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NICA: Clinic

This trip I got to see a side of PMI missions that I had not seen before. Our Team Director in training, Stefani, was on this trip, along with her husband Josh. Once I heard he was coming on the trip, I was so pumped to shadow and learn from him.  Stefani lead our team to Uganda so we were old pals, but I had not met Josh before. I was hoping he was open to the idea of me picking his brain, following him around, helping out, etc. To my surprise, he was that and much more. He was working on patient profiles so this allowed him to visit with about a dozen patients and photograph them in their home, which I was able to be apart of! Josh was so willing to have me assist, talk out the best photos of the day and why, help him decide on best location to shoot in the patients homes, etc.  

It was such a cool and humbling experience to explore around with Josh and help him really capture the essence of the people we were serving. I learned lot about photography, of course, but also the people who came to clinic. Being at the front of the line I feel like the registration team often gets them in the door then doesn't know what happened to them, why they came, what they were treated for, etc.. By doing patient profiles with Josh, I was really able to get a better understanding of how helpful PMI is to these communities. The gratitude, in particular from the older generation was overwhelming. They welcomed Josh and I into their homes, they were amazed by all the gear, shared stories of their life, gave tours of their homes, waited patiently while we set up shop and then "paid" us in love and sometimes a cola or hot fresh tortillas off the fire.

Of course everyone kind of knows about the colorful and vibrant culture of Central America, but it's still a 3rd world country, a developing country. People, despite the colors and vibrance, live in what we would consider unspeakable and unthinkable living conditions. Most houses were made of homemade cement, masonry, sticks and cardboard. There was normally one community space for shower, restroom and cooking area/ kitchen. 

The people, they welcome us into the "modest homes" with joy. They were thankful we were there to capture the true essence of their life and lifestyle to share with others so others will understand they need to help and serve. Among the dark homes, dirt floors, dust storms, dirty bodies, bad smells, old furniture, paper thin mattresses, and many people in one home... there is beauty and Josh 
captured that perfectly. 

I was Team Leader for Registration, so that meant, I wasn't able to help with Josh until I got the team up and running. I don't for one second want myself or anyone else to think I could have been able to experience this side of PMI had it not been for my registration team. Luckily we had a handful of non-medical volunteers on this trip, meaning there was plenty of help.  I could leave for several hours with Josh and know the team was taken care of. They really stepped up and did a wonderful job working together and delegating while I was away doing another form of PMI work. 

For this trip, we had: Registration, Triage, Providers, Glasses, Pharmacy with a couple sides of Family Planning and Exam Rooms for things like: cardiac, gallbladder, and lung exams. The exams were able to be done due to Dr. Barron and his V-Scan, which he explained to me was just a hand held ultrasound. 

I feel like on this trip the group was much more integrated and less "clickish" the medical and non medical really got to know one another, became friends and were exchanging contact information before the end of the trip. 

As for Registration, our job was to get everyone registered. 

Team set up: 
2/3 people at front of door, making sure only people who were registered entered clinic site.

2 people going through the line. One would fill out form, getting name & age. One would give wrist band to each person seeing the doctor. Wrist band and form #s must match up.

3/4 people inside clinic playing the role as running. The runner would take patients from one station to the next. It seems like common sense, but often you tell them where to go, and with an average 100 people in the room, it can be confusing. 

As team leader, I was to make sure our station was running smoothly. If people had questions, they came to me, and if I couldn't resolve it, I would get a team director. Each station had a Team Leader that the team would report any issues to. 

The culture and understanding in Nica was much different than Uganda. There was a certain level of respect that was absent in Nica. The children, teens and elderly showed us the utmost respect, but the young adults were still learning that trait. At times there was a sense of them not understanding the way we were doing things, frustration was slightly higher, and over all patience was much lower than those patients in Uganda. 

It was common for patients to get their form and wrist band then leave for several hours, expecting to come back and hop to the front of the line, if we were past their number. Of course this isn't fair to those who didn't leave and waited in the heat, but they couldn't understand why they would be told to go to the back of the line. People would walk to the front and try to go in clinic, despite being told no, people would throw trash on the ground as we were picking it up right beside them and putting in our trash bags, people who had been hanging around all day, would at the last minute say they needed to see the doctor even after we had met our cap. 

These are all things people inside do not see. Once inside everyone is 'happy' because they know they will get to see the doctor. Outside clinic is a different story. While it was slightly frustrating, especially to me a Virgo who loves order, it was a lesson learned. The registration team all agreed some of the issues were just part of the culture and the process was new to them as well. PMI Nica was only a year old when we went. That meant, we were one of the first handfuls of group teams to have served in this country. Kinks were still being worked out. Translators were still learning when they sign up, they are there all day to help. Patients are learning, while yes it is hot, we are all out here together, you can't leave for hours and cut back in line, and finally PMI has been doing this for years, so there is a reason things are done the way they are.  

Brady was a champ at calmly explaining the process to patients. 
Nick was the firm door keeper and even learned some Spanish along the way. He was also great at checking numbers to make sure they matched wrist to form!
Banjor was the one who never complained, played many roles and did it all with a smile on his face. 
Kristina and Cynthia were the miracles of our team who spoke Spanish.
Steve is the one who opened my eyes to a way of thinking that hand't crossed my mind. We had to turn several dozen people away, either b/c we were full, didn't have what they needed or simply b/c church was not in session that day. At one point, he looked at me and said, Em, I just thought of something. We are in their place of worship. Somewhere they are told they are always welcome, at any time, a place they hold like a piece of treasure and here we are a bunch of gringos telling them they can't come into their own church. That has to be a tough concept for them.

The days were long and started at 6 am but each day, I was in bed tired with a full heart. 

Clinic Day 1: Aurelio Carrasco (20 min drive)
Patients seen: 222

We learned on day one that 6 churches were able to open in one year with the help of local volunteers with the PMI team. Clinic Day one was in small church with wrought iron gates and rails located in the middle of a neighborhood.  The church was a skin tone orange color. Patients were lined up in the shade along the right of the church. We used the front entrance as the point of entry. The space inside was open, within minutes of pulling up, everyone is hard and fast at work setting up their station. 

The team treated people with chikungunya , heart failure, ingrown toenails, parasitic worms, cataracts, diabetes, diarrhea, headaches, arthritis, asthma, fractures, urinary tract infections, depression, and allergies. Dr. Chico arranged a boy with a broken arm to be seen in the El Viejo clinic for an x-ray, Jose, the lead Pharmacist built a spacer for a Dixie cup that he paired with an inhaler for a girl with asthma and having an attack. Bo, a medical student, had his first patient and it was a man with an old pelvic fracture.  60 reading glasses were handed out, which is huge. In both clinic trips, being able to read the bible is one of the most important things to the patients. The glasses station has a bible on site to make sure the patients can read it before they leave.

Most of the clinic days were held in a church. The churches all had tin roofs. I bet the tin roof sounds beautiful in the rain. However, that tin roof creates a sauna by noon. At one point Dr. Hall took the temp inside, just a casual 101.4, with zero breeze. 

Lunch was prepared on site, which was different than Uganda. The church had volunteers to cook us lunch in the kitchen that was always located outside around back. Day one clinic even had a kitchen pig!

Day 1 Patient Profiles:
Maura Celestina Amador. She is 90 and lives with her daughter and two grandchildren. She's lived in the same house since 1979. Two of her sons died in the Revolutionary War and one is disabled from the war. In all she has 11 Children and six grandchildren. Maura was married for 30 years until her husband died. She makes tortillas for a living. Her daughter showed us how to make them, then gave us a bag full of hot ones. Maura home is very modest, but she has what she needs. Monday we learned how beautiful wrinkles can be.

Paula: She came to clinic for glasses to read her bible and to talk with someone about her diabetes. She's 80 years old. She's lived in same small free standing house for 75 years. She has 13 children and nine are alive. She has 80 grand and great grand children. 

Selena: Selena and her entire family:parents, aunts, uncles, cousins, all live in a compound of sorts. There is a main front door from the street. Once you enter it, there are private living quarters for the family surrounding the perimeter of the property. In the center of the property there is a kitchen area, two laundry wash stations, one toilet and two / bathing/shower spaces. Selena is 11 years old and has a one year old son. She washes clothes for a living.

Day one ended with a full smooth running clinic. I got a shout out from TJ at dinner. He told the group " If I ever own a night club, I want Emily Ballard to be my door woman" 

Clinic Day 2: Coloina Veinte de Julio (20 min drive)
Patients: 256

We start the day with a devotion on Exodus 3, the burning bush. As Jim's children said "you can't do nothing."  We drove to a small village that sat at the bottom of San Cristobal Volcano. This volcano is the highest and most active in the country. It's been erupting since the 16th century.

Clinic was a church that was a little bigger than Monday's church. This meant more stations could open up and we could see more patients. It seemed less hectic on Tuesday. There were about 100 people in line when we arrived, then people slowly came on up through out the day. Josh wanted to explore the village and try and make it to the volcano. A local translator said he would take us. We crossed a bridge just by the clinic and walk through the village, through housing and trails for less than 10 min. Then the space opens up to this massive field with San Cristobal behind it. The field is full of workers. Josh and I start setting up to take photos and ask if we can speak with the workers. A guard quickly comes over and starts talking and using his hands. He's got a machine gun strapped to his chest. Our translator tells us we can not be there, that it is private property and we can not speak with the workers. We find out that one reason may be because if  they speak to us, or we photograph something we shouldn't the land owner could be inspected. The guard thought we may be sending pictures to the Agriculture Department in Managua and would get them in trouble for not being up to code for one thing or another. We don't ask questions.  We say our good byes and found some other people to speak with and photograph. One man we wanted to find was a man we saw at the volcano. He had a load of sticks on his back walking through the volcano field. We found him and learned he lived around the corner from clinic and was in great health and didn't need to see the Dr. He told us he collects these branches then makes brooms to sell, for a living.

We tended to get a lot of adults in the mornings and children in the afternoon. Children go to school in Nica and that seemed to be very important. Children would come in uniforms after school to meet their parents. In Colonia there was a school right across from clinic, it was neat to see how curious the children were, as they watched our every move through the fence at recess. The villagers, even those not coming to clinic were very interested in what we were doing.

The coolest thing I witnessed at clinic on day 2 was DJ letting children listen to their heart beat for the first time.  He would let them use the stethoscope and they would light up when they could hear it. We also saw a women in a literal wheel chair. A plastic chair with wheels on it. There was a family that lived across the street and they had two talking birds. There was a little boy who had a pet rat. He wanted to bring his rat into clinic with him, but I had to stand my ground with a firm NO on this one!

After clinic we were able to stop in town to shop, get ice cream and walk through the park. We all bought souvenirs, walked through a beautiful yellow church built in 1885. It was a great clinic day.

Day 2 Patient Profile:
Elizabeth Valladares. She's 89 and has 14 children and 25 grandchildren. Eight of her 14 children are alive. She and her family in similar compound like Selena. She's been in this space for 40 years and her family owns the land just outside the village where we walked to see her. She was married for 60 years and her husband died 12 years ago. She makes tortillas and sells them for a living with her daughters beans. She came to clinic for joint pain and told me she was given medicine she had never seen or heard of.

Clinic Day 3: El Culurico (30 min drive)
Patients seen:150

Morning devotion was inspired by Mark 10: 32-45 and was about humility. The goal of the day was to try and be the like the greatest servant and use your gifts to do good, whatever your gifts may be.

Clinic today was only 6 blocks from PMI El Viejo clinic.Wednesday was a slow day. There were about 45 people in line upon arrival and then we slowly reached 150. Dr. Hall and Katie decided that we would cut off at 150 and spend the afternoon doing something "fun". Since it was such a slow day, I was able to help Josh a lot this day. We did four patient profiles. 

The church was large and had nice tile floors and big open windows & fans! The pharmacy received their much need restock to get them through the week. 

This church was great because they have private rooms around back for exams rooms. Privacy is always good. 

Some of us wandered around once our tasks for the day were done, we found a wood shop around the corner, two men carving from large blocks of wood. They had a picture from pottery bar and they were making the bedroom set. We walked up on the night stand making. They told us they would sell entire bedroom set for $600 vs the $2,500 list price in the catalog.

Around 3 pm we packed up and loaded up the bus. We were told we would stop by the hotel and grab our swimmy suits and we were off to a local beach! The coast was not far and we all knew that from looking at the map, but it was literally 15 min from out hotel. As we pull up, Nick and I are looking at one another like what is this place... it looked a little sketch with closed bars, random dogs, people looking at us and trash everywhere. Once on the beach, our worries wash out with the waves. The sand is black and the seashore is lined with thousands of shells. To the left the is a rock jetty with several people hanging out. To the right there is beach for as far as you can see and behind us the beach is lined with thatched roof bars and restaurants that are empty. Luis, our amazing bus driver told us they are actually very full and happening on the weekends. We have about an hour and half here, just enough time to watch the sunset. 

 Day 3 Patient Profiles:
Gregory Hernandez. He's 80 years old and lived in his house for 45 years. His house sits on the corner of two residential streets and was the nicest house we went into. We saw him then he disappeared. A little boy told us he went inside and pointed. We knocked on the door and his wife greeted us and welcomed us to their home. The front of their house was a lounge area and store. They sold fruit, flour, corn, peppers, eggs, bread, iron, cleaning. After speaking with Gregory, we learned he came to clinic knee joint pain and told us he gets really tired if he walked for long periods of time. He's deaf and can't hear well. Clinic gave him meds for his pain, but we didn't have meds for his ears. His wife Maria is 68 and they met "many many days ago". They are both from the same area and are members of the church where clinic was being held. His grandsons were there and they lite up when the photographs started, it was like they gramps was now famous! Before we left he told us " We have worked very hard for this home, God bless you for coming"

Ermojeles Canales. He came to clinic for joint pain and got meds. 75 years, married for 60 years. He has lived in this house for 45 years. His children live on either side of him. He has 3 children and 4 grandchildren. He told Josh before we came in "my home is modest but you are most welcome". It was the most modest of the homes we visited. There was a small front living room. The middle room was were the slept, there were two beds with paper then mattresses and blankets. the back of the house was the kitchen area. Out back was laundry and bath/ toilet. There were chirping little green birds everywhere! The front room is where we decided we Josh should photograph him. Under a Disney Princess poster was the spot the photographs were taken. We loved the contrast oh his sturdy old man with Disney Princesses above him. The poster was clearly for his 3 grandchildren girls who lived with him. There was homework problems all over the plywood walls in the living room, which was pretty incredible. The translator told us, when they don't have paper, they do the problems on the walls. Ermojeles told me I had a pretty smile. I thanked him and he responded " I can't smile. I see others who are always smiling but not me. Sometimes I try, sometimes I do not"

Lijia. She is 23 and surprisingly has zero children. She came to clinic for a bad cough. She was born in this village and lives with her mother. We walked about 10 min down a dirt path to get to her house where we found a larger wooden home, with a bore, regular size pig, five piglets, dogs, birds and chickens. Her mother also came to clinic. Anna is 63 and has 11 children and 35 grandchildren. She was 25 when she moved to this home.Anna came to clinic for glasses. She also wanted the doctors to look at a incision she had from a previous surgery. She told us she has a tumor in her liver. Clinic referred her to clinic in town. 

Day 3 Community Profile:
Guillermo. 81 and sells papaya to the local corner store. He picks from a field that he doesn not own and brings to this store to sell. He didn't come to clinic, we saw him in the street walking back to clinic. 

Clinic Day 4: Puerto Sur (2 hours)
Patients seen: 287

Day 4 was by far our longest day. We left the hotel at 6:45 and didn't return until close to 9 pm. This location was out in the country, buy the ocean close to the Honduras boarder. It was very hot this day and very little breeze. This was the rowdiest, least patient crowd so far. Several herds of cows walked by throughout the day. One herd had a 10 year old boy on horse guiding them. The church was a beautiful bright teal color. We noticed toilets were build high up on cement stilts, when we asked why, we found out it was because they were so close to the water if they dug from the ground down, they would hit water.  People were doing laundry in the river,  using a well in front of the church, swimming in a volcanic natural spring. Day 4 took the longest to figure out the order of the patients coming in. They were lined up in the sun, which they didn't like, but we didn't have a lot of choice. We decided we would move half back by the trees into the shade and take half with us up front and have them sit around the wall on the front porch. This worked for most of the day. We had some issues, of people not coming to clinic hanging out on the shaded porch or people who were some of the last numbers, trying to skip line. This day was long, due to right as we were packing up, one of the last patients had a cyst on his forehead. Bo and his team including Dr. Hall put him in  private room and for over an hour, removed the cyst and stitched him up. 

This gave Josh and I time to do patient and community profiles. He did several on his own during the day, when I could not leave. Together we did three. 

Day 4 Patient Profile:
Juana. She is 16 and have a 6 month old daughter, Arixa. She lives at home with her parents down by the river bank and came to clinic for flu, cough and headaches. She was given vitamins and ibuprofen. She's lived here with her parents since she was born. She is single mother and washes clothes for a living. 

Day 4 Community Profile:
Josh, Stefani and I had Louis borrow a car and he drove us down to the beach. The fisherman were coming in for the day and the shore was lined with dozens of boats. Toward the horizon there was huge armed shipped. Louis told us that was the boaders guard. He pointed out where one mountain was Honduras and one was Nica. Boarder controls this area very strictly. We walked along the beach and followed a young boy up the sand to his street and home. His name was Josias Ismael. He's a 13 year old fisherman. He fishes everyday with his father and uncle, he told us he recently got his own boat. His younger sister, Jorlyn Vanesa is five and she loves to fish too, although she told us she was only "allowed some of the times". Next door was Jesus who is 63 and has been fishing for 20 years. This beach village was full of life, kids playing soccer and baseball in the streets, women cleaning fish in open kitchens, women cooking on open fire and men tending to the boats coming in. 

Day 5 Clinic: El Viejo (20 min drive)
Day 5 clinic was, lets say, organized chaos. Clinic has never been held at a PMI Clinic before. Outreach clinics are free and PMI city clinics are not. So it would be confusing if we always did free clinic from a paying site. However, we were in town on the one year anniversary of El Viejo so they wanted to do a one time trail. The goal was to get people in the clinic to show them what is is all about, spread the word and help the clinic grow. A lot of people just don't come in b/c they don't know what it is, or know they have to pay. We wanted them to see the type of service they would get for the payment. The people of Nica make on average $8 per day. They can come to our clinic and get what they need (for the most part) for $4 or less. Pretty freakin' amazing.

We had people sitting in chairs under a tent in the street and would bring them through the front door.  It got a little hectic inside, b/c there wasn't a lot of space for people to wait to go to the next station. Triage was moving faster than the providers were, so there was several halt stations, where we had to let the flow catch up. Another issue was pharmacy. Normally there is a separate holding areas for people waiting to get their meds from pharmacy, but since space was limited they were being sent back outside and not sure of what to do. A handful of patients would take off their wrist bands, and try to give them to others, thinking they were done with them, when in fact they were not. This causes a problem, b/c the # on the wrist band and # of the form that pharmacy is filling, need to match. We don't want the wrong person getting the wrong medication! Since we are dealing with a language barrier, # on wrist band and paper work were a huge resource for us, to insure people were getting the proper medication. People not wanting to leave after clinic was also a small problem, they just wanted to sit under tent or try and get back inside.

It was a totally different experience holding clinic in the city at the PMI site. I think a lot was learned on everyone's end. Most importantly I think the community got to see what their money will get them, how well run the facility is, how well staffed and stocked PMI keeps it. 

Overall this was another very successful clinic week. We saw and treated over 1,100 patients! 


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