Wednesday, May 29, 2013

Managua, Nicaragua

By: Drew Blackman

Prior to my trip to Managua, I had arranged for a hotel shuttle to pick me up at the airport. As I walked through customs and baggage claim, I saw numerous shuttle drivers with whiteboards emblazoned with hotel monograms and guests' names written in dry erase marker. None had my name on it. I continued through the airport and out into the muggy Nicaraguan night. Finally, I saw something name. Written in pencil on a piece of three hole paper ripped from a spiral notebook. I followed the driver, expecting to be led to a bus, or van, or car, or something with the words "Hotel Casa Naranja" on it to reassure me we were heading in the right direction. No such luck. Just a dented, scratched 1990's era Toyota hatchback. I got in and we drove through the night, through unfamiliar boulevards with no street signs. I had studied the city map briefly before my arrival, but as we wound through dark streets past residences made of corrugated sheet metal, I was admittedly lost...and nervous. Eventually, a small lit sign read "Casa Naranja", and I had arrived at my home for the next two weeks while I would experience orthopedic surgery in the capital of the poorest nation in Central America. Hotel transportation was only the beginning of the differences between my experience in Nicaragua and what I am used to in St. Louis.

I spent the majority of my time in Managua working at Hospital Antonio Lenin Fonseca, HALF for short, which is a public hospital that serves as the major referral center for uninsured patients throughout the nation of nearly six million people. In Nicaragua, there are three tiers of healthcare: privately insured, government insured, and uninsured. The gap between three is staggering, but that between those with insurance of any kind and those without is particularly chasmal. The private insurance-only hospitals were on par with most community hospitals in America in terms of resources, facilities and capabilities. The hospitals that accepted both private and government insurance seemed to be on par with smaller American community hospitals. HALF was different. The hospital itself was outdated and the interior lacked the cleanliness one typically associates with hospitals. Patients were housed eight per room, with no air conditioning in the 100 degree heat. Patients, or their families, brought many supplies from home, including sheets and fans. Family members provided much of the nursing care that did not involve administering medications, as well.

The majority of my clinical days spent at HALF were in the operating rooms, assisting primarily in fracture surgeries. Many of the Nicaraguan surgeons who operate at HALF also have a private practice at another hospital to supplement their income, as fulltime HALF surgeons are paid around $1400 per month…although the average income in Nicaragua is only around $2000 annually. On days they operated at HALF, these surgeons would bring most of the necessary equipment with them from their private hospital, including orthopedic implants, instrument trays, patient positioners, and scrub nurses. On days when these outside supplies were not available, the surgeons relied on the hospital’s inventory, which was severely limited. The hospital is unable to purchase many of the newer generation fracture fixation devices that we take for granted in the United States, and thus relies on older fixation devices as well as donations from international surgeons. As a result, options are limited. Issues with outdated sterilization equipment and poor organization within the sterile processing department serve to further limit surgeons’ options at the hospital. Despite all of these challenges, however, the surgeons are able to work with what is available to perform satisfactory operations for their patients. There were six operating rooms, with one or two being devoted to orthopedics per day. Two surgeries per room per day was average, which was hardly enough to keep up with the influx of new patients coming through the doors each night. As a result, on the orthopedic ward, patients with lower extremity fractures lied in bed for weeks, awaiting their turn in the operating room.La Hospital Escuela Antonio Lenin Fonseca, or HEALF, is one of the largest medical training programs in Nicaragua. Their orthopedic residency training programs is regarded as the best in Nicaragua. My trip to Managua was arranged through Health Volunteers Overseas, who has partnered with HEALF to bring international surgeons to HALF with the primary goal of provide training and education to the residents. Orthopedic residency at HEALF, and at other hospitals in Nicaragua, is much different than in the United States. Residency is only three years, although this has been changed to four starting in 2013. Residents are taught by their attendings primarily by observing in the operating room and during department-wide ward rounds, which occur once weekly. There is one hour per week devoted to didactic resident education, in the form of a basic orthopedic knowledge lecture given by one of the upper level residents. Given the lack of skilled ancillary staff in the hospital, the residents take on many additional duties, such as running the fluoroscopy machine, cleaning the operating room between cases, and making sure all the instruments for each case are available and ready for sterilization 48 hours before the surgery.

 During my time at HALF, I was able to interact with the residents on a daily basis and provide some teaching in the inpatient, outpatient, and surgical settings. They were all very eager to learn how different clinical scenarios would be handled in the United States.

A busy clinical schedule limited my time for sightseeing while in Nicaragua, but a surgical cancellation on Saturday and a day off on Sunday allowed me a weekend to experience the countryside. I spent an afternoon hiking on the Mombacho Volcano overlooking Lake Nicaragua. On my drive home, I was stuck for 90 minutes in traffic after I was detoured off the main highway on account of a huge street carnival that lasted well into the night. I also spent a day exploring the uncrowded, and largely undeveloped, beaches at the southern extent of the Pacific coast, eating ceviche and watching surfers prepare for the upcoming World Surfing Championships.I am grateful for the opportunity to have had this experience and grateful to those who made it possible, specifically the orthopedic department here at Washington University, Health Volunteers Overseas, and Dr Dino Aguilar in Managua.

These trips are an important tradition that can help inspire a sense of international stewardship and facilitate future overseas volunteering. I hope the relationships I formed during my two weeks in Nicaragua will help me with trips to HALF after I finish my orthopedic training.

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