Black Cloud

Buenos Dias, Amigas. NH aqui:

It has been a few days since my last post and so much as happened. So remember when I mentioned the great missionary Exodus? Well, Thursday night, the missionaries leave the compound. I am left with another family practice doc and Abby, the ER doc, to man the entire hospital. The missionaries have been joking with me in the week leading up. They'd be like, "It will be FINE. Most likely, nothing will happen. Remember that year though during retreat when there was an 11 person MVC and only 2 docs with so many injured patients? Remember that?" Very comforting. Well, anyways, Thursday night and Friday were not that bad. I got a 6am call to come help with a delivery. The family doc had been on call but since they like to have a doc for the baby and a doc for the momma since the nurses are not NALS certified, I went. The delivery went fine but the baby came out depressed. Since I am house sitting all of the way up the hill, I do not make it until the baby was already out. I walk in and the baby is not crying, and they say to me, "Do you know how to tracheal suction." "Yes," I say. But I'm thinking to myself, "Well, in theory at least." But I do tracheal suction and eventually the baby starts crying. I rounded on all of my patients and then was actually able to steal a couple of hours to go snorkeling for my first time EVER. We swam way off the beach to find this beautiful reef, and I could not believe the diversity of wildlife and the colors of all of the coral.

Josh and I are up the hill around maybe 5pm, and I hear over the radio the ER doctor. There's a delivery, and she needs some more help. I get down there pretty much in time to gown, glove, and catch baby. Baby is a little depressed but looks pretty good. Mom has a small lac that i get to repair. Fun stuff. Everybody who is reading this knows this is right up my alley. However, then we start having trouble keeping the baby's saturations up even though the baby actually looks pretty good. We decided this is an urgent but not emergent need for transportation to Ceiba, a city about 1.5-2 hours drive from here. Oh, and there are no ambulances running tonight so if we want them to be transported, we will have to do it ourself. As Abby is arranging this and sorting throught he mountain of paperwork (birth certificates, etc.), I see a man in the ER for her. At this point,we are busy, but it is under control. We get a call saying there has been a motorcycle accident. As soon as Abby walked into the ER and saw the chaos, she sent out a radio call. "Everyone who has hands and/or a car, COME!" A husband, wife, and 2 year old boy had been on a motorcycle (in the dark, mind you) and hit a horse. The wife had some minor lacerations but otherwise looked ok. The husband has a pumping scalp laceration and is covered in blood and his eyes are both swollen almost shut indicating further head injuries. We are putting him a C collar when I look over and say, "Who's the kid?" Abby said, "He must have been a part of the accident too," and we quickly turn our attention to him. The 2 year old has complete left hemineglect: eyes are looking off to one side and he is only using one side of his body. Abby, being the ER doc she is, decides he is the most urgent (as we are almost certain he has a head bleed) and starts preparing a car to take him to La Ceiba. She decides, since I am most up-t0-date on my pediatric life support certification, to send me with the intubation kit, a monitor, and a suction kit with the reassuring words, "He has a good chance of seizing, coding, or dying on the way there. Be ready." Thanks very much.

As she is putting the child in the back seat of the car, he starts seizing. I have already drawn up Phenobarbital and push a dose as we take off with mom, grandma, and our driver, Brad. He does not stop seizing with the first dose of phenobarbital so I give him a second dose. He finally stops seizing and remains pretty stable the rest of the trip with an occasional desaturation that goes away with suction. The whole trip, he only responds to painful stimuli and when he does respond, it is only with his right side. We get to the government hospital, which Brad says is a great improvement on the previous facility and walk immediately into the ER bay. I have been told to BE FORCEFUL, because if I am not, this child could have to wait hours to even be seen. I meet a doctor who I know at once is a resident, probably an intern, by the fatigue and panic in his eyes. I tell him the story and tell him that the patient needs a CT scan STAT. He is very kind and seems to know what he is doing and understand the urgency of the situation. But they don't do CT scans anymore here and would have to take the patient 20 minutes down the road to another hospital. Ok, let's do that. Now. The little boy now starts waking up and to all of our amazement and relief, he starts moving all of his extremities and crying. YAY! Perhaps his paralysis is not an expanding head bleed but a smaller one causing seizure activity. He still needs a CT scan, but we are thankful that he's showing improvement. Anyways, we leave the little boy once the attending comes down. The family, of course, does not have the cash in their pockets for the CT scan, because they came straight from the sight of the accident to the hospital. Brad give the money (about $150) to the hospital so they can take the child. I know this is not "When-Helping-Hurts"-Savvy but who cares? What are you supposed to do? The rest of our transports have arrive: the post-partum lady, her baby, and the husband. The husband apparently had an arterial pumper from his scalp lac that they were unable to repair at Loma de Luz. Instead, they put a large pressure dressing around his head that seems to have stopped the bleeding for now. I get back to the hospital around 1am.

I am actually on call Sat., and I am busy with ER consults but its nothing too bad. A vomiting child, a foreign body in the eye, a miscarraige, you know. I had one nighttime consult but was in bed by midnight and did not get any other calls. This morning is Sunday and there is no ride for me to go to Honduran church and the missionary church is not going on so Josh and I are taking a true Sabbath this morning. (Well, besides me going in to round.) There is more, but I am tired of writing, and you are probably tired of reading. I know I keep promising pictures, but they will come. Thank you all for your continued prayers. They are much needed.

Oh, and as far as the "black cloud" title goes, I believe that mine has followed me here to Honduras. Its kind of a big joke back in Greenwood, but I forgot to warn Loma de Luz in my application process that I draw in chaos. Kindly though one missionary said that she has been praying for this. She has been trying to train nurses, but their census has been low. Since I have come, they have gotten lots of learning. That's one way to look at it.

Philippians 4:19 "My God will supply all my needs according to his riches and glory."

The safe zone

Diving at the Waterfall

Big Star Fish

Tarantula

Hey guys J here again. Finally.

Since I last posted some pretty cool stuff has happened, along with some not so cool stuff. First the cool stuff. I did get to go snorkeling the other day and saw some pretty cool stuff. Big star fish and lots a colorful fish. Turns out its really hard to take pictures of fish under water while the waves are rocking you one way and the fish are swimming the other. I did manage to get a decent video though which I'm posting and hope to get some better shots later. The water was really clear considering all the rain we got the night before. I'm told there is another better reef further up the beach and hope to hit that one in the weeks to come.

Sunday we went to the Honduran church which is pretty much all kids it seemed like. NH of course got the kids talking and playing with us pretty quickly. I find using my spanish with little kids is alot easier than with adults. True they are alot closer to my level but I feel less judged somehow. When A kid laughs at your accent or grammer problems its so much less insulting for some reason. There were a couple girls there that were just too cute. Don't believe NH has downloaded those pics yet though.

Later that day we went to this sweet water fall where people could swim and jump off of this really high cliff into the water. I just hiked around it looking for critters though. Total bust in the wildlife department. But the impromptu Baptism was pretty cool.

Monday was a pretty slow day I guess. We had lunch at the little place just outside the compound where this Honduran lady has a kind of fast food restaurant. "Fast" being a relative term of course. Probly won't be eating there again seeing as how I have had to spend the last 24 hours in "The safe zone". For those of you unfamiliar with the safe zone allow me to explain. The safe zone is the radius around your toilet that you are confident you can overcome should nature call. The formula is based on your typical regularity (R= trips per hour) which typically lies between 0.1 and 0.2 for most people who are not sick. The next factor to take into account is stride length (S= # of inches per step from back toe to front heel). For those with a longer stride length who are able to cover more ground in a single step your safe zone will be slightly larger. After determining S you simply divide it by 2. Initially some obstacles may play a small roll in determining the safe zone but after you realize your zone is shrinking you can simply remove these (chairs, fans, etc.) to simplify your math. So to break it down for you. "The safe Zone" (in ft) = R(S/2) NOTE : only applicable for #2 trips #1's have a completely different formula, Which for me was 5to8(12in/2)+30-48ft. I'm pretty sure I have just created the most TMI blog post of all time. One cool thing about last night though was NH discovered a Tarantula right outside our door which luckily was inside the safe zone, so I was able to get a few pics of it.

It's Wednesday now and I think the worst is behind me. Not sure if thats a pun or not. Hoping to be able to get out and do some stuff again soon.

J

Eating at a Honduran food stand = diarrhea for all

NH here:
I know you are all probably getting quite tired of me writing. Josh, however, right now is confined to the bed and the toilet. It is not a pretty sight. I am having similar problems but not as bad. I attribute it to my rockin' immune system from eating off of the floor as a child. Anyways, he promises to update you soon.
Update on me: I feel as if my comfort zones are being stretched in every direction. I am fairly comfortable with the whole living-with-no-air-conditioning-lots-of-bugs stuff that comes with this territory. However, this is the first time since actually getting an MD behind my name that I have been treating people in another country. This is the first time I have actually been expected to know what I am doing and make important decisions. It feels like being an intern all over again with all of of the fear and self doubt. God brought me through my intern year stronger, and I know He will do the same for me here. I often think of the verse from II Corinthians 12:9 that says, "But my grace is sufficient for you, for my powers is perfected in weakness." I am comforted both in knowing His sufficiency for me and my patients but also that He is a God who uses the weak (like me).
I was dealing with a child last night with probable glomerulonephritis and high blood pressure. He went into status epilepticus. I don't care how common seizures are, they are scary... for everyone involved. Anyways, I gave phenobarbital IV, and he came out of it. Please pray for his continued healing, and my wisdom in treating him. He is 9 years old, in alot of pain, and scared to death. I too, honestly, am scared to death. As many of you know, you can give me adults in critical condition and women delivering babies, and I love it. Give me a sick kid, and I am scared to death.
I was also part of a twin C-section yesterday. awesome. Both babies came out crying. Mom is doing great.
Pictures to come... I PROMISE!

The great Exodus

NH here:
Well, friends,
An update on my last post: The baby is doing swimmingly. (I shall post a picture later). And after tossing and turning all night praying for my older patient with pneumonia, I walk in, and she looks SO much better. I think that she has finally turned the corner and will make it. Praise the Lord. (as Billy White would say).
I just got back from a day of clinic. There was nothing terribly exciting so I will take this time to fill you in on yesterday. We had originally planned on going to the missionary church, but we heard Saturday night of a Honduran service that was several miles up the road and decided to tag along with a missionary couple and a team from the U.S. Great decision! The church was, I don't know, 75-80% children. Many of these are children from the Sanctuary House Children's Center, just down the hill from the hospital. This place serves as a home for 30 something children who are either 1.) chronically disabled requiring close medical attention, 2.) from very rural areas and needing access to education, and 3.) abandoned, abused, at risk, or just needing a safe place to live for whatever reason. We were sitting at church surrounded by children who were all looking very unsure of these new gringo faces present in their congregation. All it took was a little broken Spanish and allowing them to "do my hair," and we made some fast friends. There were two girls, Josenda y Reina, who even Josh loved. I am pretty sure he would take home with us if we were able. Reina was delighted when I told her that her named sounded like the English word for rain and went around telling everyone. I have to be careful though, because then the rest of the children kept coming up to me wanting to know what THEIR name sounded like in English, looking very sad when I could not think of anything.
After church, we piled into two pick-up trucks with a couple of families from the church, a missionary couple and their grandchildren, and the team from Oregan. We set off for the waterfall. The water was cool and beautiful, and we all enjoyed watching the more daring of the group climb to the top and jump off. Benton is the grandson of one of the missionaries who has lived here for 10 months now. He is VERY precocious and says "I am more Honduran than American now." He decided that he wanted to be baptized. He was baptized on the spot by the pastor from Oregan. Such a beautiful, impromptu ceremony that would rival any of the formal baptism ceremonies that we have in the states. It reminds me of my own baptism by a Sudanese pastor named Abraham in a tributary of the Nile.
Prayer Request: Starting on Thursday, there will be a great exodus of health care providers, and I will be left to man the hospital with very few helpers. Thankfully at least one other physician will be staying. It is exciting but frightening at the same time as all of the providers throw as much information at me at once. "In case of emergency, call...." "The delivery kits and ultrasound machine can be found here....." "At night, the ambulances won't come so you may need to drive them yourself." It is scary, but I know that the Lord will be with me. Please be with me as well in your prayers.
Blessings to you all!
NH

Neonatal Advanced Lift Support Class comes in handy.

So there's nothing like getting my neonatal advanced life support training just prior to coming to Honduras and getting some first hand experience. I was woken up from my bed around 10:30ish pm by Rimas, the husband of the ER physician saying there was an emergency C-section. I rush over with 2 OB nurses who are here with a team from Oregan. The patient is a G1 lady at term with no rupture of membranes or previous problems during pregnancy. She came in with some contractions and when placed on the monitor had fetal heart tones less than 100. She was having deep variable decels that then turned into late decels, and the OB Dr. started making plans for C-section. Abby, the ER physician, did the anesthesia, which consisted of Ketamine and Fentanyl. I was with baby, accompanied by two veteran OB nurses. The baby came out deeply meconium stained, floppy, apneic, and bradycardic. We stimulated the baby and did deep tracheal suction that pulled up a decent amount of the aspirated meconium. Then we bagged the baby who was still apneic and bradycardic. When we are getting everything ready for intubation, the baby finally lets out a cry. YAY! The baby is still a set-up for infection after the aspiration, but when from APGAR of 3 to an APGAR of 7. Praise the Lord. David Davis would be very proud.
Sorry to all of you non-medical people who do not think my medical jargon is very interesting I thought that I would share. Josh will probably blog tomorrow about the rest of our Sunday which was very lovely. It included a Honduran church service and a hike to a waterfill with a spontaneous baptism. Stay tuned.
On a sadder note, my 70 year old patient with COPD and pneumonia is still in pretty serious condition. She has improved some, but I still worry every time I walk by her room, and she is struggling for her breaths. If we had a reliable ventilator, I would have already intubated her, but instead, we are giving her antibiotics, nebulizer treatments, steroids, and hoping for the best.

un senor y una doctora

Regular Scorpion

Whip-tailed scorpion

The view from atop the water tower. Pretty, huh?
Whiptail Lizard

It is Saturday morning at 6:00 am as I write this. I find myself going to bed early (8:30-9) and waking up around 5am. It is a nice schedule actually. I have always liked the lifestyle of awaking with the morning light and going to sleep when it gets dark.

I had my first day of clinic yesterday. It went pretty well, I think. It was like any day in clinic with a new system. The hardest part was not the medicine. The hardest part was learning what medications I have available and what labs they have available (yes, they actually have a pretty extensive lab AND radiology room). My interpreter's name is Ramon. He is what they call and "islander" which means he is actually black and speaks a language that is a strange combination of Spanish, French, and English. He, of course, also speaks English and Spanish flawlessly.... so jealous. My Spanish leaves alot to be desired, but I am working hard at it and find myself able to understand most conversations but often unable to find the words I need to participate.

Many of the things I saw in clinic were problems I was familiar with which was a relief. I saw one mystery case: a young (30's) man with 2 weeks of periodic fevers, joint aches, headaches, and malaise. He looked like he felt terrible. His malaria test was negative so I thought he could have the flu or Dengue fever neither of which I am able to test for. I gave him symptomatic management and will have him RTC on Tues. We had two patients who showed up simultaneously to our emergency care center. This put both myself and the other doctor working on hold in our clinic since we were the only docs around. He ended up sewing up a child's lip who fell from a tree and bit through her lip. I was left with an older lady with a COPD exacerbation, not from smoking her whole life but from cooking over an open flame and breathing in the smoke. We admit COPD most nights at Self back home so I felt very comfortable with this. The biggest challenge was finding medications that she needed AND they had in stock. For instance, I write for Solumedrol. They come back and say they have no Solumedrol. Ok, well, what about Prednisone? No prednisone. Prednisolone? Yes. Ok. Give her that. She was pretty sick and satting 88% on maximum dose oxygen and I hope that she does not get worse. They have one ventilator that sometimes works and no ABG machine.

Some of you who are not interested in all of my medical talk but perhaps wondering how it is that these patients are learning about Jesus. Well, when I am finished seeing a patient, they go to the "consejero" which is Spanish for counselor. There they meet with a Honduran pastor who listens to the patient, counsels them, and shares with them the truth of the gospel. His other job is to figure out how much and if a family is able to pay. You see, Loma de Luz is not a free hospital. They work on a sliding scale bases. There is one fee for locals (the lowest of them all), one fee for those who live outside a certain boundary since they have other hospitals available to them, and foreigners (the highest price). They rarely turn someone away, but they have had people claiming they cannot pay but probably can. This is Oscar, the consejero's job.

J and I may be headed to the reefs to go snorkeling today if the rain did not muddy the water too much.

J here:

Seeing as how I am not a Dr., I spent yesterday somewhat differently. I helped Rimas ( one of the Dr's husbands) clean up and organize part of a bodega (warehouse). It took about 4-5 hours total i guess, but felt like longer in this humidity and heat. I know some of you are wondering why I wasn't out trudging through the jungle finding animals and taking pictures. Well it was day one and I really had no clue where to go for one and we are going to be here for quite awhile so I have plenty of time. I did however find some pretty cool stuff while cleaning out the bodega. Hopefully I can get the pics to upload for you guys to see. After we finished working I came back for a cold shower (which felt great) and laid down during the heat of the day till NH got back. Being the culinary masters that we are we cooked up a pretty tasty dinner. We then broke out the Kindles for awhile before heading to bed. It did rain a good bit last night, but I'm hoping it didn't muddy the reef too much for us to go snorkeling this morning.

Bienvenidos a Honduras

NH here:
We have arrived. We landed around midday in Honduras. This was really strange to me since all of these kind of trips for me have been to China or African which require days of traveling and overnight flights. This was kind of like flying to California....no biggie. We are met by Don Sergia Avila, a man holding a sign ready to drive us. We tell him en espanol that we need to exchange money. He takes us to the money changer who is a guy standing on the sidewalk with a stack of US dollars and a stack of limpiras. Let me tell you. That really inspires confidence. But J did some quick math to make sure we didn't get totally cheated. We then head to the car with our luggage. If any of you have ever been in a developing country, you know. There are always multiple, very agressive people waiting to "help" you with your bags. I was ready for this and held tightly to mine. This did not stop a persistent Honduran man from trying to grab my suitcase as I put it in the car and then demanding un dolor.
We then began a 3 hour drive to La Ceiba to meet our missionary sponsors. We watched out the window at the intricacies of a new country and held on for dear life because Sergia apparently thinks he's a Nascar driver. We watch people traveling down the road in a variety of ways. There are a fair amount of cars and motorcycles with also many people riding on horse drawn buggies and bicycles. We were amazed at the things they can carry on a bike. At one point, we saw a child who could not have been more than 6 years old carrying what appeared to be an 80lb bag of rice on his handlebars. We passed fields of sugar cane, banana trees, and tons of lychees (a spikey red fruit with a white inside. delicious!) which are currently in season.
In La Ceiba we were picked up by our missionary sponsors: an emergency medicine doctor, her husband a pilot, and their 10month old Aliyah. We went grocery shopping there since where we are going there will not be the opportunity to go grocery shopping and headed down to the hospital. On our way (J wanted to make SURE I did not forget this), we saw a jaguarundi, a large cat that is comparative to a miniature jaguar.
We arrive and it is dark, and we explore some. The hospital is as pretty as it looks in the pictures, and we are really close to the beach. On our way here, the missionary told us how the hospital is currently working to be off the grid. They run off of regular electricity during the day and a generator at night. The hospital harvests palm oil that right now they sell to the government for processing. They are in discussions to try to buy a processor that will allow them to run fully off of palm oil and then be energy independent. I am tired but J is crazy full of energy. We explore a little around the compound, go watch Survivor with our hosts who we're delighted to discover are also fans, and settle into sleep.
I am starting work tomorrow. Apparently they are short doctors.
More to come.
NH