¡Hola! ¿Cómo están y sus familias? Hoy, escribo sobre nuestro viaje al campo- a El Roblar.  El Roblar es una comunidad en las montañas, nord y este de Managua- esta cerca San Jose de Los Remates, y tiene 500 pesonas- aproximamente 90 familias.  MINSA tiene una clinica en San Jose, pero el aceso no es facil por la gente que vive en la comunidades de las montañas. Pues, AMOS tiene una oficina en San Jose, también, y le da apoyo a la comunidad de El Roblar. Hay una promotora de la salud, Ariela. Ella es una de la comunidad y les da cuido a la gente aqui.  Visita las embarazadas y niños, les da tratimiento a los enfermos (cronicos y agudos), y le da educación a la comunidad- en escuela y charlas de  El Roblar.  Hay un comité de Salud en El Roblar- consiste a miembros de la comunidad.  En charlas, miembros hablan de la salud de la comunidad y hacen planes a mejorar.  Pronto, enseña las madres sobre nutricióny anemia.  Además, AMOS le ayuda Ariela a recomendar por El Roblar con MINSA.

¡Manos Limpios!
(Clean Hands!)





En Inglés:  Today I write about our trip to El Roblar, one of the many mountain communities here in Nicaragua.  It consists of 500 people, about 90 families. It is north and east of Managua, near a village called San Jose de Los Remates.  There is a MINSA clinic (Centro de la Salud) in San Jose, but it is not easily accessible for those who live 6-8000 meters above, especially when there are not really any roads- but paths-- that often ascend (or descend- depending which way one is headed) rapidly.  AMOS also has an office in San Jose, and has trained Ariela to be a health promoter in El Roblar. She is a member of that mountain community (--and will start nursing school next year--) and provides care: prenatal & postnatal visits, treats people with chronic & acute diseases (and makes appropriate referrals), and educates the community about health issues. She also facilitates the health committee of the community.  We attended a meeting- the involvement was very impressive.  In order to address the issue of childhood anemia, the committee is going to begin to have nutritional education for mothers & families. AMOS also helps the promoters learn how to advocate for their communities with the government.

The Hike to El Roblar is a bit arduous- I really enjoyed it, but at the same time, I cannot imagine hiking either way And being 38 weeks pregnant- or suffering from an illness...or being debilitated in any form or fashion. In addition, once one has ascended up the mountain side, the houses are not collected in any type of fashion that one from a more urbanized area would consider a village, or hamlet.  Saying that- families often live closer- but one's nearest neighbor might be a 1/2mile or more away.  The photo to the right reflects a picture I took whilst only partially up the mountain side- one can see San Jose in the distance. 

Now we are back in Managua, and tomorrow is our last day of clinic.  It has been a really good time, I will elaborate a little more on this in another blog.  I think that both Caroline and I are really appreciative of this experience- and have learned alot about Nicaragua, the people, and (of course) the clinical aspects- especially in another language.  The brain gets quite full at times.  I have great empathy for those who come to our country and the difficulties they have with English. In improving Spanish, there are days where it is easier than others, and depending on how tired, or anxious, or whatever I am, the language is easier or more difficult.  It was gratifying to hear today, from Dr Gonzalez, that she saw a patient today that Caroline & I saw last week- the patient said she didn't think we understood her- but when Dr Gonzalez reviewed our Soap note, we had understood her perfectly & ordered the appropriate treatment for her complaints- and then told this to the patient.  Also- the people we have come across have been very kind and patient with our language skills- and have also helped us.  Here is to hoping for good relations between North and Central Americans. 

                                  

¡Buenas Noches, amigos-- espero que Uds. estan bien esta noche!  Pues, clinic is wrapping up- since the last time we wrote, we have continued to see patients with urinary complaints, dizziness, respiratory infections, and tinea versicolor.  We learned a new word for urinary symptoms, "chistata", which includes burning, pain, and frequency.
Very few people drink enough water here- we have done alot of educating about the benefits of agua consumption- I thought about pulling out the old "Bebe Agua" song our group wrote last year for the Honduras trip, but didn't want to end up in a Nicaraguan prison for assaulting someone's ears.....

As far as living here is Nicaragua, we have learned a few things:
1.  Nicaraguans are a very kind, hardy people.  They are durable and are able to sustain things that we in the USA would crumple at the thought of.  We have met some really great people not only here & in clinic, but also out on our escapades through the country-- let me add that they are patient, too, as we stumble & grow in our language capabilities. 
 2.  Time is not a fixed entity.  A rigid person would not survive well here. Time is very fluid and changeable.  A few minutes may be literally only a few-- while at other times....in USA terms, it would be a "long" time. The same is true with the internet connection: "a click away" has varying lengths of time. 
3.  Nicaragua is a very eclectic country.  I have seen a lot of what R. Coburn describes in his book, "My Car in Managua".  I think that you could find anything here-- if you look for it in the right place. There are certainly all types of transport on the roads: cars, buses, vans, bicycle taxis, horse carts, and ox carts....this includes major roads, like the Carretera Sur and Carretera Vieja León.
4.  Implementation of a plan is difficult- and often what is on paper does not match up with what actually happens; although this is true anywhere.

5.  Some are starting to come around in valuing women.  In one of the first meetings/rides that we had with Miguel, our wonderful taxi driver here in Managua, he let us know that he did not beat his wife.  We have seen other promoters of the worth of women in our travels as well.  Medical care- if one can access it, it quite quick to initiate specialty referrals for both women and children.
6....And, finally, the bus is not actually "full" until there are so many people in said bus, that the door cannot close..and even that is variable, as sometimes there are riders on the outside.

 I am grateful for the time that I have spent here. It has been a real growing experience that I am not likely to forget anytime soon.  Hopefully I will be able to bring the family for some of the Spanish/cultural schools...they can learn what it is like to live in 95 heat without air-conditioning!! (and see that children can, indeed survive without video games/computers...etc). Yes, John & Christian I love you!

                                                                               Pupito

¡Buenos Dias y Saludos!  Es un día muy bonito aqui. Anoche tenemos lluvia y ahorita el tiempo hace menos calor.  La Clinica Samaritano fue muy bien.  Martes fue el día de scabiosis, y ayer fue el día de bebe.  Tenemos muchos bebes- todos fueron muy hermoso y bonito...y cuddly (no se como a decir "cuddly" en español)  También, vemos varios pacientes con diabetes y hipertensión.  Carolina y yo hacemos un presenctacion de power point por la comunidad y Dr Parajon sobre diabetes. Un grupo de apoyo de diabetes empieza pronto.

En Inglés:
Hello!  It is a beautiful day here: we had some rain last night that has cooled things off well.  Clinic El Samaritano continues to go well.  Tuesday was scabies day, and yesterday was baby's day.  We had some beautiful little ones.....We also saw a few patients with diabetes & HTN.  Caroline and I are presently working on a presentation about diabetes in spanish for Dr Parajón to use in a local community support group that begins soon.

¡Hola todos! ¿Cómo estan?  Somos bien- poquizas un poco cansado, pero no esta mal.  Hoy, digamos clinica y León (León despues).  Clinica continua bien, nuestros pacientes son muy amables y simpaticos.  Nuestras abilidades de la lengua estan mejorando, pero a veces esta dificil. Jueves, pregunte un hombre a hablar un poco mas alta porque yo no lo oige--- pues, el vino cerca a mi, y dice muy alta y despacio el problema. :)  Fue no enojado, solamente piense que yo no puedo oir.

Además, tenemos un reunión Viernes con Dr. Parajón.  Hablamos sobre clinica y lombrices.  Aparece qui, ascardis y giardia tienen un compañera- trichuris.  In Inglés, trichuris es "whipworm".  Necesita les da pacientes mas de un pastilla de Allbendazole a removar trichuris.  Normalmente, recetamos Albendazole por 3 dias.   La fundación Amos quiere ayudar MINSA a hacer las guías mas corriente sobre lombrices.

From Caroline: This weekend we visited Leon, the former capital of Nicaragua.  It is a beautiful town with many cathedrals to visit, as well as a large university, including a medical school.  Saturday we arrived early and were able to walk and tour the city before an afternoon horseback riding tour.  We went to Rancho Los Alpes, just outside of Leon.  We rode through the farm and down the road to a local family home.  The family showed us how to milk a cow, and how to make corn tortillas from scratch.  The family participates in a program with Rancho Los Alpes to help teach others about their way of life.  The creator of the program at Rancho Los Alpes met with us at the family’s home and told us about her views on helping the community she lives and works in.  They are doing some great things to help teach tourists about Nicaragua and help the community as well.

Today we went hiking with a group called Quetzaltrekkers.  They are a non profit organization that helps three main community groups in the Leon area.  They plan hikes and camping trips to make money to give to the groups as well as sharing their volunteers with the group.  They took us to Cerro Negro, a relatively young volcano in Nicaragua.  We made the climb in a little over an hour, and then slid down the volcano side on a board fashioned as a sled.  It was a wonderful experience and had some great views.
If you are interested in viewing what these two groups do, click here:
http://ecolodgelosalpes.com/
http://www.quetzaltrekkers.com/

¡Salud!  Espero que Uds. estan bien.  Estoy muy cansada ahorita.  Hice mucho calor hoy, y no viento. Ayer, el viento le ayuda el tiempo a sentir comfortable.  Pero, no lloro :)  Tenemos algunas pacientes interesantes hoy- una  jovena que tiene Bell's Palsy, un hombre que tiene cólesterol muy, muy alta- el nivel fue 702.  Recibió una receta para Pravastatina, aspirina, y una referida al cardiológo. Además, recibió educacion de viviendo saludable. No tenía obesidad- solo un poco sobrepeso, pues, la cólesterol problamente esta parte genetico.  Ayer, envíamos al hospital un hombre que tuve presion arterial alta- 160/120 al brazo derecha y 172/120  al brazo izquierdo y dolor de pecho.  Hoy, regresó a la clinica mejora. No tenía infarto o otros problemas. En hospital, hayan hecho electrocardiograma, hayan sacado sangre, y le hayan dado medicina, pero el no pudo a contar cuales medicinas o resultados ha tenido. Pues, sacamos mas sangre a cheqear la colesterol y triglycerides. Fue alta, y recetamos para Omega-3 porque no quiere a pagar de Pravastatina o otros medicamentos.  Aun cuando la clinica tiene bajos costos, no son bajo por todo.  Algunas pacientes no quieren a pagar mas para laborotorios o algunos medicamentos. No todos laborotorios o medicamentos estan gratis aqui, pues a veces se siente a poco a la sistema de la salud in Los Estados Unidos.  Algunos pacientes no dicen que nuestra clinica no es cara, pero algunos tienen ansiedad de los. Costos son importante. 

En comparación, los cargas de un pocos otros hospitales privados son eso: a dos, Ud paga 552-575 cordobas por consultación emergencia. No incluye otras necesitas. Al otro la carga es dependiente en nivel de consultación: 690- 1610 cordobas. Pues, 50 cordobas a Amos Esperanza y Salud es bien.  No se las cargas de otras clinicas. 

Continuamos a trabajar en Español. Continuamos aprendiendo. Dra Gonzales es muy bien- nos ayuda cuando la necesitamos.

En Ingles:
So- today was hot!! and interesting.  We had some patients with some pathologies- a young girl with Bell's Palsy, and a middle aged man with a cholesterol level of 702. There is not a lipidologist here, so we are starting him on pravastatin, aspirin, and sending him to the cardiologist. He is not terribly overweight, so there it probably has a genetic component.  Yesterday, we sent a man to emergently to the hospital with  hypertensive crisis: 160/120 in the right arm & 172/120 on the left.  He returned today- said that he did not have an MI- and also that they ran an EKG, some labs, and gave him some medicines, but could not remember any results or what the meds were. He was better today, so we checked his cholesterol & treated the elavation with Omega-3 Fish oil, because he did not want to pay for Pravastatin. Which leads now into the economic discussion:  although Amos is a low cost clinic, it is not low cost for all.  We have had some patients tell us how reasonable and low the costs are, but some are very concerned when they have to pay for some meds & lab services. Not everything is included in the consult cost.  It is similar to the US- cost is really important.

In comparison,   at a couple of the private hospitals, it costs any where from 552-575 cordobas (C$) ( I am using cordobas, because if I were Nicaraguan, that is what I would be paid in.) to have an emergent consultation. Another's charges depend on the level of consultation, and range from 690-1610 C$.  So, the 50 C$ at Amos is pretty low, although I am not sure what other private clinics charge.  To be fair, the MINSA hospital will see you emergently if needed without charge, but you will pay for other items, as noted before. So access to health care is still an issue here- and not only from economic issues, but also geography.  Matagalpa, Jinotega, and the eastern side of Nicaragua have the lowest access rates due to lack of clinic and provider availability. It is difficult to access health care if there are no providers near you.

In conclusion, I'll leave you with a poem written by Javier Campos, called "Return to Sender"  It reflects that although the streets have names here, they are not posted.  It is amazing how people learn how to get around.

Return to sender (Managua, Nicaragua Postal Service) I

Turn at the corner known as “gallo más gallo”
2 blocks toward the lake, and at Doña Blanquita the Belle’s house
look to the right and up a little
as toward the sky and then lower your gaze to the tree charred
in the earthquake, right there where
Don Francisco props himself up in the window to talk
with Pedro Xavier and that Gloria girl,
at the next house take just three steps,
knock on the door where there’s always a rocker,
and deliver these poems and this letter, please.
And if nobody takes them or the person whose name
is written on the envelope is no longer living,
return to where you came from.
Go slow, looking over your shoulder,
who knows if the address is right,
and perhaps someone will ask you, Mr. Mailman,
who are you looking for to these many hours in this neighborhood
in Managua?

Hola :)   Hoy fue un buen dia- no observamos pacientes con Dra. Gonzalez- vemos unas pacientes: amigdalitis, otitis, dermatitis, infección de la orina, impetigo...y sintomas de menopausia, por ejemplos. Los primeros pacientes fueron un poco dificil porque además estabamos aprendendo cuales farmaceuticas actualmente estaban en la farmacia- y a veces tenemos dificultades con la lengua-- pero, los pacientes tenían muchas paciencia, y fueron muy amable. Mejoramos durante el dia.

Farmaceutica del dia:
       Ambroxol:
                        nombre comercial- Acitiviton, Muconorm,  Ambronorm
                         indicación: tos- es mucolitico, fluidacante, y expectorante. usa con bronquitis (aguda o crónica), neumonía,  o asma que hayan retención de los secreciones
                        No usa en el primero trimestre de embarazada.  Ten cuidado con mujeres lactando.
                        Efectos: Ocasionalmente náuseas, pirosis, dispepsia, vómitos y diarreas
                        Dosis: Niños menores de 2 años:  ½ cucharadita (2,5 mL) dos veces por día.
                                   Niños de 2 – 6 años: ½ cucharadita (2,5 mL) tres veces por día.
                                   Niños de 6 – 12 años: 1 cucharadita (5 mL) dos o tres veces por día.
                                   Adultos y mayores de 12 años: 2 cucharaditas (10 mL) tres veces por
                                   día.
                       Interacciones:  Ambroxol aumenta esos antibioticos en tejido pulmonar:            
                                   amoxicilina, doxiclina, cefoxurima, y eritromicina.  No aparece ser perjudicial.
                                   Toma con comida.
                       Información de monografia de Ambroxol.

En Inglés:  So, basically, Ambroxol is a mucolytic used to help loosen secretions.  It should not be used in the 1st trimester of pregnancy, and, with caution in lactating mothers because it is excreted in breast milk. It augments the above antibiotics in the pulmonary tissue, but this doesn't seem to cause harm. Side effects include N/V, dyspepsia, and heartburn, so it should be taken with food. I hope that no one minds the "drug of the day", but it helps me to learn about medications here.  We are planning a visit to a local pharmacy.
    
Today was a good, but challenging day- we did not shadow today.  It was a day to treat patients.
We saw several, although clinic was not terribly busy. We also learned which medications were actually in the pharmacy- although we had a list, there was still a little trial & error!  Fortunately, our patients were very patient- our language skills are growing rapidly, but there is still lots of room for improvemnet. As the day progressed, the language part got better, and when we really needed help, Dra. Gonzales helped us. 

Now- for Easter.  There seem to be 2 opposing view points on how to celebrate the holiday.  Some people choose to go to church and have a quiet dinner at home with family- and maybe go to a private (and quiet) beach.  Some choose to go to San Juan del Sur .... and Fiesta. There does not seem to be one typical Easter dinner- at least with the people that we know.  When in Granada, the main church was decorated outside with...not really stations of the cross, but scenes related.  We did not see any processionals, but there were some people viewing the scenes. 

¡Saludos de San Juan del Sur!  Ha estado una aventura interesante:
Si no le gusta el gentío, ruido, y congestión de los carros,
no vayan a SJDS durante la Semana Santa.  La Semana Santa aqui es una enorme fiesta donde gente que vive aqui sale el pueblo, y muchas personas de Managua, Costa Rica, y otras lugares la vienen. ¡Nos quedamos 10 minutos afuera el pueblo, al Hotel El Jardín, y podemos la musica en la playa!  Normalmente, SJDS es muy tranquila.

PERO, hemos tenido un buen tiempo aqui.  Durante la viaje del bus a SJDS, emcontramos 2 estadounidenses cuando el bus quitó (en Rivas).  Acordamos a tomar un taxi por la fin de viaje- y compartimos el costo. Fueron muy amable.  Ella, Sarah (de California) ha trabajado en Guatemala desde Enero con un NGO por sostenable medio ambiente urbano.  El (de Oregon) fue un videographer.  Trabaja en Costa Rica ahorita.  Ambos regresan Los Estados Unidos en Mayo.  "El link" de NGO de Sarah es:  www.elinfinito.org
Va pues, llegamos en SJDS sin otros problemas. 

Además, encontramos Mary, su esposo Stefan, y su perro bonita. Mary, pocas mesas antes, trabajaba con Dr Turner a DUSON.  Ahorita, viven en SJDS  Queremos a hacer una vida aqui y estan explorando opportunidades por trabajar. Fueron muy, muy amable. Vamos a La Playa Hermosa ayer y despues comemos cena.  ¡Pueden cocinar!  También, nos enseñan su primera casa- se llama "The Earth Ship".  La casa ha construido de gomas, lodo, botellas y usa energía solar.  No usa energia de "grid". Es muy bonita y interesante. Hoy, montamos los caballos:

Una cosa mas: a La Playa Hermosa, se  contribuye al medio ambiente.  Los jefes del Hotel Playa Hermosa compran huevos de tortugas del mar de cazadores furtivos, y cuando las tortugas empollan, los jefes les ayudan ir el mar.  Es la Liberacion de Tortguas :)  Evidamente, los huevos de tortugas del mar son muy bien para machisimo, y es porque furtivos los roban y compran.  Además, les ayudan las iguanas, quienes aqui estan en peligroso.

En Inglés:  It has been an interesting adventure here in SJDS!  Travel tip #1:  If you are not a fan of giant
wild beach parties, traffic jams, and noise, do not come to SJDS during Semana Santa (the week before Easter).  It is a giant fiesta.  Most of the locals leave, and people from all over flood the town for partying purposes. Normally, SJDS is very tranquil.

Travel tip #2:  if you want to be sure to get to where you are going in a reasonable period of time, do not take the chicken bus.  It is a good cultural experience, though-- but when ours quit in Rivas, we met 2 other Americans who also were travelling to SJDS (on the same bus), and shared the cost of a taxi.

She, Sarah, is from Ca., and has been working in Guatemala with an NGO to help with sustainable and environmentally friendly urban living.  The link to the organization's website is: www.elinfinito.org     He, Casey, is from Oregon, and is a videographer.  He has been doing some work in Costa Rica.  They both return to the USA in May.  The rest of the trip was uneventful.

Yesterday we met Mary, a former DUSON employee who worked with Dr. Barabara Turner.  We also met her husband, Stefan, and her beautiful dog, Jackie.  They moved here a few months ago and are exploring what opportunites are available here.  They can also cook!!  With Mary and Stefan, we visited La Playa Hermosa. It is beautiful, and a fun place to go to the beach, but also has an environmentally friendly purpose.  The owners/managers buy sea turtle eggs from poachers, and once they hatch (and are strong enough), release them back to the sea.  Apparently, sea turtle eggs are thought of as important for a man's virility in CA. (I will avoid the temptation to comment here.)  The Playa also is a refuge for iguanas, who, in Niaragua, are an endangered species- although not so in other countries.

Another interesting thing yesterday was "The Earth Ship".  This was where Mary & Stefan first lived when arriving in Nica.  It is a house built out of used tires, bottles, & mud. It is awesome, and totally off the grid- solar powered, and the water is filtered effectively by plants. There is also indoor plumbing, and a shower with cold and HOT water.  Hot water is not something common here.