14 July 2009

NIcaragua Day 7


Our last day in Nicaragua was fraught with decisions. What to do? Some wanted to go to the beach, others wanted to go to Granada. One guide. So, we left early enough to do both!


First stop, the beach (Pacific side). Much like Ocean City, our local beach here in the States, the beach is lined with businesses vying for tourists' attention. Quite unlike our local area, billboards do not line the main road to the shore; instead, men come running from everywhere (on foot and on bike) to greet you and offer to escort you to the best restaurant on the beach. Restaurant, in this sense however, is a grass covered pavilion where you can stow your gear, hit the beach, and all of the food and souvenir vendors come to you. In droves.


My morning was spent debating religion over local rum and cokes. Others went down by the shore and sunbathed. A few, the comic-relief team, rented surf boards and headed out to catch some waves. They quickly learned, however, why they were the only ones out there. While looking out to sea for the next great ride, they lost track of how quickly they were heading away from shore. Fortunately, one of them is a life guard in Ocean City. As soon as he realized they were caught in the swiftest rip tide he had ever experienced, he focused their efforts on keeping parallel to shore until they reached a break and could head in. Tired, exhausted, and honestly kind of freaked, they collapsed under the pavilion. This pretty much signaled it was time to move on to our next destination, Granada.


The beach to Granada seemed like a three-hour ride. It was our day off, so I didn't bother with a watch. But we drove east, heading up into the rolling hills. The roads were in fantastic condition, and Nicaragua has a lush, green landscape. We passed through small towns and villages aplenty. Men working in fields, kids playing football [soccer], and people walking everywhere. We saw two processions: one was a wedding party trekking down the side of the road. The second was the population of a small village walking in celebratory costumes led by a priest and altar boys: a celebration of the their saint's birthday.

The road through Granada to Lake Nicaragua was packed with a Saturday market. It reminded me of Cairo. Children and dogs running everywhere, stalls of produce, cheap clothing and household necessities spilling out into the roadway, mules and horses milling about, and baskets everywhere — piled along the road, stacked on rooftops and women's heads. But the time we finally turned off the thoroughfare, I was surprised we hadn't taken on extra passengers or a chicken or two.

Our turn-off brought us onto a wide road through a much quieter part of the city. Tropical trees and low stone buidlings lined the cobbled street. From here, we reached the park providing access to the boats which ferry people around the islands dotting the lake.


Lake Nicaragua
is the second largest lake in Latin America (after Lake Titicaca) and has the distinction of hosting the planet's only population of freshwater sharks, as well as a host of incongruous aquatic life. Geologists think it was once a bay of the Pacific Ocean, which over time was enclosed from periodic lava flows.


An archipelago of islands dots the lake in the Granada vicinity. Many are just large enough for an average home. Some have large, luxury estates. Others have a few humble dwellings with fishing boats tied up along the banks. And then one tiny mound of land is appropriately named Monkey Island.


Our destination was a small island restaurant. A covered pavilion with an assortment of tables took up about a third of the island. Two modest infinity pools, homes of the family who owned the restaurant, and the kitchen area made up the rest. Fishing boats anchored behind the kitchen rocked gently against the banks, waiting to get the next day's fresh catch.


The food was a wonderful mix of cultural favorites. Freshly caught fish was displayed for selection by those ordering seafood. The relaxing atmosphere ended abruptly, however, when darkness began to fall, ushered in with deepening clouds. Fearing an on-coming storm, our boat captain raced back to the Granada shore. Um, yes. Raced. Totally exhilarating!

10 July 2009

Nicaragua Day 6


We ended our week the way we started: back in the clinic. This was a day for follow-up on the patients treated on Monday: removing stitches, checking healing, and a few more mole removals thrown in for grins.


In the morning, I went over to the school with Kristin (who had been spending a lot of time with the community outreach), Steve (medical-student-to-be), and our translator/guide, David, to meet with one of the sisters and visit a few homes of children La Merced would like to sponsor for school. (Shameless plug: $100 covers a year of tuition and uniforms for a child. Email Tina Perrotta at tina@la-merced.org).


The first home was one of a long row of shacks bordering the main thoroughfare and sewer runoff in Managua. The mother met us outside to lead us through a short, narrow path of fence on one side and corrugated metal on the other. Seriously narrow. Anyone beyond medium build would have had to sidle their way through. The one son who needs to be sponsored was at work. Morning school is for the younger kids, while the older kids are out working. Then, in the afternoon, the older kids attend classes. Her youngest son met us in his underwear, roaring exuberantly. Playing lion, perhaps? The narrow path led to a small courtyard with a cooking area to the side under an overhang.


The home was neat and tidy. Water was everywhere from the morning cleaning, but as half the home is exposed to the elements, the floors were drying rapidly. Adjacent to the cooking area was the main living area, with a curtain partioning off the sleeping area. The mother's graciousness openness is testimony to the adage, money isn't everything.


The next family we visited was currently living with a grandmother who ran a small market in the front of her home.


She's anxious to have her home back to herself, so the family is under quite a bit of pressure to find other living arrangements. Her daughter, husband, and four children had moved in with her when her husband was laid off.



He's been able to find part time work at a pizzeria, but has to rely mostly on tips. Out of that has to come costs for public transportation to work (it isn't close), and food, as he often isn't welcome to eat at home. The couple's two young sons are currently at home, and the daughters are both at school at the local parish.


After our visits, we returned to the school to meet the daughters and visit with some of the other children before returning to the clinic. One of the girls had been a patient on Monday, with a particularly painful keloid on her foot. While her mother waited outside for her, I had stepped in to let her hold onto me during the procedure. It was great to see her again, and I was pleased she remembered me. Unfortunately, she had disregarded the doctor's orders to rest her foot and keep it dry by going to the school dance. No stitches out for her!


Back at the clinic....


... good progress was being made on the patient load. They had a rhythm with patients rotating in and out of the two beds in the makeshift OR.



One patient returned who had had a cyst removed from her foot. On Monday, while she was pointing it out, our screener noticed she wasn't using her right hand. She asked to see her arm, and was shocked to see what looked to be a gaping hole with phenomenal scarring.



About 20+ years ago, while the U.S. was embroiled in hearings over the Iran-Contra affair, she was crossing a river with her two-month old baby, attempting to flee from conflict that had erupted in her community. A bullet ripped into her forearm, the one holding the baby. It traveled up her arm and exited out at the elbow. The baby fell into the river and drowned. Both time and poor surgical work had impaired the nerves in her arm, putting her hand into a permanent claw position. While only her cyst was able to be removed on this trip, La Merced is planning to discuss her case with experts here in the States and hopefully be able to do more for her on a return trip.


At the end of the day, the government administrator of the clinic spoke for a few minutes, expressing appreciation on behalf of the people we had been able to help. Her daughter had made little wooden ornaments which she presented to each of us with a thank you inscribed on the back. It was a small gesture, but it garnered a huge outpouring of emotion from the La Merced team.

09 July 2009

Nicaragua Day 5

Okay. If I wasn't so far behind on blogging, I'd come up with more imaginative titles.


Our fifth day here was also our last day at the hospital. Steve and Michael, both college students considering medical school, have been our comic relief. When they weren't assisting in the OR, they distributed toys to the waiting children. Today, they broke out the sticker books, and no one was left out of the action!


The first surgery of the day was pretty usual for us by day 5: a painful hemangioma on a little girl's back. The demeanor of many of these children when they were wheeled into the OR truly amazed me. This patient was very docile, completely nonplussed despite the number of people working on her: taping tubes, adjusting IV's, covering her face with a mask, not to mention the horrible taste/smell of the anesthetic.


With the more than adept OR staff, you would think it was surgery as usual. However, there were some telltale signs that this wasn't a state-of-the-art facility! At one point, I was asked to photograph the rusting OR tables and a white piece of rusted, dilapidated equipment which La Merced is hoping to replace for them. And while (unlike the clinic) it was an air conditioned envrionment, at one point we caught the AC unit spitting out water right on top of the sterile area (in the foreground below). The affected pieces had to be replaced, and the table relocated until the unit finally 'thawed out.'


Our last two surgeries of the day both involved hands that were badly scarred, and consequently, the scar tissue was interfering with the proper growth of the fingers. The first was a small boy who had grasped the tailpipe of a motorcycle with both hands when he was a year and a half old.


The second, was of a girl who, when she was two, was being pushed in a hammock when it caught on fire over a nearby open flame. They couldn't get her out in time, and her face and hands were badly scarred. It took them two hours to get her to a hospital. Following the accident, her mother left her, she never had any corrective surgeries, and the woman who brought her in to see Dr. Perrotta claimed to be her aunt to be authorized to allow her surgery, even though she and her husband had taken the child in when no one else in the family stepped up to take care of her.


Since she had never had surgery, and there was so much scarring everywhere, Dr. Perrotta had to make a hard decision as to what was the most critical need at the moment. Like the previous patient, the scarring on her hand had inhibited proper growth of her fingers, yet on a much more severe scale. Three-fourths of her right thumb was entrapped inside the burn scar. The x-rays show four fingers, but only a nubbin of a thumb. Its bones are overlapped inside the soft tissue of the hand. Her other four fingers are inhibited by flexion deformities from scar contractures, rending the hand pretty useless. So the goal for the day was to release the thumb, reconstruct it, and give her pinching ability with that thumb and the index finger.

I think this may have been the messiest surgery I witnessed. He had wanted to do it with as little blood as possible, so he had the anesthesiologists drop her blood pressure down to keep the open wounds from bleeding. However, they were unable to locate a standard pediatric bp cuff with a manual dial, and the one they finally rigged up didn't hold. Blood was everywhere. I was amazed the docs could even see to continue operating. Once they were able to release the thumb, the question became, how to get the thumb to stay in the proper position during the healing process.

What they felt was the obvious answer, put in a pin, wouldn't work because the hospital had no pins. So after much debate, they put in a few well-placed stitches with a heavy material, and after grafting the skin over the newly created thumb, bandaged it with a splint. (Ha ha, I'm sure if you have a medical background you are astounded with my use of medical terminology! ;-)



I think today was by far the most stressful in terms of challenges. Personally, I would love to see this brave little girl brought to the States for state-of-the-art hand reconstruction, as well as the surgeries necessary on her face to give her some chance at a normal life without the points and stares of strangers.

08 July 2009

Nicaragua Day 4

Today the medical staff of La Merced arrived at the hospital to find patients already lined up in the waiting area. The schedule for today included a baby with a cleft lip, a girl presenting with an early stage of a neurofibroma, a boy with webbed fingers on one hand, and Ivan, the young man with the hairy nevus.

The baby with a cleft lip was only 2 months old. Having delivered three beautiful children myself, I cannot imagine the conflicting feelings a mother must feel when she discovers her newly born child is disfigured. After my experience today, I can only surmise the stress and frustration must be heavy. Once the surgery was complete, I showed her mother the photo of her baby with her fixed lip. She burst into tears, so relieved and happy to see her child whole for the first time.




The second patient, a very sweet, quiet, and happy young girl, presented with the beginnings of a neurofibroma in the back of her head. It's a sobering condition, as there is no guarantee that, after removal of as much damaged tissue as possible, the tumor will not return. It's heartbreaking to think that such a sweet child, without access to regular checkups, could face a future of severe disfigurement if the condition isn't kept in check. This case proved particularly interesting, as once Dr. Perrotta had excised a good portion of the tumor, he discovered two tubes protruding from deep along the spine. Consultation with the neurosurgeon confirmed that they were indeed feeding the tumor. She said an MRI would be needed to confirm the exact location of their origin, and then she could operate along the spine to remove them. Dr. Perrotta took out the tumors growing along her skull, then closed up. The staff of La Merced later conferred and decided to apportion some of their funds allotted to hospital diagnostics to the fee for a private MRI so she could get one as soon as possible. Otherwise, she would be added to the months-long waiting list of government-provided health services.





The next surgery was fascinating. Dr. Perrotta had to separate three fingers of a young boy which had grown fused together at the base. He deftly demonstrated the zig-zag cuts necessary to assure the best healing for minimum scarring. Where the fingers were cut apart, extra skin was needed to graft between them. A doctor from the hospital worked alongside, cutting the graft from the boy's groin area while Dr. Perrotta prepared the fingers to receive it.





Then finally, Ivan. He and his mom had left at 5am for the hour-long bus ride to the hospital, and he wasn't even scheduled until end of day. He was understandably stressed and anxious by the time he was allowed into the waiting area. As mentioned yesterday, a skin expander is necessary to fully excise the hairy nevus with minimum scarring. Already, his face bears evidence of early attempts at removal with extreme scarring as a result. The skin expander, over time, slow stretches out the surrounding skin, so that a graft is not needed from elsewhere, the nevus can be cut out, and the clean tissue can be stitched together with only a minimal scar left. Because we did not have one, all Dr. Perrotta could do was a face lift to remove as much as possible without overstretching. To Ivan's frustration, he would once again leave the hospital without his hoped-for result. But this time, we could give sound assurances to him and his mother that we would remain in touch and actively work to get the equipment necessary for that one final procedure which would change his life.





It was an exhausting day with only a short lunch break eaten in the hallway outside the operating rooms. The La Merced crew left for the ride back to the hotel with a mix of feelings from the elation of giving concrete results to some patients, while having to leave others with still more work to be done and no guarantees. Even tracking down the skin expander for Ivan won't be an immediate solution for him. The first OR and physician availability for him to have it installed isn't until next July.