Nicaraguan Coffee and Six Fingers

The weekend is here in Nicaragua and for the Navy Medical Strike Team that means two more days of humanitarian assistance in Somotillo, Nicaragua. We are starting to get into a routine, and today we were up in plenty of time for breakfast and without the disaster from Friday morning. Snoozing in and out along the way on the bus sitting next to Dr. Lynn Sterni, I apologized each time I fell asleep on her shoulder. I think I am becoming narcoleptic. Either that or caffeine has no effect on me any more. Probably the latter. When we arrived at the site I visited my friends Erika and Cristina and baby Angel at the food stand, and Erika made me two strong cups of coffee as I held little Angelito. The premature baby had had diarrhea for the past few days so I questioned whether he was able to get any sleep the past night, and they answered yes, that the medicine had worked and the baby had slept. “When are you going to give him a bath?”, I asked. Sure enough that’s what they were preparing to do as the father cut a plastic bag of water and poured it into a metallic bowl, and in went little Angel for a good scubbing. The chickens scrambling nearby took a moment to observe. They would be lunch in a little bit. If they only knew… Cristina shooed them away and she showed me the green T-shirt she had on today which said “Jamiaican Me Crazy”. She had no idea what it said or where Jamaica was, so I told her what it meant. She smiled.

My translator today was a gorgeous 19 year old woman named Ariadna from Managua. I couldn’t for the life of me figure out why she was here volunteering her time to translate. She was not part of the Mormon church crew and just didn’t seem the type to do community service on the weekend like this. She was shy and her English needed some work. I was patient and by the time we had seen a dozen or so patients she had the hang of it. It was only upon further questioning that I was able to ascertain that she was starting a job next week in Managua at a call center where she would have to be speaking English. So this weekend was her forced practice. Not a bad idea. Smart girl I surmised. And she told me she had a fascination with Looney Tunes Band Aids (Tweetie Bird to be exact). I obliged and she put one on her arm and then in a show of team spirit put one on my arm as well.

An elderly woman came in mid-morning (I think her name was Matilda) who had six fingers on each hand and six toes on each of her feet. Most cases of polydactyly (extra digits) people have a non-functional appendage, but this woman had an extra “pinky” on the lateral portion of the hand that had full functionality and worked very much like an opposable thumb. It made for a handshake like none I had felt before. She was a very sweet woman and proceeded to give unsolicited hugs to both Ariadna and I in a show of thanks. Genetic mutations such as this are fascinating to me, so I asked Matilda whether any of her family shared this morphology. Her sister had extra digits as well, and sadly she was not able to have children (she had lost three due to miscarriage). You could just sense and feel the long life and wisdom this woman had had.

For lunch I showed Ariadna how to eat an MRE (she was mesmerized), and I decided to risk eating the quesadillas that Cristina and Erika were preparing. Over by the stand I saw the two main Chiefs for the site – Chief Francis and Chief Weber. They are the ones who make the site function logistically (busting their tails in the searing heat all day) and I tip my hat to them. Chief Weber is permanently based with the USNS COMFORT in Baltimore and is going to ride in the Baldwin PA Health Ride we are doing in October – www.healthride.org Please check it out and make an impact in combating childhood overweight and obesity.

Every patient I see I make sure to ask what type of work they do. People in the Somotillo region are mostly farmers that grow corn and beans. This morning I met a guy named Jose who grew and processed coffee. I told him about my love for coffee and he told me all about Nicaraguan coffee and how it is the best in the world. I mentioned (in passing) that I would love to try some, not thinking anything of it. Well, guess who showed up this afternoon on his bicycle with a big green pot of coffee and a matching green coffee cup- Jose! He had gone home and brewed some up fresh for me and the docs. With a bit of trepidation I accepted Jose’s cup of Nicaraguan Joe. It was awesome! Hit the spot. In return I scrambled to find a “regalo” (gift) to give in return and luckily in the MRE container there was a leftover Lemon Pound Cake safety sealed in the brown plastic. I gave it to Jose with pride and told him that this is what we eat with coffee in the U.S. He opened the package and smiled after taking a bite of the pastry. Whew…..

The day ended with us seeing a bit less than the day before – about 1500. Since the town had only a few thousand people, we began to realize that those people we thought looked the same as yesterday, probably were the same people from yesterday…….
Oh well, it’s all good. We’re providing a stockpile of medication for them. The longer it lasts the better. Just so long as they know the proper usage. And it’s not like we are doling out Diprivan or Propofol or something like that (MJ).

I am trained as a medical doctor of the Allopathic discipline. Many other docs are trained additionally in the Osteopathic discipline, learning to do “adjustments” and chiropractic treatments. I have never been much of a fan of these but tonight I changed my tune. After several days of seeing hundreds of patients I felt like dog doo, and my back was stiff as a board and my neck jacked up. Barretti is a D.O. (Osteopath) and so I gave in and asked him to crack my back and my neck. I am now a believer. Thanks Mike. See, I knew under that insolent hard shell with your jaded view of the world, there really is a nice guy who can crack peoples joints and allow them to feel better.

Nicaragua- Woman with 20 Children

“Baldwin, Holy S%#* it’s 6:15!” screamed Mike Barretti. “Bus leaves in 15 minutes!” We had both slept through our alarms and we scrambled to get ready on Friday morning for the trek back out to the medical site in Somotillo. Mike elected to forgo the cold shower and shave in order to get some breakfast, as I chose to face the frigid water in hopes that the bus would be late and I could still snare some biscuits and coffee on the run. Dang that was cold! I exited the shower and tried to slide the door back the entire apparatus came unhinged and crashing downward. Shaving my my beard and at the sink navigating around the broken plastic/glass was a chore. The morning was indeed off to an interesting start! And as anticipated the bus was bit late, so I inhaled some eggs and beans and threw some coffee down the hatch and then boarded the bus to Somotillo. I took a moment to reflect that although we were in the second poorest country in this hemisphere (behind Haiti) the beauty of this land was worth a million. The view out to the San Cristobel volcano looked gorgeous in the morning light and many of us leaned over each other to try to get a moving photo through the bus windows (note to reader- this never results in a quality photo). During the drive I embarked upon a new book by Michael Creighton called NEXT and then sadly was told that he had passed away last year. The Harvard medical school grad wrote many novels and also was the force behind the TV show ER.

We reached the health clinic in Somotillo at 8 am and the line of patients was enormous. I tried to take a picture that captured its enormity- the crowds of a few thousand stretching down the street and around the curve. It reminded me of the start of a large marathon race. The majority of the patients were mothers with their children. Most of the fathers away in the fields working. I went over to the food stand that I had spotted yesterday run by a few ladies named Erika and Cristina and they yelled out, “Hey Andres!” Wow, they remembered. “Me falta un café (I need a coffee)”, I said. This was no STARBUCKS. The water heated up in pot over fire, a chicken ran by, and Erika’s premature little girl was crying at top volume. The instant NESCAFE coffee was not nearly as good either, but it woke me up and got me through the morning. Cristina begged me to get her baby some more vitamins, and also some cream for the rash. I saw a stash of medication that they had collected already (no doubt in barter) and began to see the way that things work around here.

My translator today was an extremely knowledgeable woman named Karen who currently lives in Managua but grew up in the United States in Los Angeles. Her English was better than many Americans I know. She had done quite a bit of medical translator work before, and with these skills we set a rapid pace of seeing patients. It was a good thing considering the line outside. In the examination room with us were Dr. Barretti, Dr. Ed Taylor (Family Practice doc), CAPT Sheehan (Nurse Practitioner in Public Health Service). We were flying. By mid-morning we had already seen about 800 patients, and the line outside still kept going and going… Most patients here in Somotillo were the same- country farmworkers and housewives – the overwhelming majority of whom had headache, gastritis, and dizziness. So much so that we were already filling out the forms by the time they presented to us. Some unique patients that I saw were a woman who had no teeth, but wanted to show me her smile anyhow ☺, a man sporting a Nautica (one of my sponsors) cap and having no idea what Nautica meant, and an 80 year old woman who had twenty children over her lifetime. At eighty years of age she told us that her youngest was 30 years old, and that only eleven of her children remained alive today. Many of them were killed in the Contra-Sandinista conflict during the 1980s she said. I had to take a moment and regard the uteral courage of this woman. Upon further questioning I found out that she has over 100 grandchildren all throughout Nicaragua. What a life force!

The crowds were so large that we ate a working lunch, having some MRE crackers and cold beef stew while answering questions about headaches, gripe (flu) and cough (toz). Early in the afternoon Karen and I went through the typical patient visit and wrote out the prescriptions for a nice mumbling young lady and thought we were through, but at the end she opens her mouth and showed us something. She had a frenulum (that piece of tissue that connects your toungue to the bottom of your mouth) that held her entire tongue down. She had extremely limited movement ability for her tongue and she was able to tell us it prevented her from rolling her R’s and speaking effectively. I thought how nice it would be to get it cut back, and ventured with the woman over to Dentistry to see if we could do some minor surgery. No more surgery room aboard the USNS COMFORT, but with some urging and serious courage on this girl’s part we decided to do it right then and there. We numbed up the underside of the tongue, and got out some sharp scissors, and Dr. Sanchez dissected away avoiding the large bleeding vessels and carefully giving this girl the ability to move her tongue around (something that we take for granted every day). Afterwards she could roll her R’s (I still can’t for some reason and am considering a frenulumectomy, but others tell me that is not the problem).

The afternoon wore on and we began to see our first patients from Honduras. CDR Ed Taylor, who is from Honduras originally, jumped up and told the room when he encountered a nice woman from his home country. She had heard of the USNS COMFORT team being close by and had crossed the border to be seen. Several more followed and many more would come over the next few days I am sure. Outside the crowds became unruly outside the pharmacy, and the pediatrics waiting areas were overflowing us adult providers agreed to see some kids as well. The pediatric bail out was fun and gave a change of pace to see some different issues- lots of scabies, diarrhea, parasites, and parents stating that their children were not eating (no appetite). Most of these children were normal weight and their mothers were the opposite. But have to put it gently. Health education and reassurance I think is ofen times the most valuable in this type of setting and population.

By the time 5pm came it had been 9 hours of seeing patients, and in all the site had seen close to 2000 patients. I must have seen close to 150 and Barretti, Taylor, and Sheehan was up there as well. As we so often joke on this mission that it is “Not about the numbers” CAPT Sheehan pushed the joke even farther as he grabbed the stacks of hundreds of patient encounter forms and flipped through them all. It was a record setting day out there today, and the most prescriptions given out by far for the entire mission thus far. Great job to the Medical Military Strike Team led by Dr. Cole!

Thoroughly spent we retreated to our hotel in Chinandega, and found one hundred of our fellow humanitarians there as well. The boats and helicopters were grounded due to bad weather and they all would be staying over crashing on our floors, or on cots if available. I joined the table with CDR Santa (UNC grad and Navy NP), Jefferson Medical Student Majit Gupta, and several others including Dr. Richard Soetens, a Dutch physician. Soetens claimed a cot in our room. I’m not sure if either of us got any sleep that night with Barretti’s drunken snore. Well, until tomorrow from Nicaragua. Buenas noches.

Mission to Somotillo

The mobile medical strike team (MMST) led by CAPT Jeff Cole assembled at 7am on July 9th in the casualty receiving area onboard USNS COMFORT  Our mission- get to the remote rural town of Somotillo in northwestern Nicaragua ASAP to relieve fellow humanitarians and wreak as much positive goodness on this town over a five day period as humanly possible.  This was it.  What we had trained so hard for. 

Donning our high speed sunglasses, stethoscopes, and lifejackets we ran up the stairs to the main deck to get on the uber fast RHIB (rigid hull inflatable boat) and get quickly to shore.   “Go ahead and take a seat!”, shouted Gunnery Sergeant Roberts. “It’s going to be awhile!”  Sure enough, the strike team was foiled once more on achieving an expeditious delivery to target.  We took a seat, and some of us even laid down for a snooze on bed of lifejackets.  

After finishing three books over the past few days, I was glad I snagged a few more before leaving on the mission this morning.  I whipped out my IPod and a murder mystery by Dean Koontz and tried to stay focused on the five-day mission that awaited us.  My teammate, Dr. Mike Barretti, cursed the situation and then cursed that I was reading books.  Barretti means well, trust me. He finally has made a valiant effort to quit smoking and for that I am proud of him.  

 A few hours later we descend onto the RHIB held by a single tether line to the ship crane above.  Sure hope it doesn’t snap, I thought, while preparing to do a inverted dive and duck if it for some reason it did.   We touched down safely and were on our way.   Instantly the feeling of Navy pride returns as we are skimming the water toward shore.  Barretti is making the best “Washington Crossing the Delaware” stance he could and I snap a photo.  

This is what it must have felt like back in the day (well sort of).  Just at that moment, CAPT Sheehan leans over and informs me that the Carinto harbor that we are about to enter was mined by the United States just under three decades ago during our “clandestine” operations working against the Sandinistas.  Sure hope they are cleared now.  Wow, what a difference a few decades

 and the fall of the Soviet empire makes.  I see that Sheehan has quite a bit of knowledge on Latin American history and a penchant for political science, so I make a mental note to pick his brain over the next few days about the “true” state of affairs here in Nicaragua. 

By the time we reach shore it is 10am and we board the bus for the bumpy ride through Chinandega northward to Somotillo (about 3 miles from the Honduras border).  Wow, this is the Short Bus!  I sandwich my legs into the small seat space by the window (why did I have to pick the seat with the wheel well???) and knees jab into the back of my teammate in the seat in front of me.  Next to me sits a lady volunteer and I thank her for being a member of the team and helping on the mission.  I tell her that she should join the Navy (always recruiting J) and she tells me she doesn’t want to shoot guns and be sent to the front lines in a war zone. Really??? I begin to form an answer, but then decide it is not even worth it. Back to the book.  We pass by Chinandega, and see the sign- 60km to Somotillo.  My legs have lost feeling by this point, but I ignore it and press on.  

Off to the right hand side we catch a glimpse of an enormous volcano (it must be 10,000 feet) with steam spewing from the top.   I come to find out the name of the giant is San Cristobel and it is one of seven volcanoes that are semi-active in the country.  

By the time we reach Somotillo the Dean Koontz book is almost history, and it is just past noon.   We carefully approach the target site making sure to hit every pothole along the way, and once secure, we charge the building (Centro de Salud – Raymundo Garcia) and announce the cavalry is here!  Our fellow humanitarians, weathered and spent from their numerous days here, are overjoyed to see us.  Ready to go, the first thing we do- lunch!  Luckily the Centro de Salud (in addition to a large amount of flies) has a set of rocking chairs that instantly remind me of Cracker Barrel.  Dr. Schwartzman (heart sweat man), Dr. Arthur (fellow Duke grad), and I man the rocking chairs and ingest our MREs.  The relieved troops leave for the trek back to the ship and the new MMST sets up shop.  The area where we are seeing adult patients is full of flies, BUT it is air conditioned (when the electricity is working).  I look at the bright side.   Barretti doesn’t.

It always takes a few patients to get back in the swing of things after being back onboard the ship for a while.   The Spanish isn’t quite flowing right.   You are caught off guard by a different regional style of the medical Macarena “dolor” dance.  But eventually things get going, and you’re back in a routine again.  This town is interesting.  For one, it is definitely “el campo” (the country) and all these people are farmers, or do something related to agriculture.  Somotillo is an impoverished town with little to no infrastructure and this tells me that 1) there will be less chronic health problems due to obesity 2) there will be more rashes, allergies, GI issues, skin infections, parasites due to lack of hygiene and 3) there will be A LOT of children because there is not much else to do around here besides create them.  

 

As the afternoon progresses I am working without a translator, which I am able to do, but boy does it get tiring.  A female patient asks me if I am from Cuba, I say no, she asks me if I am from Mexico, I say no, and finally she says United States?  Yes.  Peculiar.  Later I come to find out from CAPT Sheehan that Cuba (and to some degree Mexico) have had a large impact on the medical care and medical training of the people in Nicaragua.  This woman had never seen a doctor from the United States helping (especially one that could try to speak Spanish).   

 By the end of the day I was desperately in need of a coffee, and so I ventured out into the dirt road looking for some instant café.  There were lots of roosters running about, and guys on their “Tricicletas” – that’s what they called them here for the bikes to transport people around.  I found a food stand and it was super filthy.  I surveyed the scene where the coffee was prepared and that was not as bad, so after some discussion my gut and I agreed to give it a go.   

What’s the worst that could happen?  The senora preparing the coffee invited me into her “shack” and I saw on a hammock her small baby that had recently been born eight weeks premature.  The woman begged me for some vitamin drops for the babe and to give her some extra money.  I gave her some help and returned with the drops in time to pick up my coffee.  It wasn’t that bad (and as I’m writing this no issues to speak of). 

 

We packed up shop around 4pm and boarded the buses for the long haul back to Chinandega where we would be spending the night at the Volcanoes Hotel.  Thank goodness for Dean Koontz and his easy to read murder mysteries.  Just as the killer was about to strike, BOOM! , a tire blew out on the right back wheel of the bus, and we ground to a halt.  I have never seen a tire changed so fast by the driver of a bus.  He found a rock on the side of the road, and backed up onto it (using it as a jack), and changed that tire like a NASCAR pit crewman.  Most of us used the extra time to visit the bushes on the side of the road to take care of some business. 

 We were slowed by a banana carrying truck the rest of the way, so by the time we reached the hotel the Koontz book was complete (they got married).  I gave the book to Barretti and he scoffed at first, but ended up taking it.  We’ll see if he reads it.  The Volcanoes hotel turned out to be extremely nice.  A quiet place, with view of the volcano in the backyard, and a nice bar and restaurant.  The MMST settled in for our first night ashore and did what a joint medical team does after a hard days work.   Until tomorrow…..