An American Resident in Nicaragua + Jamie's Flor de caña

Hanging out with my sister in nicaragua was amazing. I already posted many beautiful pictures on Facebook of Telica (a volcano which I have to say was as amazing as it looked/probably was more amazing), however, it's my birthday, I'm drinking the flor de caña that my sister left me, alone, in between visits from Jamie and Liz Sladecek, and I recently downloaded the app Newsify so I'm pretty up to date on Ebola, the conflict between Russia and Ukraine, and IS/ a beheaded journalist who prayed the rosary openly and apparently worked for Teach for America. I'll post something warm and fuzzy about hanging with my sis later, but Rum + international news + no frantic work on projects that were due 2 months ago because it's your birthday = a poorly edited but long anticipated moment of reflection on what it means to work in a country that is not the all amazing US of A.

So Nicaragua and working in a hospital here: if you are swiss/german/canadian like most of the foreigners I have met here or American/Estadounense like me (is anyone else embarrassed that we call ourselves American like Canada, Central America, and South America don't exist?) you would not enjoy being treated at HEODRA, the teaching hospital of Oscar Danilo Rosales Arguello, aka the public hospital where everyone gets free medical care.

Does that mean it's the shady hospital that all the extranjeros (travelers) I run in to think it is? I would actually argue that it is a really great example of a developing country getting the job done. So yeah, I have an American friend who was blood typed wrong. Yes, I have witnessed that labs get "lost" (who knows where they went) and there are no bili lights/exchange transfusions are a regular occurrence. Maybe there's not defibrillator/ventilator/EKG in the PICU here. Those things are all true.

But here is what you didn't know: THESE DOCTORS ARE WELL TRAINED.
Child with crazy heart defect (to my non-medical friends) aka single right ventricle with Ebstein's anomaly (to my medical friends) comes into the ICU. I am ashamed to admit that, although I have taken care of many, many, many of these patients, the attendings here can explain the surgical repairs better than I can… even if I were allowed to explain it in English. And that's a patient that they can't do anything for, ie. they have never seen these surgeries, whereas I have seen many. They know what's up. So they can't send all the crazy tests. When I do an LP for a seizing kid in Nicaragua, I can't send pipecoic acid and B6 or whatever the hot, new spinal fluid test is. Up-to-date (a medical reference website/crutch for me/spoiled American doctors) is a luxury, and the residents here have to memorize everything.

They report the deaths of the day (mostly preterm infants) on a nearly daily basis, but they still really feel it when the 12 year old single ventricle kid comes in (who has been dying since he was born due to lack of pediatric cardiothoracic surgeons) even though there was no real point in intubating him because there is no ventilator. He just couldn't get a transplant here.

So what's different here… There isn't enough soap. There aren't enough gloves. We had a ward full of urinary tract infections and no media to grow urine cultures on. There is no ventilator, defibrillator, or EKG in the PICU… because the machines walked away/broke. The laryngoscope is a size 1 (that's for babies. You use your finger to help you intubate a kid over a few months old). The cockroaches live side by side with the patients/doctors, and we ran out of IV fluids last week.

That stuff is all pretty bad, but there is good news: they have really good doctors here.
Sorry doctors with a master's degree in global health, they don't need you/me. They need the baptist organization that came to evaluate the PICU to see what they would need to do to renovate it/make it an actual ICU. They need the organizations that come (on a pretty regular basis) to bring medical equipment, not just balloons. They would probably also love to work with the Global health masters students when they have to do their research projects (every resident has to do one) because who wouldn't want to work with an enthusiastic grad student who could devote 10 weeks to collecting/processing data when you work 36hrs straight on a Q4 day schedule (every 4 days they work 36 hours straight for all 3 years of residency).

If I had to state 3 things this hospital needs, it would be the following:
1. Mission groups to solicit which supplies the hospital needs/Nica residents to take the time to make a list.
2. Philanthropic organizations that can buy big ticket items/renovations
3. Global health researchers to look at supply chain issues for lower cost hospital supplies

If I could add a 4th thing that I'm interested in, it would be connecting doctors/residents conducting research in Nicaragua with global heath students in the US. I really think it would be a win-win to foster partnerships between Nica residents and US global health students.

So what does that have to do with world events?
A pretty amazing human/doctor from a hospital where several of my friends rotated in medical school was the doctor with Ebola who came to Atlanta. I genuinely believe that he is the personification of what it means to be Christ to others through medical mission work, and I deeply respect how he has handled his situation.

As a person working in global health with thoughts of medical mission work, I have to say, I doubt this situation completely blind sided him. I'm sure he didn't head to Liberia expecting to nearly die, but there is an inherent acceptance of risk when you sign on to be a medical mission worker. Why doesn't everyone do it? It's hard. The conditions are bad/waaaay worse that the American standard of living. And yes, you may get some weird, incurable disease. Hate to break it to you, but there are actually lots of options. I know one friend to had the privilege of experiencing Malaria in Africa (shout out Chelsea Whittle/lets be clear, and I'm being sarcastic when I say privilege). There is a remote chance that I could get dengue, malaria, or chikungunya here in Nicaragua (don't worry, mom, it's unlikely). That's not to mention ebola and marburg. I would be silly to just take those risks for granted. The same as journalists in war-torn lands and doctors in developing countries generally know (or quickly find out) exactly what risks they are taking, I have considered that working here is not a safe option.

Why mention this? It's not to say that I'm doing anything praise-worthy here - I'm pretty sure I'm benefiting more from this experience that the Nicararaguans I work with. What I am saying is that the world needs more people like Kent Brantly and James Foley, more people like the teachers who cleaned up Ferguson when school was closed, more people who are the average joe with their own short comings, but who show up to the fight. The more I see of the world, the more I realize that the majority of human beings are a mess with potential for amazing good. You don't have to be a selfless humanitarian, or on the fast track to sainthood. Despite all of the horrible atrocities in the news today, the people I just mentioned and the doctors in Nicaragua who care for their patients despite a frustrating lack of resources are an inspiration to me and remind me that, even in dark times, all is not lost. The quote that I first heard on NET and than I come back to over and over again seems like a fitting end to this post:

It is not the critic who counts; nor the one who points out how the strong person stumbled, or where the doer of a deed could have done better.

The credit belongs to the person who is actually in the arena; whose face is marred by dust and sweat and blood, who strives valiantly; who errs and comes short again and again, because there is no effort without error and shortcoming; who does actually strive to do deeds; who knows the great enthusiasms, the great devotion, spends oneself in a worthy cause; who at the best knows in the end the triumph of high achievement; and who at worst, if he or she fails, at least fails while daring greatly.

Far better it is to dare mighty things, to win glorious triumphs even though checkered by failure, than to rank with those timid spirits who neither enjoy nor suffer much because they live in the gray twilight that knows neither victory nor defeat.

- Theodore Roosevelt

There are ebola outbreaks, mobs looting local shops, no ventilators, and violent extremists, but there are also doctors who give away the one treatment option, teachers who model civic duty, journalists who dive into war-torn land to share their story with the world, and the average doctor in Nicaragua who doesn't immigrate to the US but stays to take care of their country. Some of those stories have a happy ending. Some do not or are ambiguous. However, if we aren't failing often, it is unlikely that we will ever win glorious triumphs. Now maybe take a moment to pray for those who take these risks day after day and think about what small risks you could take.

Multilingual

I've been to surfing turtle a few times on the weekend, just for the day. I think it's my favorite because it's quiet, no body cat calls at me, and there are fun travelers to talk to about their adventures. This weekend I had enough time on Friday to come out and spend the night for the first time. It was the usual swimming, sunning, and volleyball with the bonus of having some cool girls from Maryland, a Dutch couple, and a Canadian/Egyptian couple to talk to. I love hearing travel stories from other people. Americans should travel like Germans and Canadians do. I've met a ton of Germans and Canadians here, but not a lot of Americans, except at this fancy beach hostel. I mean it's beautiful, but you can't really learn about a country if you don't live there a little while. 

Maybe it's because we have boat loads of debt when we're done with college, so there's no way to spend the summer after college volunteering in a Nicaraguan after school program (that's what the German and Swiss people in my hotel are doing). Maybe we don't speak enough languages. I was in the kitchen with two of my Swiss/German friends and a French couple walked by. My friends attempted some French, but ultimately were very disappointed in themselves for not being able so speak more French. These are the girls who natively speak German, talk to me in nearly perfect English, and spend their days teaching Nica kids in Spanish. But they really thought they should also be fluent in French. I'm pretty sure I'm not the only American who is pretty proud of herself for being reasonably fluent in one other language. I'll admit, this trip has made me think maybe I should have learned some German (like Charlotte McNabb) in high school. It would be much easier to talk with my hotel mates. 

I'm going to pretend like it's because we don't have nearby countries to travel to and practice our new languages (… please ignore Mexico and the French Canadians - they're so far away). A Dutch couple from Surfing Turtle told me that (in some schools) they study English from the age of 4, and by high school are studying German, English, French, and Spanish. I don't know how much of it they remember, but can you imagine an American school being successful at that? Another girl in the Surfing Turtle conversation told me that she teaches elementary school in Maryland and that her school is implementing "integrated" Spanish curriculum where they insert Spanish phrases into the usual, day-to-day lessons. At first I thought that sounded ok (after a certain age, it's impossible to pick up an accent if you've never heard it. Why not expose kids to a bit of another language at an early age?). Then she told be that the promotional video for the program featured a principal saying "Hola!" with her thick Wisconsinian accent… maybe not as helpful as I thought. 

I don't have any pics for this, so here are a few bonuses:

Storm rolling towards the Cathedral

I leave for a few months and my parents do this… I love those crazy kids.

Surfeando

Last weekend I tried to surfear (yup. That's how you say "to surf" in Spanish/in Nicaragua). You will notice there are no pictures of me actually surfing. This is for two reasons: I'm trying to live in the moment guys! You can't spend all your time making people take pictures of you, forgetting to live life. Also I never really stood up on the board... But here's a picture with someone else's board (I really didn't think to take pictures until someone else was using my board). 

Poneloya

Not me surfing

My surf instructor was a very ambitious 16 year old from Nicaragua who tried to convince me he was a 20 year old from San Diego. I mentioned before that the current is super strong here so I would walk out with the board a little ways (by walk I mean move my legs without going forward and then get knocked over or washed back 3 feet by the next wave), and then he would sort of pull me and the board to some surfable location. He'd turn the board around and give me a push when the right wave came. At best I would get into a squating position (like a toddler playing in the mud) before falling off again. So many bruises. But no blood this time. We did that routine for about an hour and I realized I needed to go join crossfit and then come back and try again. It really was fun, but I think it would really help if I had exercised at all in the last 3 months. We'll see how things go once Liz gets here :). 

gatorade, pancakes, and Chinandega

I got my obligatory bought of GI distress after safely making it nearly 3 weeks living off street food. Really I think it was a virus - the whole hotel had it, and we don't exactly use a dishwasher… or have hot water for the washing of communal dishes. I slept for an entire day in between trips to the bathroom, but the next two days were the weekend. Although the idea of eating was unappealing, I no longer needed a toilet at my side. What was I supposed to do? Lay around all day in my warm room, with my dwindling groceries and watch tv all day? Why not go with my hotel-mates and lay around all day an the beach with the healthful sea air to cure me and Gatorade and pancakes at my fingertips.

I only needed a few of the zofran that I badgered the travel doc into giving me. 

The next weekend, I went on a weekend adventure with the resident I had been working with. All of the residents have been super nice. Helen is the resident who was stuck with me following her around for the first month. Not only did she put up with me asking for excruciating details about how to write a note here, but she invites me to her family's house in Chinandega, a nearby town. 

She was post call Saturday, so we went for breakfast and then took a bus from the main terminal in León to her house. She took me to the grocery store and told me what all the fruits and vegetables were. This is a sapodilla. It is delicious and surely horrible for you. 

Sounds like a small thing, but it was actually super helpful. We bought a few candies and fruits to try and headed to a fair in town. It was the feast day of Saint Anne, the patron saint of the town. 

Helen and her super cute niece.

Saint Anne float

walking through the market

I drank about a gallon of pitaya juice (dragon fruit), and found out later that it turns your pee red/I wasn't dying. 

Her dad works in some sort of management position at a fishing company (Chinandega is close to the shore). He brought home shrimp and some kind of fish I've never heard of and couldn't translate. The first night he made this delicious tomato based shrimp dish and the next day Helen cooked these guys - mmmm:

Helen kept laughing at me for taking so many pictures of food. Apparently I'm a typical American http://kitchenette.jezebel.com/ny-restaurant-figures-out-surprising-reason-for-custome-1604058077. I guess this post is full of food. weird. 

She took me to the mall (there isn't one in León and it was pretty fancy). There was no GAP, but we went to the flor de caña store (famous Nicaraguan rum), and I convinced her to drink some with me. Rum > GAP.

We didn't get back until the next morning just in time for work, so it was a little mentally exhausting, but totally worth it. 

beaches and mangroves 7/19-7/20

Meredith had advised me that German travelers were avid tourists and that I could probably just tag along with them. On my second weekend, they were going on a mangrove tour. Mangroves are trees the have some crazy looking roots that grow out of the branches and and keep the salinity of the estuaries stable. Here are a bunch of pics from that. 

Near the end of the trip, you stop at a deserted beach that is a sea turtle reserve you can stay there for $10 a night + meals and watch the turtles come up on the beach at night. There are always a few turtles, but it's not quite the season (mid August to October). It was gorgeous. In addition to being beautiful, the horizon is empty apart from ocean and sky. I think every other time I've seen the ocean there have been boats and oil rigs in the distance. 

After the tour we had fresh seafood for lunch and then went to surfing turtle lodge for the rest of the day.

The current is super strong here, so we took a few spills in the waves. Around the time I was getting the hang of it, the girls I was with looked at me with concern and asked me if I was ok. I had a tiny bit of sand in my eye but I smiled and said I was fine. They still looked mildly horrified. It turned out I looked like a character from a horror movie with a steam of blood and salt water flowing from my nose. Oops. Probably from pinching my nose while wearing a nose ring... But I couldn't feel it at all.

We sunbathed and played a volleyball tournament before dinner. After watching the sun go down, we took the last boat off the island and headed back home

Hot mass

You've heard of hot yoga (link to Craigslist yoga mat). It's the body bending, core work out all know and pretend to occasionally do plus the added excitement of a thermostat set to a balmy 105 degrees (In Texas you can just go outside). The idea is (I think) that the heat loosens your muscles allowing you to do the poses better while simultaneously allowing/forcing you to sweat out more toxins/life giving water.

Hot mass is similar. For those who are not with it enough to make it to 8am mass, a 10:30 mass is available. The first thing I notice was this guy: 

Can't see him? Try this:

Still no? Here:

I arrived at mass at 10, so I got to be there for the rosary. By the end of the rosary, I was perspiring. On later Sundays I realized this was partially because I was not seated between the open doors with a through breeze, but in this rookie state, I didn't know any better. Mass started and things started heating up. As I sat there, I felt the similarity to hot yoga and imagined the sweat dripping down my back to be toxins leaving. I was at mass, maybe it could be like sin leaving. Offering up the sweltering heat for forgiveness of sins? The closer I got to being able to bend into flying cow pose, or whatever, the more I had to remind myself to sit like a lady. Half way through the homily, the godpigeon couldn't take the heat and took off. I made it to the end, but I'm pretty sure I at least sweated out some minor offenses. 

6 stages of transition

I think a new job is always a bumpy ride. Here are the stages I've gone through in the last week:

1. Enthusiasm:
Yay! Nicaragua - it's beautiful, it's hot (this is great! I miss Texas!), my Spanish is going to be so awesome, beaches!

2. Charlie Brown's teacher:
What language are these people speaking? I think they pronounce the first consonant, and after that, all I hear is vowels. (I thi the proou the fir coos, an afe tha, al I hea i voe =  Mwah mwah mwah mwa mwah).

3. 3rd year medical student:
That was most of last week. It was like being in 3rd year of medical school for 3 reasons:

• The words that a doctor says to other doctors always sounds like another language. It was like trying to get a Spanish speaking person to teach me German. I understood about 80% of their Spanish at best. then they started saying all of the peculiarities of medicine… 
• the pimping. Duke attendings just don't ask the level of biochemical detail that my attendings in medical school did. But don't worry, all my ex-attendings from medical school, my Nica attending has taken up the torch and asked me for the specific cell wall composition of staphylococcus and the factors that make it more likely to create an abscess. If only I could understand the questions…
• I was totally useless last week/annoying. Given that I couldn't understand half of what my attending/coworkers said, I was not trustable to take a history or write a note/discharge summary/order/find the lab/find radiology/answer questions from patients/call consults. I actually attempted a discharge summary (unsolicited) and my very sweet (intern) resident that I'm following around told me it was a great effort but I did it all wrong… in the nicest way possible. I tried not to hover, or look like I was slacking/uninterested. Yes. I've done this before. In medical school. blah. 

4. Awesome weekend:

What to do when you feel defeated at the end of your first week? tag along with some nice german/swiss people to go on a mangrove tour/to the beach!!

These lovely humans whom also live in my hotel let me tag along on a wild life tour that culminated on a deserted beach reserve where sea turtles lay their eggs (at night - I didn't get to see any). 

low tide 

some nice german friends

me and some manglares (mangroves)

these are mangrove trees (red mangroves). Their branches grow into the water of estuaries like roots and keep the salt content of the water stable so that the estuaries can be the hot bed of... marine reproduction… that they are. 

the turtle reserve. horrible view. very crowded. apparently you can rent a cabin their for $10 a night and watch the turtles at night. 

obligatory pic with the water. 

coming back to the town near the tour

Then a few of us went and found http://www.surfingturtlelodge.com , which was gorgeous, and (bonus!) there was no death grip riptide so we got to go swimming :). 

Sidebar: While out jumping in the waves, my new friends started looking at me with concern and asking if I was ok. I had a tiny bit of sand in my eye, so I blinked it away, and smiled, and said of course I was fine. It turned out that, in the process of pinching my nose to avoid a netti-pot-like nasal lavage I had stabbed my nose with my nose ring. Apparently had blood streaming down my face and chin like a bad vampire movie. I got out of the water (to avoid attracting sharks, of course) and pinched my nose like a good pediatrician until I wasn't wiping away handfuls of blood every time I let go. To be clear - it didn't hurt at all, but I guess the salt water that was also running down my face diluted it and made it look like I was hemorrhaging in front of my new (non-medical) friends' eyes. sadly, no pictures were taken of this event. 

since I had abandoned the water, we transitioned to laying on the beach and drinking. this was followed by a game of volleyball that my team ended up winning by a "rock off." Apparently this is the non-american but infinitely cooler way of saying playing rock, paper, scissors. We had 3 teams, the teams each had a match against each other, and each team won one/lost one, so we rocked off to settle the score. allegedly, the winning team got free drinks and the losing team had to dance on the bar and get iced (throw back an entire smirinoff ice while on one knee), but we had to leave before these things occurred. 

Surfing turtle lodge is on a peninsula that you have to take a boat to reach, and we left with the cooking staff, so it was a beautiful walk to the boat (on the beach with the full moon out and lighting in the distance (far distance) over the water). 

Unfortunately, at the end of the day, I learned another white girl lesson. It sounds responsible to put on your sunscreen before you leave for the day. However, if you sit for an hour with your backpack in your lap and one leg against the bus seat in front of you, this is your prize:

5. 4th year medical student! 

some how, over the weekend, the people I'm working with realized that they have to talk to me slowly and enunciate (like an elderly person whose hearing aids don't work), so I understood most of what happened today. I also learned to write notes!!!!!!!!!!!!! and I'm really excited about it. just like a 4th year medical student. I can do something useful!!! and the shine hasn't worn off from having to write 8 notes an hour like it's my job. today went better. 

Now i'm hopeful for the future: step 6: resident/fluent spanish speaker??

soccer and socializing

It's easy to forget here that I still have real life things that I need to do - apply for fellowship, a QI project... Yesterday I slept some and then went to meet Ellie's friend Meredith to watch the soccer game and play with the baby. On the way home, I noticed a bar right next to my house that had some orange-clad Dutch people amassing for the afternoon game. 

Since I've been here, my inner shy person and made a reappearance, but, as always, I would rather have a few minutes of awkwardly introducing myself than spend any amount of time lonely/awkwardly hanging out by myself (in this case, I think that would mean watching spanish dubbed movies in my hotel room for two months - unappealing).

I suppressed the social anxiety and dove into the crowd of Dutch. Within minutes if acquiring my Victoria (local beer) a Dutch woman who who turned out to be the owner of the bar had painted my cheeks with a face paint crayon in the design of the flag of holland. 

My neighbor proudly explained to me what a skilled diver Robben is, and, in typical American style, I explained why I thought Tim Howard is the best keeper in this World Cup (although the guy said the Costa Rican goalie unarguably had saved more goals in total). Psh. But did he save 16 in one game?

By the end of the game, I made a friend, and we spent Saturday night exploring the night life. Have I mentioned yet that I'm turning 30 while I'm here. We went to a hostel where some other Dutch people were staying and collected a group for going out. I would guess that the average world traveler these days, based on this hostel, is no older than 25. Subtext- I felt old. Just going to say it once. From now on let's call it feeling wise.

One of our new Dutch friends blissfully continued his 12 hour buzz in celebration of World Cup success while being that awesome drunk guy who has happily befriended everyone in a 100 yard radius within 10 minutes. Meanwhile, a kindred spirit and I drank about a gallon of water (weather than alcohol) while dancing in what I can only assume was a sauna fueled by body heat and human sweat. This kindred spirit is an American who shared my desire for personal space on the dance floor - it's always nice when you're not the only person who finds it weird that it's socially acceptable to dance all over near strangers.

When we could no longer take the heat, we wandered back to the hostel (Bigfoot hostel). On the way, we picked up some street meat and gallo pinto. It's just rice mixed with beans, but it seems to be the breakfast, lunch, and dinner of champions here. Bigfoot was playing some sweet jams that took me back to high school and everyone else back to infancy (new music!). J/k everyone knew the songs and politely agreed with me when I yelled something about flashbacks to high school.

Around 1am I resisted the urge to dance all night and some of my new friends were nice enough to walk me back to my hotel. Don't worry. It wasn't hard to wake up for mass. They ring bells before mass and shoot off fireworks after mass. Yup. Fireworks. After every mass. It's broad daylight so it's the equivalent of gunfire in beauty and sound. I'm pretty sure there was a 6:30 mass. Definitely an 8am mass. And I made it to the 10am. Really I got to the cathedral at 8:30 because the hotel people told me mass was at 9, but that just meant I got to eat breakfast and write this before the 10 am. Here's breakfast: nacatamales and coffee :). 

Otherwise known as breakfast tomales as far as I can tell. I love traveling. If being a doctor doesn't work out, I'm just going to move here and teach surf lessons. Right after I learn to surf.

Leon, Nicaragua

Long time since I've blogged. Equally long time since I have traveled like this. As I started writing this, I realized that I am in a bright yellow hotel room, exactly the color of the hotel room that I used to stay at in La Esperanza. I can't decide if that makes me feel more at home or not. Here's how it's gone so far:

The good: 

- Ellie (my chief resident) got me in contact with one of her friends who still lives here. She was wonderful enough to get coffee with me, walk the city a little, summarize the last 100 years of Nicaraguan history for me, and let me play with her baby. So that was pretty great. 

- my taxi driver from the airport was perfectly on time and I successfully had a meaningful conversation with him in Spanish on the 2 hour drive from Managua to Leon.

- this city is so walk-able.

- I found the ATMs and bought a local phone. 

- viber works well, so I can have long conversations with far away people with that app. 

- my hotel room is perfect. 

- people seem nice. 

The mild to moderately inconvenient:

- american airlines gave me a pretty annoying 12 hour journey from Austin to Managua. Such jerks. But I guess it could have been better if I hadn't chosen a flight with two layovers. That was my fault. 

- My Spanish is variably good enough depending on the topic of conversation is. I went to the hospital today to meet people and get things set up. It's like starting wards in medical school - a whole new language - except in a language that I understand 85% of at baseline. When I started on the wards in medical school, I had to ask what things meant all the time, except people were speaking English. We just use a lot of short hand and jargon in medicine. Now it's Spanish and I can't decide if I people are saying weird hospital-isms or if my Spanish just isn't good enough. I repeat back everything people say six times just to make sure I understand. It's important things, like their expectations of me and where I'm supposed to be on Monday. 

- I've forgotten how to be a good traveler: do you take the passport and leave the copy or take the copy and leave the passport? I think the former. Can I flush the toilet paper? probably not…? No using the air conditioner during the day. 

- missing 4th of july at home/ the best fireworks ever by one day. 

Over all, Ellie's friend made me really excited about the city, and I'm pretty sure my Spanish is going to be awesome by the time I'm done here. This is going to be great.