.

In another completely normal occurrence, tonight I arrived at the doctors’ house for dinner only to find a tiny owl sitting in the TV room.  He was the cutest little owl I have ever seen (Ok perhaps the only owl I have ever seen in live action, but still incredibly adorable) and was no larger than my fist.  He was rather panicked after I entered the room and kept flying headfirst into the mirror.  I called for Peter and his friends to help me get him outside, and then the situation got a little less “normal.”  Just as the boys arrived, the lab tech from the hospital also entered.  I laughing told her the situation only to see her face grow very serious.  She informed me that owls are the servants of witches and should be killed.  Just then another woman arrived and they both began throwing holy oil and chanting prayers at the owl.  I protested to no avail.  One of the boys was sent to fetch his machete and I fled, unwilling to see the perfect little creature skewered.   I went in search of Dr. Rudy hoping he could calm the madness, but he was not to be found.  I returned, only to see the boys sitting outside. “Lo mataste?” I asked hesitantly.  They laughingly informed me that killing the little owl would be a service to the world since it was evil.  I tried to convey, in my poor Spanish, that It was just a baby bird who had gotten lost.  One of the Peter’s friends has a cute little teenage crush on me.  I seemed to be getting through to him, and again asked if they had already killed the bird, or if it was still inside?  He mumbled something in Miskito, and then told me he would let it live for me.  He opened his hands, where I had not seen that he was concealing the bird, and threw a tiny bundle of feathers skyward.  Without a sound it spread its wings and flew off towards the moon.

Siempre en la lucha

27 de Enero, 2012

A young man lies quiescent in the emergency room.  He is painfully thin, no – thin does not even begin to convey it.  He is so cachectic that every bone can be seen pushing through the fragile skin. His cheekbones seem close to piercing his face, his eyes are deep set and wounded.  The only signs of life can be found in those eyes, and the faint movement of his chest muscles as he struggles to take in oxygen.

His family brought him in.  Months and months of indeterminate fevers, months and months of blood tests – all to no avail.  Night sweats, and a cough that just wouldn’t go away, and then the weight loss started… kilograms almost literally melting away before his family’s eyes.  The doctors in the city had no answers to give, just more antibiotics, more treatments that might be the right one, and somehow never were.  What led him to come to this little rural hospital in the wilds of Honduras?  Was his family here?  They brought him by boat from hospitals with far better resources than we can offer.  Better laboratories, more tests, more scans, and updated machines.  Certainly not better doctors, but doctors can only do so much with the resources they have.

I admit when I first saw him I had two completely different feelings at the same moment.  I was filled with pain for his suffering, but I was also immediately intrigued.  Possible diagnoses started rushing through my mind.  The understanding of pathophysiology, the joy of medicine – of looking at the clues, the symptoms, and unraveling the mystery.  Putting everything together and trying to find answers – oh how I had missed the challenge!  In the Intensive Care Unit one it constantly analyzing and assessing, making minute by minute decisions and again analyzing the results.  Here is Ahuas I have many tasks, and I am learning new things daily, but there has been nothing of the critical analysis and polymorphic associational  thinking that I so love.

So, I began to think.  What can cause dramatic weight loss, intermittent fevers, and nightsweats and not show up on a blood test?  The immediate thought was TB of course, but he had had a negative tuberculosis test done in Tegucigalpa some months back.  HIV?  Malarial hepatopathy?  Had they only done a sputum sample to test for TB?  What if he actually had tuberculosis in some other part of the body – the abdomen for example – and it wasn’t showing up in the sputum?  Some sort of immunological disorder?  Dr. Ovelio was the doc on-call, and I looked over his shoulder as he ordered blood tests and xrays and discussed what more we should do.  I looked into the young man’s eyes, and squeezed his frail hand and tried to convey hope.  Perhaps we could find the answers.

Unfortunately it was both very simple, and not that easy.  The tests came back quickly and positive.  It was definitely tuberculosis of the lungs – quite advanced – and malaria to go along with it.  We started the correct treatments, but his lungs were already so damaged, his body lacking any reserves.  A day after arriving his oxygen saturation began to drop.  He was placed on supplemental oxygen to no avail.  The next morning I arrived at report to hear that his oxygen saturation was reading in the 50s.  Dr. Ovelio and I went into the tiny isolation room where he had been admitted.  Here there are no N95 respirators and negative airflow isolation precautions.  Just a small “aislado” room kept apart from the rest of the hospital where a gaunt chest was heaving his last breaths.  We tried to deep suction his lungs to no avail.  His fingers were too cold for the pulse oximeter to read.  His eyes were lifeless now, no longer seeing his father weeping beside him.  Finally we stopped trying.  His chest stopped heaving.  He was dead before seeing his 30th year.  We had all the answers – we knew what microbes infected his wasted body – but somehow the quest was no longer so intriguing.  Analysis loses its joy when the answers fail to assist in any way.

Could we have done anything different?  Probably not.  It was most likely already too late when he walked through the clinic door.  Yet it leaves me with a sense of futility and frustration – at the system, at a country where there is more need than can be sated, at myself, at the doctors from before who couldn’t diagnose him in time, at any number of things that are wrong with the world.

The struggle continues…

The struggle to find medicine and treatment for worldwide populations who cannot pay…  The struggle to not just give up when you realize how little one person can actually do…  The struggle to stretch resources to help as many people as possible without cheating anyone…

I held the father’s hand while the mother screamed.  I stayed in the little room to see the body covered in a sheet and to hear the mourners begin to sing.  The father’s sobbing slowly subsided, and then the day continued on.  There were surgeries to do, and there was insulin to give, and student nurses to oversee.  I don’t know why some deaths are so much worse than others, but when I first saw him, and he squeezed my hand, I saw the tiny glint of hope in his eyes – the hope that maybe we could save him.  But we failed.