El Salvador II

I’m writing this on Sunday, July 24, but I probably won’t be able to send it out for a while. The internet and phones have been down for several days and we don’t know when they’ll be working again. So I’m feeling a little cut off from the outside world. Then again, I spent two years in Guatemala with no clue what was going on outside of Central America, so I guess this is nothing new.

This week was more of the same. I did three more clinic days at the site at the stadium (Polideportivo) and an additional day at another clinic site at a school (Santiago). Santiago was great because it was located only yards away from a beach, so I got to walk on the sand and watch the waves crashing. The people there had built boxy houses with walls and roofs made of palm fronds all the way up to the sand. Possible natural disasters aside, not a bad place to live.

The families here have the same concerns that they did in Guatemala: my child isn’t eating enough, his stomach hurts, he gets headaches. Which is code for: can you give me vitamins and deworming pills? Of course, I’m glad to hand them out. I have this mental picture of me working in the ER once I get back to Baltimore and dismissing parents’ complaints by saying, “Just give her some vitamins and mebendazole. She’ll be fine!”

Of course, I’m trying to dig deeper, too. I’m finding lots of asthma here, just like I did in Guatemala, but it can be tricky. Every parent will tell you that their child coughs all the time, but often that just means that they cough every time they get a cold. We also see a number of kids with more complex medical conditions; they’ve had comprehensive evaluations in local hospitals, but their families can’t afford the medications or imaging that have been prescribed. One unfortunate kid I saw was a seven year old with imperforate anus who had a colostomy. The colostomy bags were irritating his skin, so he just has a cloth wrapped around his abdomen to serve as a diaper. He needs surgery to create an anus and take down his colostomy, but sadly we were not able to do it on the ship.

My favorite patients this week were 9 day old twins with cleft lips and palates. I admit, I complain a lot about newborns—especially preemies—because of their irritating habits, like stopping to breathe for what seems like no good reason. But I still go crazy over cute babies, and these two were adorable. They were there with their grandmother and aunt. The funny thing is that at first we all assumed the aunt, who was very petite, was the mother and that she looked amazing for having had twins just nine days before! The mom was actually at home recovering from a C-section. The twins did come aboard to be evaluated for a possible repair, but unfortunately they are simply too young to do the surgery right now. It was a big disappointment for us and the family. The good thing is that the family already has a good nipple for feeding the babies, who appear to be getting plenty of calories. I think they’ll do fine until they’re big enough for surgery.

We have had the chance to enjoy some local food and culture. Before I arrived in El Salvador, I knew that I didn’t want to leave without eating some pupusas. These are corn tortillas stuffed with beans, cheese, pork or other fillings then fried. They are served with hot sauce and shredded cabbage, and they are delicious. And when I say delicious, what I’m really saying is that they are one of the greatest foods ever invented by mankind. I think Satan could have tempted Eve with a plate of them. I was worried I maybe wouldn’t get any: we have been under heavy security in this country and have been restricted to the ship and our clinic sites. There is a big violence problem here, although most of it is gang-related. The people we have met, however, have been wonderful. In fact, a group was at Polideportivo one day giving out pupusas to show their gratitude to us. They even made them right on the site. You can bet that I was very grateful to them, too!

That same day, a local high school put on a cultural presentation for us. They had traditional dancing, accompanied by keyboard, guitar, drum, and two off-key recorders. The girls wore colorful, flowing dresses, and one poor boy had to dance along with all of them. The school choir also performed, and that turned out to be one of the unexpectedly moving moments of this mission. They sang Beethoven’s Ode to Joy, though with different lyrics in Spanish and accompanied by their music teacher on guitar. I couldn’t help but think of the original words in German and their message that all men are brothers. Here I was, in a small country in an often forgotten part of the world, listening to Beethoven. The kids may not even know who Beethoven was. The distance between nineteenth century Vienna and twenty-first century El Salvador, after all, is great. But while they sang, we were united by the hope written into Beethoven’s melody.

You know, I can’t solve many of the problems I find here. I don’t know how big of an impact I’m having, no matter how many starfish I throw back in the ocean. But moments like that remind me why I’m here.

Well, we leave for Costa Rica tonight. We’ll be at sea for a few days, then we’ll have liberty in Costa Rica. I hope you have a great week, and I’m already looking forward to sending out another dispatch soon!

El Salvador

Hello from El Salvador! To be honest, the past week was not nearly as exciting as the first, mostly because we spent three days in transit to El Salvador, plus time to take down the clinic sites in Guatemala and set up in El Salvador. So I was on the ship for nearly a week until I was able to go ashore again.

I did have a few things to keep me busy while we were at sea, like educational conferences and an abandon ship drill. No, I didn’t have to fling myself overboard or anything; we just had to grab a life jacket and head up to the flight deck, where they called muster. If you’re not there, they go hunting for you throughout the ship, and then they have you climb a deck above the flight deck so everyone can see who didn’t show up. Luckily, I had advance warning, so no embarrassing walk of shame for me. I also got to go on a tour of the ship’s engine room. We saw the furnaces, the engines, the giant shaft turning the ship’s propeller, the generators, the desalination plants, and the garbage incinerators. It was incredibly loud and hot (the thermometer read 110 degrees), but it was fascinating.

Otherwise, I got a lot of studying done plus a lot more reading. With no TV and internet that only goes about a kilobyte a second, there’s not much else to do.

But now we’re in El Salvador, docked at Acajutla. Here we can walk down a ramp off the ship to the pier, unlike Guatemala. I’ve been to one of the clinic sites; it’s a stadium with raised concrete bleachers covered by a canvas canopy. There are lots of birds in the metal struts holding up the dome, so you have to wear a hat if you want to avoid being bombed from above. Our clinical areas are located underneath the bleachers, so we’ve been able to keep out of harm’s way. We’re seeing the same kinds of medical problems we saw in Guatemala, and the people are just as grateful for any help we give them.

The patient I think I’ll remember the most was an eight year old girl who was brought in by an elderly woman. She was a beautiful girl with big, lustrous brown eyes. But she has a seizure disorder and has never been on medication. Her left arm and leg are stiff; she cannot walk or say any words other than “agua,” though she can babble with great enthusiasm. Her caregiver explained that even though the girl was not a blood relative, the caregiver had taken the girl from her mother’s home because the mother was not feeding her. The caregiver said that it was difficult to take care of her, because she has a few seizures a week and the caregiver has to carry her on her back everywhere they go. But she said that it was all worth it. While she told me this story, the girl playfully slapped my palm with her right hand. Then she laid her hand in mine and let me hold it for the rest of our visit. It broke my heart that there wasn’t much I could do for her at our clinic, though I did refer her to a neurologist. Even so, these are the kinds of encounters that have made a big impact on me.

Well, I’ll be working hard in the coming week, seeing lots of patients as usual. After that we leave for Costa Rica.

Guatemala

I wrote this letter yesterday, and I figured I'd create a blog and post it so more people can read it. I'll probably post about once a week, depending on how busy I get. The internet on the ship is extremely slow, so I won't be posting pictures for now.

Greetings from the USNS Comfort! Since I have the day off today, I thought I'd send out an email to let you know how I'm doing. Unfortunately, our internet connection on the ship is very slow, so I won't be sending any pictures for now.

The ship is currently docked at Puerto San Jose, Guatemala, although we're leaving for El Salvador tomorrow. The largest city nearby is Escuintla. When I was on my mission, I was mostly in Guatemala City and in a town called Jalapa, which is to the east of the capital. This area is within my mission boundaries, but this is the first time I've been to the coast. Guatemalans divide their country into "tierra fria" and "tierra caliente"; the hot areas are the coastal regions, where it’s hot and humid, and the cooler areas are in the mountains, where the weather is much more temperate. As you can guess, we are definitely in "tierra caliente"! There are palm trees everywhere, fields of sugar cane, and huts with thatched roofs made of palm branches. We are docked in an area that is frequented by cruise ships, so there are souvenir stalls and a restaurant on shore that we can visit.

A typical work day begins at 4:30 am; I get up, get ready, eat breakfast, and go to muster for the boats that are going ashore by 5:30 am or so. We are then driven in vans to the clinic sites, which can take up to an hour on bumpy dirt roads. The clinics have been set up in local schools; there will typically be between four to nine pediatric providers at each site. There are pediatricians, pediatric residents and nurse practitioners that are with the navy as well as volunteers like me. The clinic sites also have family medicine, internal medicine, dentistry and opthomalogy, and they often have orthopedics, cardiology, radiology and physical therapy as well. We are seeing lots and lots of kids. On our busiest day so far, we saw 250 children. The patients are coming to line up at 2 or 3 in the morning to make sure they are seen. Patients who need surgery are taken to the ship; usually, it’s things like eye surgery or cleft palate or hernia repairs so the patients can get off the ship before we leave. The work can be draining, with the heat and humidity and the need to see lots of patients quickly. We usually finish about 3 or 4 pm, then head back to the ship. So far I’ve been working two days in a row with a day off after that, so I do get a chance to recover. It will take three days to get to El Salvador, so it will be nice to relax and get some studying done.

It’s a big adjustment to work with limited resources. There are only so many medications in the pharmacy, and getting imaging or consults can be a challenge. This means that I have to rely on my own clinical judgment most of the time, and I have to be ready to think flexibly and creatively to solve clinical problems. I’m seeing lots of malnutrition, anemia, and asthma. Many families can only afford to feed their children beans and tortillas; fruits and vegetables are too expensive to eat regularly. When parents do have money, they often let their children buy sodas, candy and chips at the local stores. So it’s no surprise that the most common complaints I hear from parents are that their children aren’t gaining weight, they have bad appetites and they get stomachaches and headaches. Most parents are very interested in getting vitamins for their kids. I’m happy to give them out, but I’m doing a lot of education about nutrition. Of course, parasitic infections are also rampant.

Treating asthma here is particularly challenging. The air quality in Guatemala is terrible; the houses have wood fires and are full of smoke all day, and garbage is burned in the open air. Many of my patients have asthma symptoms, but so far only one child I’ve seen has had a mask, spacer and albuterol inhaler at home. Usually, the parents have to take their children to the local centro de salud (health center) for albuterol nebulizations. I’m giving out lots of albuterol inhalers and starting kids on controller medications, just as I would in the US. But this is a very problematic approach. You can’t control asthma with just one month worth of medications. And I don’t have masks and spacers to give the kids, so I doubt they will get the medications properly at home. We do instruct the parents that they can make a spacer out of a water bottle, but this won’t work very well for younger children. So I do what I can and hope for the best.

The biggest problems with the local health system are distance and price. You can get excellent care in Guatemala City, but it takes two hours to travel there and it’s expensive. You can get many medications in the local pharmacies, but they can also be expensive. When it comes down to choosing between food and medications, food will win every time. It can be heartbreaking to see children with cerebral palsy or other chronic medical conditions who just won’t get the care they need here, and there’s very little we can do for them. But our patients are very grateful for the care we give them, and it’s wonderful to make a difference, however small, in the lives of these wonderful people. Today, a group of us went ashore to teach a group of local midwives and nurses Helping Babies Breathe, which is a simplified method of newborn resuscitation. It was clear that they were an experienced group that had been trained well in the basics, so it was exciting to teach them more advanced techniques like bag-mask ventilation. They were enthusiastic and grateful, and they will able to take the training materials we gave them to the outlying towns so they can teach others. It’s encouraging to think of the big difference just a couple hours of training can make.

All in all, I’m having a great time. It’s hard work, but it feels great to serve. And of course the kids are incredibly cute. I hope you are all doing well, and I’ll try to keep you up to date with my adventures. Next stop: El Salvador!