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!