Rose's last night

We began this project over two years ago - it is truly hard for me to believe that our first venture here in Nicaragua is coming to a close. Richard, Pam, Rachel and Saleena have one more morning at the hospital in Matagalpa.

They saw so many babies. We wonder what we can do to help to improve conditions here. In Daro we learned of the organization that Irene referred to earlier, that cares for families that survive by scavenging in the dump. The group that had provided these children with a meal a day stopped earlier tis year to send that resource to Haiti. Wow, how does one choose? We are committing to support this area - will there be something that pulls us away? The economy has affected the people here - less is being provided- even Rainbow has made cuts to the feeding centers from serving 0-12yrs to serving 0-6 years. The beans and meat supplements have been taken off the menu too.


Highlights for me: Seeing us here in Nica working, seeing patients, becoming friends with people here, learning from our mistakes and planning the next trip. The school for the deaf in Dario, the great staff at La Pradura, Brad's driving, my driving, the other drivers driving! Spending two weeks with my daughter working! The coffee at La Pradura!

We will have much to digest in the next few weeks!

Last night in Nicaragua

This is Irene and it is Wednesday evening. Hard to believe that it's already time to go home. This has been an incredible journey which has made an amazing difference in my life. So... back to work in the hospital. Dr. Richard, Salina, Rachael and I spent time with the doctors and nurses in the PICU and NICU's. It was so interesting to see the differences between our units, equipment, practices, etc, and then to see the similarities in the caring hearts and souls of the medical staff-certainly no difference there. We saw several newborns with disabilities or premies who the staff told us were expected to die and were receiving comfort care, though many of these children would have survived in our facility. Dr. Richard, with the help of his "tech team" prepared and presented an awesome presentation for grand rounds. On Tuesday, Rachael spent another day in one of the rural communities with one of the Rainbow docs. Rose, Pam, Kari and I went back to the social services building in Ciudad Dario to meet with the people involved with the Programa Amor. They work with the children in the streets, but mostly with the children who live near the dump and go there with their parents to go through the rubbish to find recycleables to sell. The staff had prepared a workplan for us, explaining their mission and how they feel they can be supported in their work. As a social worker, I found this situation to be so sad, yet hopeful for the impact they are making--all are volunteers. I am intrugued with how our community may be able to assist. So, off I go. Richard, Rachael and Salina continue their work until the end of the week. So hard to leave.

The Weekend

After attending a Nicaragua/Wisconsin Partners meeting in Managua Saturday - we took the old road to Leon on our way to meet Rachel, Salina and Kari in Chinandega. What we learned this weekend:

Never, ever take the old road to Leon. The key descriptor "old" means holey, unpaved, really bumpy and driving in the heat at about 20 mph for 2 hours - wondering about that semi racing up behind you. And the buses!!!

The Pacific was great.

The north route from Chinandega to Sebaco does not have any gas stations - except for the house that sold gas by siphoning it into old milk jugs! We actually didn't care too much at that time how we got the gas.

Still it was a solid road and fine scenery.

To the Hospital in Matagalpa today. Back to work.

Friday afternnoon

From Rose...we finished at the Centro de Salud in Ciudad Dario - our second bag containing medicine finally arrived - minus the vitamins. For some reason vitamins are suspicious and were taken to be analyzed. Joanne and Richard ended the day with a presentation on Neonatal resuscitation. It was well received - and while we were in the class a baby was born around the corner - barely five pounds, a girl. Vigorous and beautiful, as all new borns are. After the birth mother and baby share the recovery room with whomever is in need of a bed. This afternoon they shared it with a woman having an asthmatic attack. The clinic could use another room. Again a picture would tell the story.

We had a final meeting with the medical director and said our goodbyes. The team moves back to the hospital for next week.

Rachel, Salina and Kari left this afternoon for Chinandega and the Pacific. The rest of us are staying behind to enjoy a rotary meeting and another meeting tomorrow in Managua. I guess the girls were not that interested in this. We will join up with them on Saturday eve and drive them back here on Sunday. I am looking forward to the ocean and maybe a shell or two.
We say goodbye to Brad and Joanne tomorrow too! They will be headed home for a firefighters convention. Our group will really miss our Driver/navigator/and colleagues!!

March 18 - Valle San Juan and Ciudad Dario

This is from Rose - Yesterday we were so tired that some of us - well, me for instance went to bed muy early. We had spent the day at a Rainbow Clinic in Valle San Juan, about 1 hr 15 from Matagalpa. The team saw children - but since the docs are all pediatricians that makes sense. There are just so many children it always surprises me.This was a more prosperous community with an active hammock industry. We learned about their water issues - an electric pump brings water to the community, but the electricity is not always working - it hadn't been for two days and they were running low on water. But the pump began working mid afternoon and the community swarmed to the pump with every type of carrying container that you can imagine. I wish I knew how to post photos. They tell the story so much better than my words.
For instance, Candida lent Rainbow her home for the clinic. She sat proudly in the entry all day long coordinating and watching over things.
The clinic is managed by the scholarships students - secondary school aged - they keep the lists of patients and help people in and out.

Today we were at the Centro de Salud in Ciudad Dario. We immediately learned that the scale at the clinic did not function and the docs needed to get accurate weights in order to prescibe medications. So Dr Brad and Rose took the van in search of a "balancier" or something like that. We went to the hardware store - sorry no scale in all of Ciudad Dario. You must go to Managua. Or you can go to Centro de Salud and they will weigh you. It was hard to tell them in our broken Spanish that we had come from Centro de Salud, and it really wasn't for us - Honest! Well Brad and I would not be put off. After five stores we finally convinced a store owner to sell us his personal scale for 24.00 American dollars.
We felt very successful and enjoyed the rest of the day watching children.
Tonight we are going to a restaurant that is supposedly the best steak house in Nicaragau. Yummmmm.

Day 1, Group 3

We went to the Pedernales Community, a Rainbow Community south of Matagalpa. Dr Richard and Dr Joanne worked with Drs Rachel and Salina seeing children. So many children.

This is Dr. Salina Paarlberg............good day today. Worked with Dr. Richard and saw 16 patients. For the most part, we saw several upper respiratory infections just as in the states; several complaints of cough, fever, and rhinorrhea. We had a couple of complaints
of kids sleeping with their eyes open:). Most patients looked well; we had 2 slightly ill patients that came in with abdominal distension and diarrhea. They were treated for parasites; albendazole 400 mg po for one day. Waiting for the next adventure.................

This is Richard Strauss writing now. Pedernales is a small appearing community a few miles off the two lane main highway between Matagalpa and Managua roughly 45 minutes from Matagalpa. It's down an unpaved rutted one lane road that seemed to end in a little ravine surrounded by mud/brick/tin huts with dirt floors. We wondered why such a community was established in the first place however long ago it was founded, and we assumed it's because there was a hole in the ground with a water source that was a source of fresh water for those who lived there. The well was across the road from the feeding station that was doubling as a clinic today, and it was the site of a drowning last week when a young boy fell into the well and couldn't be rescued. The people of the community are now looking to build a fence around the top of the well to avoid another tragedy. As Salina said, she and I saw 17 children today, and Rachel and Joanne saw another 15 to 21, with the third group seeing another 20 or so patients, for a total of 63 patients. Most were beautiful little kids with minor illnesses, and some had walked for great distances over rocks, branches, dirt paths, and creek beds to arrive at the "clinic." Lots of families are used to receiving medicines at their visits, and most of the patients we saw didn't need anything, so mostly we gave away toothbrushes, toothpaste, and stickers. And it was hot in that hut. It's very hard to imagine that people live, cook, eat, and sleep in those conditions. When there were no more patients to see, we returned to the hotel to clean up, and then we took a 20 minute ride up the road to eat dinner and wander around Selva Negra (Black Jungle), a gorgeous coffee plantation/nature reserve/community several thousand feet above Matagalpa (which itself is around 2000 feet above sea level). Tomorrow we head to another small clinic with the doctors from Rainbow Network.

Group one - notes from the clinic team, from Paul Klas

Dear Nicaragua team:
Wanted to give you an interim report on the trip, and it was fantastic. I will review how things went for us, and the successes and difficulties we encountered.

First, the connections to Managua were easy. We were about 2 hours late getting into Managua due to a flight delay, but clearing customs, with everything we carried could not have been easier. We had all of the documents, but sailed through customs without a problem. We met a RN (Rainbow network) representative whom Rose had made contact with, and he had to take away the Carbemazepine. For some reason, carbemezepine is a controlled substance in NI and can only be prescribed by licensed pharmacies in the country. They also had to take all of the vitamins to have them analyzed. We eventually saw the vitamins again, but never did see the carbemazepine, and it became clear we never would. That was ok, as the entire country is out of it, and many people have seizure disorders in the country, so it will go to good use, but was not something we could to prescribe.

We had a good night sleep. All of the accommodations were easy and perfecto. We then slept, and enjoyed the wonderful breakfast at Las Mercedes. The rental of the van went easily, although Budget was out of vans, but they had made arrangements with Dollar for the same price, and we got a nice 15 passenger van which we needed. We had so many suitcases, that we really needed it. I believe we had 15 suitcases.
The drive to Matagalpa was so easy. Remember, leaving Las Mercedes, you need to enter the Pan American Highway as you leave the hotel, but then make a U-turn and start heading north to Tipitapa and off you go. You really can’t miss it. Keep going to Sebaco, where there is a really nice market. We had shoppers extraordinary (thank you Rachel M, and Judy K) who kept us well fed. The mandarinas there were particularly excellent as are the bananas. We found the bake goods excellent and the potato chips were great too.

We then went past Sebaco, and remember that the road forks at that point, one major road to Esteli, and one to Matagalpa. Stay on the Matagalpa road, all of the way to Matagalpa. We then got into Matagalpa, and decided to go to the Selva Negra coffee plantation for the day. At this time it was about noon. To get there, you bypass the first road to Jinotega, but get into Matagalpa and once there look for the second turn off to Jinotega. Take that road for about 15 kilometers. Once you see the old military tank, which will be on your right, turn onto the road. Go about .5 miles, and you will enter the plantation. We had an awesome time. There is a lovely German restaurant to eat at with great coffee and excellent safe food and very relaxing. We went on the most lovely rainforest hike. We saw gigantic trees, and eventually were enthralled with a pack of howler monkeys. It was a huge highlight. Also, nice little shop for you to buy some things at. Then back on the road for a 20 minute ride down the mountain. At this point it was about 5 pm, and the sun really does set at about 6, so we were back in Matagalpa by 5:30. Do remember to follow the rule about no nighttime driving.

Once you get back to the main road in Matagalpa, make a left, and continue straight. You will go through a traffic light. On your right you will eventually come to a Mercedes Benz repair station, and you turn right. If you start going up a steep mountain, you have missed it. You go about a mile up and down some huge hills. You will cross a yellow and green bridge on the way. There will be a turn to the left that takes you to Hotel Saint Thomas. It is incredibly steep, and if you are in a 15 passenger van, you will need to go really slow, figure out the angle to get up it. The junction of the road and the road to St Thomas has a steep angle to it. There will be no way to go without hitting the undercarriage of the van, but if you go too slow, you will spin your tires. Not too hard, because even Mark N could do it! Check in at St Thomas was easy and the accommodations are spartanly wonderful and include great hot water, cool, comfortable surroundings. The food passes the Klevan test. We recommend the large Nicaraguan platter of meats, tortillas. It feeds 5 people easily for about 20 bucks. The Tona beer is better than the Victoria, and we recommend not having more than 4 per night! (Just kidding)

Actually, we did work. We met with Dr. Candido from the Rainbow Network for breakfast the next morning. We actually then met Marcos, our translator extraordinaire. We had to meet with the minister of health from Matagalpa. They took away our medications for the MINSA clinic, and promised to get them to Dario where we would work. It actually did get there, but we did push them to get it there. We told them we would check. We then spent the whole of Monday getting the ultra sound machine going. Amazingly (and I mean amazingly) the ultrasound machine had arrived in Dario in a crate from GL about one hour before we got there. To his credit, Dr. Candido had arranged a collaborative effort to get both MINSA doctors and RN doctors trained. They had done just as we had asked, to get a collaborative group of doctors to be trained on the machine. Mark N (MN) then gave a 1 hour talk on the basics of ultrasound and then we took a break.
MN, JK, and I then had our moment of truth, if you will. It was much like Apollo 13, when the space capsule had to be powered up before the reentry into the earth atmosphere. We plugged it in, and nothing happened. Oh no! One of the Nica doctors then noticed that the main power cord for the computer was not connected; we put it in, and shazam, we were in business. Mark worked hard for 5 straight days, training them in US on live patients they brought in. They brought in numerous patients but much of it was obstetrical, and they became very facile at doing ob us for simple things like dating, fluid, position and placental location. They also worked on abdominal, gall bladder, and pelvic pathology, although, I believe it was more difficult to become proficient. Only MN could say, but I believe he was truly impressed with the
doctors. They “were like sponges”! Mark then worked all day for 5 days, teaching ultrasound. Mission accomplished, and great job, MN. We will hear a bit later about our last sad encounter on Friday. Dr. Candido described this as a “dream come true”.

This reminds me, everything we do, has to add value to Nicaragua, MINSA and the RN. Every night, the 5 of us met and thought hard about what are we doing, does it make sense, does it add value, is it a good allocation of resources, is this win-win for us and them, does this improve our partnership. It makes your head spin and actually hurt sometimes. I know for certain, the us machine accomplished that.

What about the rest of us. JK and PK along with Max and Rachel then spent 4 days checking out clinic opportunities. Our first day on Tuesday occurred at a RN outpost near Dario. We took about a 40 minute trip to a very rural area. Tough travel with the van, but we made it. The clinic was set up in a rural hut, feeding center. It was made of mud. We had rough wooden tables, and chairs made out of sticks. It was awesome. We had our medications, and also some rainbow meds. JK and PK had two translators. We saw only children, which is easy, because this is a land of children. We saw 60 patients including scabies, pneumonia, colds, some skin infections, gastroenteritis, and rashes. We all thought that the experience was superb and a good value. There were some problems with medications, as we didn’t have everything we needed. There were no worm medications with us at that time. RN has no inhalers and for asthma, uses prednisone and oral salmeterol, and oral theophylline without levels. They also use mucolytics and dextromethorphan for coughs and colds. They use metronidzole and mebendazole or albendazole for parasites for children with diarrhea and abdominal bloating.
JK and PK then spent the next day at another RN clinic way out. We had to ford a stream in our van. PK got stuck, couldn’t get the van up the river bank, but the nica driver we came with was able to do it. Finally we made it. Similar clinic, but many of the people had come a long way over a mountain, walking about 2 hours with their children to be examined. We had another great day.

One note, two of us, MN and Max did get gastroenteritis. Please, do take along your azithromycin and imodium. You could be sorry if you do not. We all got bit a small amount by mosquitoes, but not much. It is the dry season now, so not a huge problem. However, there still is some Dengue and malaria around. There is plenty of clean water to buy in the towns, or especially at the hotel. It is a dollar for a large bottle. Tona is plentiful.

Thursday we began our work in the MINSA clinic.(MC). The MC is run by a wonderful, compassionate woman, Dr. Arelys Rodriguez. She was prepared for us. JK and PK worked in two rooms, side by side for the next 1.5 days. We worked with our translators who filled out the forms we needed to see patients. We had a list of the medications we had available to us, which included their formulary and the medications we had brought for the MINSA clinic. They provided us with the list of their formulary, but many of the medications were unavailable, and that included infant Tylenol, any vitamins, ibuprofen. They had nothing to treat scabies with, nor were there many antibiotics except amoxicillin. With our translator, we would write down the patient name, age, birth date, and then their diagnosis. That was all they needed for records. There was no written record to keep in either clinic. In the MINSA clinic, we again saw only children. PK was more than delighted to see just kids too. We saw about 40 children the first day and 25 the second Friday morning. Many of the kids were sick with just coughs and cold. They do not give out cough medications there. However, the only effective medications we had for asthma was oral prednisone tablets and the 10 inhalers we had brought. Judy had seen some significant wheezing in her clinic. The care of respiratory illness here is really subpar, not because of physician knowledge, but because of cost. (This would be a great project to work on.)
A
t about 11 am on Friday, JK and PK were cruising along, and then, in walks a mother with a 15 month old baby who was clearly sick. Thankfully the baby was directed to JK who noted a distended, fluid filled abdomen. The child had moderate respiratory distress and a significant tachycardia. The child had some distant history of a mass resection as a neonate we believe in Managua and was said to be cured. JK knew this great guy who did us in Nicaragua, and scooted in the van down to the clinic that MN was working in. MN did an us and discovered a large retroperitoneal mass, massive ascites, and metastatic liver disease. Judy had to give some bad news. Disposition was difficult, whether to send to Matagalpa where we knew this great pediatrician was working (JT) or to Matagalpa. In the end, correctly, JK knew the great JT was still resource limited in Matagalpa, and so the child was directed to Managua, probably for terminal care.
The Thompson family with RT and Saline arrived after a 5 day vacation to Little Corn Island in the Atlantic. They had no problems with their travel and made it to Hotel St. Thomas on Thursday evening. After a several hour meal on Thursday night, we made plans to get JT, ST, RT and Salina to the Regional Hospital. After a morning meeting for Breakfast with Marcos and Dr. Candido, most of us went to the Regional Hospital for introductions, and getting the Hospital crew going at the hospital. All went well. Last we heard, the team was heading off to the NICU, PICU, general pediatric units to begin their work. Will be interesting and telling to see how it goes. JT will hopefully pave the way for RS and his team for the last week in March where they will finish out.

We then, finally had a bit of education. I wouldn’t call it a disaster, but a learning experience. PK did a teaching on basic, basic ACLS. PK wanted to teach them how to run the defibrillator. We began with basic rhythm recognition. Besides one doctor there, beyond normal sinus rhythm there was very little they knew. We showed them the basic rhythms, then showed them on Max (the perennial guinea pig) how to use the monitor as a monitor. They were excited about that, we think.
We had toured the health center in Dario, and of course they are resource poor. Few tongue depressors, mercury thermometers, only CBC, urinalysis and malaria smears for labs. No glucose, sodium, K, Cr, liver tests. Can screen for HIV I believe. No radiology, but they can use and have access to the new us machine. In the labor and delivery suite is a delivery bed, and a bassinette. They had no resuscitation bag. No oxygen. They have IV fluids and oxytocin, but no other meds.

There are four doctors that work there. They are on call every fourth night, and cover the clinic from 4 pm to 8 am the next day. They staff the er with a nurse, and sleep on a wooden bed when they can.

The Strauss, Martin team arrive next weekend and will begin their work with RN and MC. The residents will join them - returning to the hospital fo rtheir last week in Nica.

What do we have planned for the next team? Given that the Strauss family is not getting in to Managua until Sunday night late, we have planned that on Monday am the team would head to Matagalpa. The pediatric residents Rachel and Salina will be in Matagalpa, awaiting the arrival of the team. I would suggest that IS, RN, JS and BM spend the weekend touring. On Monday am, the team could head to Matagalpa, and spend the day traveling, possibly making the trip to Selva Negra. The team would then head on Tuesday to RN in Dario. Dr. Candido would have a clinic set up on Tuesday and Wednesday in outlying clinics near Dario. On Thursday and Friday, the team would work in Minsa Dario. On Friday afternoon, the team would do a teaching at 1 pm. I might suggest teaching the MINSA staff NRP, as best as it can go. Probably, then, one vehicle would head down to Managua to go home and the other would head back to Matagalpa to finish up the hospital rotation with RS and Salina. That is the plan.

Good luck and safe journeys to you!

From Cesar Amador y Molina Hospital in Matagalpa

Monday March 8
We started this International Day of the Woman with Rachel leading the
7am peds conf on neonatal sepsis. It was very well received and they
really appreciate her ability to speak Spanish. Selina is working on
tomorrows discussion on Asthma.
The Pulmonary Pediatrician gave us the bad news that our young girl
with asthma and pneumonia had died...as did the 900 gram baby on
comfort care because he was under 1000 grams. Birth trauma
..pneumonia..and growth retardation are common in NICU... the PICU is
all surgical these days... 8 yo with empyema...2yo with Choledoucal
cyst...and 6 month old with intucception...all should be ok. The Peds
in pt areas have many many children with every thing from malnutrition
and mild infections to JRA and renal failure from nephrosis.
The language issue is drilled into any of us when we try to round or
talk to staff of pts without an Interpreter...Sunday making evening
rounds....I had the wonderful nurses laughing very hard...but not sure
any of us really figured out what the other was trying to say. Pictures
and dictionaries only go so far.
More later...Jeff Rachel Sandy Selina

News from Matagalpa

From our Hospital team:
The hospital in Matagalpa is the sole major medical center for 450
thousand people scattered across many hours of travel to get to
regional clinics ...let alone the main medical center. The hospital in
general and the Peds area in particular are great studies in
contrast.... 7000 deliveries each year...in this hospital..but no system
to measure sugar in the babies....many ventilators...although some very
old...but currently no blood gas capability..at all. The pediatric
surgeon did 18 cases three days this week...but save for one
neonatologist...there are almost no other Peds specialists. The family
that spent seven days to get here....were too late...there infant had a
bili of 40 and appears to have kernicterus (brain damage)....but its
hard to get a bili also. Although they use their disposable cpap set
ups 100s of times...they seemed to be able to deliver very stable
levels of support. There are enough doctors in the hospital...there are
almost none in the rural areas.
The people continue the contrast...despite struggling conditions the
neonatologist was well versed in Cochran Data Base. The nurses often
have 8 pts..with several on vents...but were in good spirits and happy
to tell about their patients progress.
We have made some new friends and gained some good insights...soon the
work will get faster...they have asked for multiple presentations each
am at 7..then NICU 2 rounds...then NICU 1 rounds.... then PICU
rounds.... then the Peds ward....( and they are wards) 90 beds in all
for peds.
All for now..more in couple days... Sandy Rachel Selina Jeff

Day 2 at the clinic, Max Nigogosyan

Day two: March first
He was holding up what looked like a giant electric toothbrush. "This" my father said, "is the vaginal probe." I was sitting in the back of a dimly lit clinic watching my father holding a pose of a slightly more masculine and promiscuous statue of liberty.
We were at the clinic to deliver an ultrasound machine to a clinic in a small town - Ciudad Dario - in the middle of Nicaragua. My father, gesticulating wildly with several different instruments, was here to teach the Nicaraguan doctors how to see inside people without using a scalpel. Old habits die hard. But then again, so do patients.
I’ll back it up quick to earlier this morning. I woke up at about 6:00 and showered in under the lukewarm hose that passed for a shower. Nicaraguans seem to take things pretty literally. If a menu says steak you get a slab of meat. If a sign warns of a steep hill you had better expect a near vertical climb. If a it’s called a shower you will get pelted by a shower of rainwater coming out of a spout. Anyway, we ate a breakfast of tortillas and rice. We met with a member of the Rainbow Network who explained to us what we would be doing with all of the medicine we brought. First we had to convince the government to allow us to treat their citizens.
We went to the local ministry of health in Matagalpa: a pink building festooned with posters of Che Gevera, Fidel Castro, and Jesus. On the way in there was a metal bar low to the ground that tripped everyone who entered the building. It was a typical office environment with ringing telephones and typing typewriters. The only difference was that the secretaries were talking on cell phones and typing on typewriters. We went upstairs where there were more pictures of Che, Fidel, and good ol’ Jesus. It really was weird how many posters there were of them considering they were not exactly the three musketeers. We went inside the the office of the local health administrator. He had more pictures of the unlikely triad and also an industrial-sized air conditioner. We sat in a meeting with him for about two hours. The only thing I could figure out was that while the liberal party was in power, they built a large clinic in the middle of town. Then the conservative party gained power and decided that they should abandon the well placed and nicely sized clinic to build a smaller clinic outside of town. That’ll teach those liberals. So now the conservatives want to move back into the better clinic but they need three thousand dollars to renovate it. We just decided to placate them with two suitcases of drugs. They seemed to like that and let us go with their blessing. Chances are that those drugs are either on their way out of the country or into someone’s private collection.
We left the mini ministry of health, tripping on the bar on the ground, and climbed back into the van to go unpack the ultrasound machine. I mostly sat in the back of the clinic while the temperature slowly rose until it leveled out around 90 degrees. I watched as the doctors fumbled around with the crescent shaped ultrasound receiver. When they couldn’t get a good enough image my dad’s only advice was "add more gel and push harder." You know what’s coming. After about thirty minutes of the various physicians poking and prodding the practice gel, they decided it was my turn. Hooray. I climbed up on the table and lifted my shirt. My dad showed them what to look for: the kidney, gull bladder, and portal veins. It tickled a little. Then it was time for the other doctors to try. As per his training the first doctor seized the transponder, pushed it into my ribs, and started wiggling it around. "Now take a deep breath" my dad said. "Ya right" I said. He said something along the lines of stop flexing. Little did he realize that my flexing was the only thing preventing him skewering me with a piece of hard plastic. Eventually he realized that the extra two centimeters gained by leaning on the transponder did not actually affect the image all that much. I had similar experiences with the other five doctors. Eventually they finished me and all took part in wiping my gooey chest with paper napkins. I climbed up off the table just as a pregnant lady took my place. "Poor lady" I thought "she has no idea."

From Max Nigogosyan on Day One

Day one: Saturday February 28th
I woke up to the freezing cold. For a moment, I thought I could be back home in Minnesota. But no, it was because I was lying directly beneath a curiously strong A/C unit that seemed to have removed every molecule of warm air from the area directly beneath it: me. I did what most people do to solve problems; I curled up in a ball and went back to sleep.
Fifteen minutes later, I awakened to my father shutting off the A/C right over my head. Half an hour later, I was raised from what had become a coma-like slumber to "get ready for the day." I was given half an hour to complete the task. To me this seemed comparable to "Hey Max! Do you mind uniting the Middle East? Before din-dins? Swell."
About an hour later, I was showered, dressed, and in operation of several of my five senses. I walked to the little breakfast area and loaded my plate with fruit and bacon. At the end of the breakfast buffet there was a little table of green onions, cheese, and more bacon. I reached for the serving spoons. "What do you want on your eggs?" a man I had somehow overlooked behind the little table. I realized then that he was probably wondering why I was helping myself to his condiments. "Uh, no." I said. He started to crack two eggs. "No no" I said helplessly. But the eggs were already cracked. "You don’t want eggs?" He asked. "No thank you." I said. The man was obviously wondering what country I was from that I could just come up to his stand, steal his condiments, and waste his eggs. I walked away. He opened the door for me on the way out. I felt fairly guilty, but drowned my feelings with my ill-gotten onions and bacon.
After my lunch debacle, our group of well fed travelers loaded up a giant van with all of our luggage, totaling about twelve bags and six hundred pounds. That is not an exaggeration. We drove for about three hours, but it was not unenjoyable. In fact, it was one of the most interesting parts of our journey so far. We drove through ramshackle towns and villages. When I say villages I mean shacks totaling four pieces of tin stacked like a house of cards. I observed hundreds of barrels stacked on top of one another. I found the life of these humble barrel-stackers quite charming. After a hard day of moving water from one place to another using three wheels and a bit of plywood, I can imagine nothing more relaxing than putting one barrel on top of another, and then doing that a hundred more times.
We stopped to shop at a market. I was first impressed by the size of their produce, but then, somehow, my eyes were drawn away from the hanging tomatoes to the bright red porn shop. It was the color. No really. It was. All the other shops were various shades of brown and off-white. I guess that’s why business was brisk at the hottest shop in town. Anyway, their vegetables were really something to look at. There were carrots half as long as your arm, and stacks of melons bigger than your head.
My mother and Rachel began caressing the oranges, melons, and various other bits of the local flora at one of the fruit stands. My mother decided we should have some of the oranges. They did look quite good. The man at the stand pointed held up two oranges and pointed to my mother’s proffered dollar. Not a bad deal right? Two oranges one dollar? He took the dollar and put the two oranges in a plastic bag. Then he took three more oranges and put them in the bag. And three more. And three more. And three more. "That’s good" my mother said. And three more. She was slightly desperate now and holding out her hand to stop the man. And three more. We finally got his attention just as he was about to load three more oranges into the already bulging bag. He seemed confused that we wouldn’t want our money’s worth of oranges. The rest of our transactions continued in that fashion: us giving a dollar or two, and them unloading as much as they could into our arms. On our way out Paul pointed over to some men pouring water over cucumbers "That’s why you have to be careful with produce. That water they’re pouring, it probably came from that ditch right over there." He was right as it turned out, just as I watched I saw a man come out of a vegetable shop with a bucket of water and throw it into the street. The water then ran into a large ditch on the side of the road.
We started up the road to a lovely little house on the mountainside. It was apparently built by rich German coffee plantation owners. We went inside for a lunch of $2 bacon cheeseburgers and cake. The family directly across from us consisted of six people. A mother who wouldn’t have looked out of place in the 1950’s, and a father who wouldn’t have stuck out among a rich group of overweight Texas oil CEOs. Their three children, one of which was staring into the distance and listening to his ipod, were sucking down Cokes and wolfing down cheeseburgers. The last member of this group was a stick-thin grandfather gripping his knife like he was still in ‘Nam. He stared, dead eyed out onto the lake while his children laughed and his grandchildren tuned out.
We left the restaurant to hike in the rainforest. We started out by finding our way to an abandoned chapel that seemed to be slowly succumbing to the forces of nature. Its walls were growing moss and ferns and its roof was probably more bio-diverse than the rainforest below it. We found leaves as tall as we were and twice as wide. We saw a strangling vine that grows over a tree, completely covering it and taking its shape as the tree inside dies. What is left is the shape of a tree in giant vines and a desiccated husk of plant matter in the center. It was quite charming really. We saw a group of about ten howler monkeys running around on the tree tops.
The last leg of our journey was back into town. Our hotel was atop a large, steep hill in the middle of town. The road we had to take was a sharp ninety degree turn across the crowded streets. Our truck struggled and stalled trying to get up the edge of the road. A pair of dogs began humping to the noise. Eventually we were able to scrape our way halfway up the incline. The nearly vertical climb was not helped by the six hundred pounds of luggage stuffed in the back which made our journey upwards as tenuous as... well... driving a truck filled with meds up a steep hill in Nicaragua.
We made it to our hotel which looked like a garden and smelled like a giant pineapple. We moved our luggage into our sparse rooms (they spent all their money on the plants) and began sorting the medical supplies. I won’t bore you with the statistics of how much of whatever we needed where ever because I honestly couldn’t tell the difference between the nearly identical bottles of pink pills with latinate names.
Our dinner consisted of dishes that had names like "Tortilla carnes" which means meat and tortillas or "Tortilla res" which also means meat and tortillas. Tortillas and meat seemed to be the theme the menu.
Welcome to Nicaragua: land of Tortillas, cheap fruit, and brightly colored porn shops.

From Paul Klas

A note from Paul Klas:Rose, we had a great day. We started with breakfast and had Marcos there as well as Candido. Candido did a great job organizing. He is so awesome. I am so pleased. He had everything organized. He said we had to present ourselves to the Matagalpa ministry which we did, and that took about an hour. We met with the minister, and they actually took the medicines with them, and said they would get them to Ciudad Dario. I will let you know what they end up telling us. Rose, you wouldn't believe the day. I had a grin from ear to ear. First, we met the translator but we really didn't need her today, but I will need to have her and another rainbow translator they had for us. We didn't know this, but we will survive it all. It will be good to have another translator. Anyway, I digress. The ultrasound machine was actually there when we got there. IT was in the crate, all packaged up. Mark gave a great little talk about ultrasound. Then, the time came to see if the darn machinge to see if it worked. So, I felt we were on Apollo 13 when they heated up the space capsule. Was the thing going to work. We plugged it in and nothing happened, then we realized that the connector plug to the computer wasn't plugged in, we fixed it and whalla, it was awesome. Candido had a group of about 7 doctors who were are training. They were attentive and excellent. Judy and I watched as we were more intertested in the us machine. Tomorrow we go to outlying rainbow clinics, and we are excited to get going. Well, enough for now. We continue to be encouraged, and hope you are well. Drop a line about TZ as I hope for them many successes. PTK
March 2, 2010 7:08 AM

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