Day 16- July 23, 2012
A case of the Mondays
Monday morning found Dr. Ahmed, Sarah, Mike, and me at the Perquín clinic shadowing physicians and performing electrocardiograms (EKGs). This time around, we only performed the tests on patients with cardiac concerns; our population screening days were behind us for the time being.
Our first patient was a lovely 80-something who could not stop smiling and who immediately formed a bond with Dr. Ahmed. The two chatted and Dr. Ahmed shared pictures of her family with the sweet lady. The morning was off to a nice start with high spirits.
Shortly after seeing our first patient, Dr. Ahmed and I watched a girl wheeled into the clinic on a gurney. Several of her fellow students stood by, looking on. The girl appeared to be hyperventilating; the gurney disappeared behind a door down the hallway. It was possible that she could have suffered some sort of allergic reaction, but no one could be sure in that moment.Dr. Alba Burns called me into her office to observe a patient with diabetic neuropathy—the patient had developed an ulcer under her third toe. These are important cases given that over 8 percent of the population in the United States has the disease and many of these cases are poorly managed. Dr. Burns stressed the need to protect the ulcer so it wouldn’t expand and become systemic, risking her leg or worse.
I returned to the room I was in previously for only a few minutes when a doctor wheeled in the schoolgirl I mentioned earlier. She wasn’t moving and her hands were frozen in a contorted position, but the doctor requested an EKG, so I complied. Sarah entered the room to help place leads on the patient, and Mike entered soon after. We were told that she was 16-years-old and that the doctors suspected she was suffering from an anxiety attack.
Without warning, before we were able to conduct the EKG, the girl launched into a frenzy— thrashing about— and it quickly became apparent that we were not dealing with garden-variety anxiety. She was in great distress over something unknown. The team of doctors worked tirelessly to extract from her some information that would allow them to help her, while we students restrained her. They finally made a decision to sedate the young girl.
The next two hours nearly drained all of Sarah’s, Mike’s, and my energy as the young girl continued to come in and out of consciousness with tremendous fight and fear. Our concern was to keep her on the table and to prevent her from injuring herself, which at that rate she seemed intent on doing. She had a friend in the room who was the only person the patient seemed to respond to positively.
We were very fortunate to have that friend there to help calm the patient— until even the friend eventually fainted from her own ordeal-provoked exhaustion. The stress of the situation compounded by the minute.
The clinic finally decided to transfer the young girl to a specialist a few cities away. The smell of frustration and self-doubt in the air was stifling in the aftermath. On one hand, I know my companions and I worked diligently and tirelessly to keep this girl safe as the medical team tried to extract information that would help her, and tried to take her blood for testing.
On the other hand, I felt we were sending her on her way without even scratching the surface of her anguish.
What could bring such a young girl to the edge of hysteria? Drugs? Abuse? Friends? Love? I don’t like the idea of just passing along the responsibility of a patient, but I guess maturing as a doctor, or student-physician for that matter, is knowing the limits of your contributions and knowing when to seek the help of others. It was educational to see how one system manages a patient for whom they don’t immediately have the necessary resources.
Respiratory distress, contraceptive medication changes, pap smear screening results, and hypertension topped off our day in Perquín; we all went home exhausted. Dr. Passafaro, the Johnny Carson of late night charlas, owned the night with an exceptional cardiology lecture that clarified, at least personally, a great deal of what I had been learning with EKGs.
We were all tucked in, a little smarter and wiser after this day.
Ryan Denley, D.O. 2015
Day 15- July 22, 2012
The weekly waterfall shot
NYIT Global Health Team in El Salvador
Days 13 and 14- July 20-21, 2012
A new perspective
"There are two reasons for the existence of this museum," began our guide Carlos as we gathered around him inside El Museo de la Revolución. "The first is to remember all of our people who have died because of the war. The second is for the future. It is so that we can learn from our history and move forward together."
After our marathon run of the Chagas project, as well as its successful and timely completion (hooray!), we were able to take a few days to rest and see parts of Perquín and Morazán that we had not had a chance to visit yet. Friday and Saturday turned into an unexpected but valuable learning experience for each of us, as we gained a deeper understanding of El Salvador's history.
Over the past two weeks, we had received bits of information about the suffering and atrocities of the recent war: a doctor's son who had been killed, a former Peace Corps worker who witnessed the disappearance of close friends in his community. On Friday though, we were able to put more of the pieces together as we toured the Museum of the Revolution. The Museum is a well-known attraction in the eastern part of El Salvador. It boasts a modest building whose walls are lined with war memorabilia: stories and biographies, photos, artifacts, and old equipment. On the grounds outside, visitors will find the remnants of a military airplane and helicopter, a crater in the ground left by a bomb, and countless shells and weapons left by guerrillas after the war.
The Salvadoran Civil War, which lasted from 1980-1992, pitted the military-led government against a coalition of five left-wing guerilla groups called the Farabundo Marti National Liberation Front (FMLN). The reasons for the war were complex. Leading up to the war there was general unrest among a poor and agrarian society, two separate but intersecting political and religious movements, and the wealthy population's resentment of land reforms.
All told, more than 70,000 people were killed and many escaped to Honduras or simply disappeared. There are war crimes that have been left unresolved. The military's financial backing by outside governments and organizations independent of the guerilla movement only prolonged the war.
On Saturday, we visited El Mozote, a site where an anti-guerilla campaign massacred an estimated 1000 citizens. Miraculously, a woman named Rufina Amaya, one of only three survivors, lived to tell this terrible story. Learning about this event, which occurred so recently, was sobering; however, I was encouraged by our visit there. Over the last couple of decades, the town has been generously repopulated, a new school, church, and clinic have been built, and there seems to be a certain sense of hope alive in the murals, garden, and memorial set up in remembrance of this event.
That same day, Ron, the owner of our hotel, the Perquín Lenca, recounted the history of the war from his perspective. Ron is an American who came to El Salvador to volunteer and work during the beginning of the war. He has not left the country since then. His was a truly fascinating story, and I was impressed by his vision for the gradual renewal of the region.
One thing he told us really struck a chord. Because the area of Morazán where we are living was the center and stronghold of the guerilla forces during the war, all of its citizens cleared out during that decade. This means that today, every single person who lives here in Perquín, San Fernando, and Torola, are ex-somethings: ex-guerilla, ex-refugee, ex-military, ex-husband or wife, ex-sibling or friend.
Knowing this made me see all of the people we have been working with in the clinics in a new way. As physicians, knowing the context of a patient's history can provide a starting point to how we should provide healthcare. Ron seemed to affirm this thought by also telling us that there was a huge but understated need for psychiatrists in Morazán. Mental health here is a topic that carries stigma; it is often suppressed. However, it is both a vital and lacking resource for the people.
Sometimes I am overwhelmed by the enormity of problems that poverty, war, inequality, and the burden of history create.
The issues are both complex and interconnected; there are almost never simple solutions, and cultural, economic, and social barriers must always be overcome. It is also easy to think that we, as students, are here to do small things: shadow doctors and health promoters, do a neat study about Chagas, practice new clinical skills, take in a new culture, and eat pupusas.
However, the lessons of the past two days, and particularly our conversation with Ron, encouraged me with the realization that under the surface, there is more to our work and activities here in El Salvador. Friendship, partnership, and understanding are the keys to building trust, to beginning a conversation, and to finding a mutual vision and plans for the future. It is certainly neat to be able to be a part of this developing process with our school and within this country.
History can be either difficult to let go, or easy to forget. I hope that we can learn from our mistakes, look to the future, and move forward together.
Sarah Ng, D.O. 2015
Day 12- July 19, 2012
Dispelling disease-related myths
I am still psyched about our rápida completion of the Chagas study data collection—it only took three days, which was a lot faster than any of us had anticipated.
Since we finished the study early, we haven't spent the last couple of days in the clinic. I am beginning to miss that setting— drawing blood, obtaining electrocardiograms (EKGs), and most importantly meeting new patients in order to reach our goal of screening 300 patients.
Despite how much I miss the study, we now have more time to learn about the community and its people outside of the clinic.
Today, we headed to El Volcán to host another health fair at a school. Our to-do list included a brief educational session on sexual health for adolescents, something the principal of the school had requested. We hopped into a red mid-sized Toyota pick-up truck— this time with Max and two other new Peace Corps volunteers, Andrew and Mike— and headed for El Volcán around 9 a.m. The distance going up the mountain to our destination was shorter than that to Los Cimientos, but the view was equally mesmerizing. I couldn't help myself from continually snapping pictures, despite repeatedly capturing the same scene.
It is safe to say that we all enjoyed the ride, the sights, and the company.
We kicked off our third health fair after greeting the school’s principal, a progressive man in his mid-40s. He thanked us for coming and was happy that we would be educating the children about sexual health— a very sensitive topic, especially in this conservative community.
Our audience for this health fair was much younger than our last two groups. Kids ranging from five to twelve years of age showed up with the biggest smiles on their faces. As usual, we started with the nutrition session, continued to oral hygiene, exercise, cardiovascular health, and wrapped up with lung health.
I’ll skip the details of each health session as Dane did an exceptional job covering these in his July 13 blog on the charlas in Yamabal. Instead of simply restating what he already covered, I would like to give you some of my thoughts on the charla here in El Volcán.
We have been to three schools to date, and will visit yet another one next week. I haven't been able to interact with the children extensively, but I can see that the children of El Salvador are incredibly intelligent, hospitable, and most importantly, they love to learn.
Some of the El Volcán students seemed to be preoccupied at times because they were preparing for an upcoming arts and crafts festival. Girls and boys showed off their stitching designs. Some were patriotic, featuring the flag of El Salvador as the main theme; some were cultural, and some were abstract. In the distance, a group of young girls practiced a song or some sort of poem—I didn't understand it all, but I enjoyed it.
Dane's exercising games, including the "popular American jumping jack," were very popular among these kids. Some students were enthusiastic about what we brought them. Because they were younger than the children in Yamabal, they weren't able to follow us as closely, but that did not deter them from asking questions and raising their “paws” to participate.
After the nutrition charla, we spoke with the older students, and asked them to write down questions for us—they delivered a wide range of queries.
Dr. Passafaro began with a talk on HIV/AIDS, as the majority of questions were on this topic. This seemed a little weird because this population is very secluded, and it seemed like it was not a very big issue. But since many of the Peace Corps volunteers are trained in holding similar charlas, they were able to add important points regarding the disease and address myths such as HIV being disseminated by a handshake or sitting on public toilets.
Using Spanish-language posters, Dr. Ahmed and Jasmine then proceeded to tell the students about sexually transmitted infections ranging from herpes to syphilis.
Global health students addressed some of the other questions. One of the topics the principal has asked Dr. Ahmed to address on her numerous visits to the area was sexual abuse and harassment— Ryan addressed this very sensitive issue and did an excellent job in a very culturally appropriate manner. He assured the children that it is not right for anyone to do anything to them that makes them feel uncomfortable, and that they should speak with someone they can trust. Dr. Ahmed mentioned that the principal had a list of people they could approach for such concerns.
Sarah Siu-Heng talked about upper-respiratory infections and how viruses are different from bacteria. Jon discussed gastrointestinal illnesses, water safety, and sanitation. He informed the children that there could be parasites in their drinking water, and that in order to avoid illness, they must boil their water before drinking it. Mike then spoke about how mosquitoes are responsible for transmitting dengue. He shared ways to prevent the transmission: making sure there is no standing water and preventing the proliferation of mosquito eggs by adding to their water basins the chemicals that health care promoters distribute during their home visits.
It was then time to hop back onto the truck and head back down to the main town. Hard to imagine, but the view was even better leaving the small town than it was going up.
It was rewarding to know that there was a good chance that we helped the students by answering their questions. The communities in many of the areas we have visited are conservative and this was a great opportunity to educate young adults and to dispel many myths about various diseases.
Hau C. Chieng with Michael Nickas, D.O. 2015
Day 11- July 18, 2012
Rethinking access to healthcare
Before I go into anything else, let me be the first to tell everyone that we reached our goal of 300 patients today! Some of us thought it would take two full weeks, while others thought getting 300 patients in our three weeks here was going to be too tall a task— no one anticipated that we would be able to complete electrocardiograms (EKG's) and venous blood draws on 308 locals in just 3 days.
So congratulations are in order for Jasmine and Dr. Passafaro, as well as for everyone else who helped them along the way—this study has been more than half a year in the making. We believe it is going to be a significant stepping-stone in the screening for Chagas, no matter which way the results fall.
I hope you two remember us little guys on your way to stardom.
Today was a good day. It began at our regular time of 7 a.m. Since we only had two Peace Corps volunteers today— Max and Andrew— we traveled to the more rural clinics of San Fernando and Torola. Dr. "Miguel" Passafaro led Jasmine, Jon, and I at the San Fernando clinic. Besides a short lull in patients about 10:30 a.m. and a quick lunch, we worked steadily from 9 a.m until 3 p.m.
I am the most inexperienced out of the group that went to San Fernando, but everyone there was gracious enough to let me do the blood draws all morning since I am still new to it.
The patients we saw today were harder to draw blood from than those from earlier days - it may have something to do with the fact that the average age of the morning patients was above 60. Thinking back through what little experience I've already had, I can’t remember seeing so many cases of rolling veins and scleroderma together in one place; both of these conditions make drawing blood much harder.
The feeling I got when I attempted to stick someone but failed to draw blood was actually very similar to something I’ve felt when I was personal training; I can have 10 great, successful clients or patients, but one failed attempt can nullify all feelings of success in a second. After it happens, you take a second to try to psych yourself up, you force yourself to sit back down, and you try it again. I would just tell myself to "get back on the horse."
Then you would get another good blood draw, and you were back to it, steadily building that confidence back up.
On a brighter note, I was able to draw blood from my first child today. She was a small, skinny, 12-year-old girl who looked terrified to be at the clinic. Her mother was making her get tested for Chagas. I could feel a short vein on the lateral side of the inside of her elbow, but couldn't see it very well. There were no other veins to choose from though, so I decided to stick with that one.
For a second, I contemplated calling Dr. P over, but I realized he would tell me to "just go for it." So I set up my station and dove in.
As I unsheathed my needle and started advancing towards her skin, I kept telling myself to not mess this up: I didn't want to traumatize this little girl by having to re-do the needle stick. She quickly closed her eyes as I broke skin. Once I thought I was in the vein, I inserted the blood tube into the back of the Vacutainer; I breathed a sigh of relief as blood started to rush into the tube. I think I may have actually started to laugh at this point, out of nervous anxiety.
Even though I will probably do hundreds— if not thousands— of these in my career, I will always remember this one, and how nervous this little girl got me.
These last three days in the clinics have been more valuable than I could have anticipated, both professionally and philosophically. Not only did I learn specific skills a year ahead of my PA schedule, but I also interacted with a population group that I've never experienced before. Even though the only phrases I could communicate with them in Spanish were "good day," "sit," "squeeze," "relax," "good," "how old are you," "thank you," and "goodbye," I felt that I still got to know these people on a deeper level. I could comprehend their fears, sense their frustrations, and understand their desire for simple human interaction and attention.
As Ryan mentioned previously, most of these people wouldn't have access to any sort of healthcare in a system where healthcare isn't free. Yet these are the people who need our attention the most. They aren't going to present with the most “glamorous” cases and conditions, but they do deserve healthcare and medical attention just as much as someone who can afford it.
Now that I've seen how “the other half" lives, I am rethinking how I view healthcare in the United States. I have some major questions to ask myself over the next two years—questions about how I'm going to practice as a PA and what I'm going to be willing to sacrifice to help those who truly need my assistance.
I'll let you know how this thought process turns out in a couple years...
Dane Masuda, P.A. 2014
Day 10- July 17, 2012
Hard work brings study goals within grasp
Today, in Perquín, I saw a five-year-old boy smile ear-to-ear with a 1” bore needle in his arm; we were testing him for Chagas disease. I saw school-age girls coming into the clinic for blood screenings of their own accord.
That’s awesome, right?
The defiance against Chagas disease can be seen in the eyes of the youth. The people in this region of El Salvador do not want themselves or their families to become statistics of an endemic killer; they want to be self-aware and equipped to fight the disease.
The phrase “immensely productive” doesn’t do today’s successes justice. With over 100 patients screened at three clinics within six hours, we are excited to be closing in on our target sample size.
Our study now boasts 232 patients with 133, 66, and 33 contributed by Perquín, Torola, and San Fernando respectively.
Led by Dr. Ahmed, we at Perquín were today's busiest Chagas study team. Sarah, Dane, and our great translator Trisha provided tremendous encouragement and peace of mind to the clinic patients, and dispelled most if not all of their fears about taking the valuable test.
Dane even showcased his stellar babysitting skills by cradling a woman's two-year-old son while she was tested.
There’s a special group of people working hard to help the people in Morazán. I’m honored to be in their company.
Ryan Denley, D.O. 2015
Day 10- July 17, 2012
Well on our way to reaching our magic number
Today, the team broke into three groups (each led by one faculty member) and continued working on the study at the Perquín, Torola, and San Fernando clinics. Among the three clinics, we successfully enrolled another 117 subjects — increasing our total enrolled to 229 subjects!
Before the study began, we were a little concerned that we would not be able to reach the 300 subjects necessary to validate our statistics in the time we have allotted here in El Salvador. But we must say, because of the focus to learn proper techniques, the hard work of our colleagues, and the incredible help of the local Peace Corps volunteers, we are well on our way to reaching our magic number!
The study has allowed the freshly minted second-year medical students on our team an opportunity to learn from our faculty the proper ways to perform both venipuncture as well as electrocardiograms (EKG's) — techniques that students typically do not have a chance to perform in clinical settings until their third-year rotations.
From a community standpoint, the screenings we are running for the study have been a major hit. Salvadorans are coming from far and near to participate, and have expressed how grateful they are that we are here performing a study on a disease that affects them. We are looking forward to enrolling even more subjects in the study and helping more people in the community.
Jasmine Beria and Jon Giordano, D.O. 2014, NYCOM Academic Medical Scholars
Day 9- July 16, 2012
Chagas screenings, health literacy, and patient non-compliance in Perquín
My group arrived at Perquín about 9 a.m. There, we rapidly set up the EKG and blood drawing station. Before we even arrived, there were already approximately 14 patients waiting for us; all the doctors at the Perquín Clinic — especially Dr. Fuentes and Dr. Burns— must have spread the word about our operation. Hau ran the EKG machine for two hours straight, moving from one patient to the next. We had a majority of female patients, but occasionally a male patient would come in. In the first three hours, we were able to screen 50 patients.
One of the most memorable cases in Perquín was a five-year-old boy; his mother claimed he had been bitten by a chinche. He was probably one of the bravest five-year-olds I have ever met. Without hesitation, he stuck out his arm so we could draw his blood. He smiled during the procedure and at the end he gave me a high-five.
At times, we would see an entire family arrive in order to get an EKG and blood analysis. A few minors lined up for screenings by themselves, but unfortunately, we had to turn them away because of our need for parental consent. We encouraged them to come back the next day— with their parents— so that we could screen the whole family.
The line got shorter and our workload lightened up sometime before noon, so I had some time to shadow Dr. Burns, an El Salvadoran doctor who is also an associate professor at the University of Florida. We saw seven patients together. The first was a mother of two. Dr. Burns walked me through the medical history-taking technique and physical examination, which were very similar to what I've learned at the university.
The second patient was a five-year-old girl who suffered from pharyngitis, or inflammation of the throat, because she'd inhaled too much smoke from a wood burning stove. Dr. Burns asked me to give the patient a few suggestions on how to avoid stove smoke, and so I did.
The next patient was a little boy who presented with a fungal infection that recurred because his mom hadn't given him the correct dose of his medication, and he didn't complete the treatment. Patients' non-compliance to treatment seemed a big problem as we also saw a pediatric patient who got very sick from a viral infection because her mom omitted a few doses, claiming, "she was getting better."
I also noticed that many non-compliant cases were because of patient's illiteracy as well as the lack of education about the nature of the illness. Either patients didn't understand the need to complete a full course of treatment, or they weren't able to read and follow the directions of what was prescribed.
One woman came in with a mammogram she had obtained from San Miguel. The patient explained that getting a mammogram done in San Miguel is much cheaper on a weekday than on a weekend — it costs twice as much to get it done over the weekend because a lot more people come to the clinic when they do not have to work. She became very emotional as the doctor explained to her the importance of obtaining a mammogram— it turned out that the patient was never told why she needed one! She had the wrong impression: that she must have cancer, because her last doctor demanded a mammogram for her. Dr. Burns reassured her that the mammogram was a preventive measure against breast cancer and that according to the mammography, she was healthy and normal.
We met another patient who was illiterate and lived in a rural mountainous area in Honduras. After taking down a history, Dr. Burns taught me how to write a prescription for those who are unable to read and write. The emphasis relied on simplicity; the prescription included the dosage and pictures of a moon and sun signifying morning and afternoon. Although patients showed some understanding of what time and how much medication to take, it was hard to know for sure if they will follow the instructions as prescribed. Furthermore, some of these patients lived so far from the clinic that they rarely came back for a reassessment, therefore it is hard to provide complete care.
Today was a fruitful day as we recruited more than 60 patients for the study at Perquín alone. In addition, I gained invaluable experience in caring for patients of an unfamiliar population.
Hau C. Chieng, D.O. 2015
Day 9- July 16, 2012
Kicking off the Chagas screenings in Torola
Today was a very successful day for Project Chagas! We officially kicked off our Chagas screening at Perquín, Torola and San Fernando. All of the equipment, including electrocardiogram (EKG) machines, computers, needles, tubes, etc. were allocated to each site the night before, so this morning we were able to grab what we needed and head directly to the clinics. Thanks to our dry run on Saturday, the strong endorsements of Drs. Gomez and Fuentes, and a general announcement after church mass yesterday, there were Salvadorans lined up as soon as we arrived.
At Torola, we set up quickly, hung up our Chagas screening poster, and hit the ground running. At any given time, Ryan, Dane, or I sat with the translator and reviewed the questionnaire and consent forms with the patients, drew blood from the patients, or ran the EKG.
Under the supervision of Drs. Passafaro and Ahmed, we quickly adapted to drawing blood, even though for many of us our first time doing so was only on Saturday. We enjoyed interacting with the patients and tried to converse with them a bit.
One unanticipated factor in our study seems to be the predominance of women in the population. In general, many more women than men come to the clinics to receive medical attention for themselves and their children.
Current patient count for the study: 112!
Sarah Ng, D.O. 2015