Fair Winds and Good After-care, El Salvador

It’s the last day of services in Pasaquina, El Salvador. The same crews that transformed the Pasaquina Elementary School classrooms into the biggest hospital in the area are now converting them back into 1st Grade Math, 3rd Grade Reading, and 4th Grade English rooms. Meanwhile, the last of the waiting patients are being seen, final prescriptions written, and last health education pamphlets handed out for this country.

Which is not to say that the doctors and nurses didn’t go full steam ahead to the very end. In fact, some of the cases most in need of attention came yesterday and today. Doctor Ken Iserson, Project HOPE’s senior medical officer, saw the only case of Rickett’s, a rarer form of malnutrition caused by vitamin D deficiency, in a toddler yesterday. The boy’s mother brought him in with the complaint that “His feet are funny.” Not just his feet, though—his legs are obviously bowed outward, and under x-ray the ends of his bones significantly mushroom up, a signature of Rickett’s.

Fortunately, he got care just in time. His condition is not irreversible, and the Ministry of Health here has been in campaign against all forms of malnutrition for several years. His case got immediate attention from them, which is very good, as it’s usually not as simple as just adding more D to his diet. Most likely, he’s getting a normal amount of vitamin D, but not absorbing properly. Now, its in the Ministry of Health’s hands to find out why.

Project HOPE volunteers were also on the scene doing some non-medical assistance today. Diane Speranza and Elizabeth Roughead both participated with about 10 sailors in what the Navy calls a “COMREL” Project—military shorthand for “Community Relations,” their way of reaching out to the local communities where they harbor to lend a helping hand. Diane and Elizabeth both “got their lumberjack on” by clearing low-hanging limbs from trees that were directly over the Leones Special-Needs School. The trees were threatening the corrugated tin-roofed building, so the Navy/HOPE team cleaned them up, cleared the gutters, and even trimmed the hedges. (All this, of course, after due time was spent playing with the kids.)

That’s just two snapshots of all the activity today, though. Our Ops boss, Tracey Kunkel, represented HOPE at the El Salvador closing ceremonies today, and volunteer nurses Jane Bower, Ann Russell, Elise Chamberlain, Tina Weitcamp, and Meg Candage all were at the Subject Matter Expert Exchange with Salvadoran Ministry of Health educators, discussing El Salvador’s public health education program, rabies and dengue control, atraumatic dental practices, and El Salvador’s public contraceptives and sex education push. And on top of that, all the rest of the HOPE nurses were trying to get the remaining patients packed, together, and ready for their helo ride home.

Thanks for reading-Jacob

HOPE Volunteer Charity Braden Caring for Post-Op Patients in El Salvador

In rural El Salvador, the local elementary school has been turned into a bustling hub of medical activity. Thousands of potential patients wait at the gates. Scores more are in the initial screening process, and dozens are seeing health care providers in what were, until two days ago, children’s classrooms. As patients see the specialist doctors here, those who require surgery are forwarded to one of the 6 OR’s operating just a few miles away.

Crossing those few miles, however, will require what will most likely be the ride of the patient’s life. A Navy SH-60 helicopter will pick up the pre-op patients later that day, and hustle them aboard the white-hulled Navy hospital ship, USNS Comfort, anchored 10 miles off the coast. They’ll spend the night aboard, with volunteer nurses managing their pre-operation medication and diet, before being operated on the next day. From the OR, they’ll go briefly to ICU, then to the post-op ward to spend the night before the helo ride home the following day.

Here, in on the post-op floor, Charity Braden, a Project HOPE volunteer nurse, listens to the heart, lungs, and abdomen of her six patients as she comes on shift. Her bright spirit and enthusiasm are infectious, and soon all her patients are smiling with her. Like nearly all of the nurses here, Charity is volunteering a month of her time to deliver humanitarian aid to the places it is most needed in the Americas. Her presence in post-op allows more patients to be sent through the OR’s more rapidly, upping the “operation tempo” of the entire ship.

“Its great to be in a place where I can come do some real good in the world,” says Charity. “I’ve been trying to get out on a mission like this for three years, and both my husband and I are beginning doctorate studies later this year, so its awesome that I could do it this time. This is my first humanitarian mission, but my goal is to volunteer around the world with my nursing skills.”

A North Carolina native who now lives in D.C. and works in the ICU at George Washington Hospital, Charity is looking forward to beginning her studies as a Nurse Practitioner and to getting out on more volunteer work.

“Project HOPE is one of the few NGO’s that do volunteerism as well as they do, and its been really powerful to be part of the cooperation going on between the military and humanitarian NGO’s. They really have huge logistical capability, and we bring the extra manpower and expertise to make this mission happen. I’m really glad to be a part of it.”

Thanks for reading-Jacob

Patients and Public Relations

I spent a few moments with HOPE volunteer RN Carrie Reichert in the ICU this afternoon, while she was looking after Juan Jose, an 8-year-old boy who had just come up from anesthesia after a successful tonsillectomy, and his cheerful, hovering mother, Sandra. There were only two other patients in the ICU today, patients that for whatever reason were at higher risk for bleeding or other complications. In fact, in a “normal” hospital, they probably wouldn’t need to be in Intensive Care; but, we have the equipment, we have the space, and we have the staff, so it is no problem to give them an elevated level of care.

Getting the word out in the States about the daily struggles and triumphs of the volunteers and Navy personnel working here is a big deal, but the real heavy lifting comes in letting the rest of Latin America—and the world—know about what we’re doing here. Working through the embassy, Navy public affairs lead Matt Gill arranged for 5 different media outlets (television, radio, and print) to come aboard USNS Comfort today to tour the ship, meet the patients, surgeons, and nurses, and get a better picture of what we do here, how we’re helping.

I stayed with them for the entire tour, translating where necessary and doing a few interviews. Our first stop, of course, was the mess decks, where they got a taste of some good Navy chow. We then stepped through the patients’ process—Casualty Receiving, Pre-op ward (the Hotel), where we met Project HOPE volunteer RN Addy Wakeman, post-op wards. The cameras will get to see the OR and some surgeries tomorrow before they head home.

In the Hotel, one of the patients called out to a video crew (in Spanish):

“Hey, what channel are you guys?”“Channel four, my friend.”
“Oh, that’s the Salvadoran channel.”“…Well, yeah.”“We get Honduran television better here. Too bad.”

We’re anchored a mere 37 mile from the Honduran border, and due to the mountainous terrain, many of these Salvadorans get better reception from Honduras than from San Salvador, a three hour bus ride away.

After showing the media crews to their bunks, I stopped back by the ICU to see Juan Jose again. The night nursing staff was on, and he was now in the capable hands of HOPE volunteer RN Sarah Angelo. Both the boy and his mom were sleeping soundly—mom most likely because of exhaustion, the boy because of his hectic day.

On the post-op floor, HOPE night nurses Kelly Magee and Susan Troll were keeping things wrapped up as well. Kelly, who has been here since Miami, was in charge of the starboard wing, and Susan had six patients for the night in the port wing. Besides a few infants waking up now and again, only to be calmed by their mothers -- on the night shift, all was calm and quiet.


Thanks for reading-Jacob

Project HOPE Volunteers Help Yasmina and Other Salvadoran Girls

Three years ago, Yasmina, a 14-year-old Salvadoran girl, had received a penicillin shot to treat tonsillitis. The penicillin worked, but the very next day she displayed symptoms of “drop-foot”—she could no longer flex her foot upward to walk or run normally. The condition hadn’t improved in the intervening three years, and now her lower leg and foot were significantly atrophied and she walked with a limp.

Yasmina was now at a new Continuing Promise temporary worksite that had just opened today at the elementary school in rural Pasaquina, El Salvador. Project HOPE volunteer nurse practitioner Faye Pyles, one of two care providers in the pediatrics ward, thought she knew what Yasmina was suffering from. She referred her to the Navy physical therapist in the 4th grade science room down the hall. The physical therapist worked with her for almost 20 minutes, and seconded the diagnosis Faye had suspected—the tech who had given her the shot, either through poor training or negligence, had brushed her sciatic nerve in the process.

Even in the States, nerve damage is untreatable.

We put her in an ankle brace to keep her from a severe sprain and give some support to the leg the way her foot would if she were walking normally. She had just been referred to the pediatric neurologist, a Navy doc, when I was called away to translate another case—a woman with plantar fasciitis to whom the physical therapists were trying to explain how to use shoe inserts and do some stretching exercises to help the pain.

Meanwhile, Ann Russell, HOPE’s volunteer nurse midwife who is heading the OB/GYN ward on the ground, was having an interesting day of her own. She was seeing a lot of unwed young women, say, under 20, with severe dysmenorrhea. Back home, the most common treatment for irregular or very difficult periods is actually hormonal birth control—the scrip just says “hormone therapy” instead of “contraception.”

Continuing Promise doesn’t stock contraceptives, but even if it did, these young women probably wouldn’t take them. There is a huge cultural stigma against an unwed woman being on any form of contraception here. In fact, when Ann asked her patients the routine question of whether or not they were sexually active, they were uniformly taken aback that she thought such a thing might be possible.

She spent most of the day, then, educating these girls, and convinced them that, if they found some “hormonal therapy” medication, they wouldn’t have to miss school for an entire week every month, wouldn’t have to miss work, miss life…and that they could remain sexually inactive at the same time.

Faye and Ann were at the elementary school with Project HOPE senior medical officer, Dr. Ken Iserson, and a whole handful of HOPE volunteer triage nurses—Amy Bream, Meg Candage, and Marley Gevanthor—who upon arrival dove right into the crowd of patients awaiting screening. Even the HOPE Ops Officer, Tracey Kunkel, found herself employed in the pharmacy, working on totaling the hundreds of prescriptions HOPE, the Navy, and the other NGO’s onboard have given out so far in El Salvador.

I caught up with the Navy pediatric neurologist just before our helo flight back to the ship this evening. He had seen Yasmina just before he had to pack up for the day. If she were in his own practice, he said, he would have an orthotic device made to fit her foot, one that would place the joint at a safe angle and offer support in the way a normal foot would.

This is exactly what he did for Yasmina. He worked with the Salvadoran Ministry of Health on the site, and they have her mother’s telephone number, and vice versa. She is scheduled for an initial fitting for the device at La Union hospital on July 6th.

Thanks for reading-Jacob

On Shore, On Board and Behind the Scenes, Volunteers Continue Critical Work

The moving parts onboard Comfort never seem to stop moving. While the Project HOPE care providers were getting things done ashore and our team of nurses held down the fort aboard ship, the management team was engaged in their own work.

Dr. Ken Iserson, HOPE’s chief medical officer onboard, has spent the last two days as one of six docs on a board in charge of credentialing each and every volunteer doctor and surgeon that comes onboard. It’s a job that sounds fairly simple—yet considering that it requires reading English, Dutch, Spanish, and sometimes Portuguese, plus the sheer number of doctors and surgeons that rotate through Comfort’s OR’s, the task becomes quite formidable, especially given how critical the job is.

Meanwhile, Project HOPE’s operations officer for the mission, Tracey Kunkel, was officially handing over HOPE’s donated medical supplies--nearly $150,000 of medical and first aid supplies—to the El Salvadorian Ministry of Health for use in the nation’s clinics and hospitals.

While that was all going on, the Chief of Naval Operations (number one admiral) of the El Salvadorian Navy paid a visit to the Comfort and toured the ship and the hospital. Captain Ware, Commanding Officer of the hospital, gave him and his entourage the tour, and I ended up in front of the group of El Salvadorian top brass, (briefly, as the Captain had a lot of ship to show off) explaining HOPE’s mission, size, and makeup in Spanish.

Still, I managed to sneak into Casualty Receiving (CASREC) for a short time to see Project HOPE volunteer ER nurse Carleen Qualantone with her incoming patients. CASREC is equivalent to the ER in a land-based hospital--the first place that any patient bound for surgery goes when they come aboard Comfort. Carleen and the other CASREC nurses take whatever X-Rays, CT scans, blood work, or labs that a pre-op patient needs, then sends them to stay with HOPE volunteer nurse Addy Wakeman to stay the night before their surgery.

While I was with Carleen, HOPE volunteer nurse Peggy Goebel (who I shadowed on my first day ashore) walked by with three El Salvadorian nursing students in tow, showing them the ship, their berthing spaces, and…where they would be working. One of the major pieces of this mission isn’t about seeing patients at all, but liaising with our partner nations’ medical corps—the doctors, nurses, midwives, interns, and residents who will be in the medical work force for the next 20 to 40 years. Ken Iserson and Faye Pyles, when they were ashore, were especially good at this. They were both assigned El Salvadorian med students to help with translation (Ken speaks Spanish, but kept the med student there with him for this purpose). For most cases, both Faye and Ken would make the med student make the diagnosis.

Most of the time, Faye says, the student would be correct, but not sure of his answer, so she kept training—it was awesome for the med students, awesome for the HOPE volunteer docs to get to train, and awesome even for the El Salvadorian patients to see their own med corps growing. This same thing will be happening with these three nursing students who, out of the 400 students in their school, were selected to come aboard the Comfort for a week to help out wherever they’re needed.

And, as a final treat, I got to wave goodbye to Luciana Portello, the hysterectomy patient Elie Malloy was caring for in the ICU yesterday. I shook her husband’s hand and wished them well after her successful fibroid surgery before they left the discharge area. They say, “A smile will go a mile.” In this case, it’ll go a lot farther than that.

Thanks for reading-Jacob

Volunteers Stay Busy on Floating Hospital Ship

While some Project HOPE volunteers are running the remote triage sites ashore, many more are engaged in helping to keep the USNS Comfort’s six operating rooms(OR) up and running. Some nurses are in Casualty Receiving (CASREC), the first place a patient will go once she lands on Comfort’s flight deck. Some, like Addy Wakeman, keep the pre-op ward, where patients stay the night before their surgery (as it is affectionately called “The Hotel”), running efficiently. Still others help in the OR, or in Post-Anesthesia Care Unit (PACU), where I found HOPE volunteers Amy Bream and Elizabeth Roughead today, or in (Intensive Care)ICU, where patients are moved after coming out of PACU, which is where I tracked down Elie Malloy.

I moved backwards through the flow today, meeting Elie in ICU first. Elie’s main patient was an El Salvadorian woman who underwent a hysterectomy yesterday. Her husband was always close at hand, especially when Elie moved her or shifted her position with the help of the other nurses in the ICU. When it was removed, her uterus was about twice the size of a normal woman’s, and filled with fibroids. Now, everything is tracking well and she is scheduled for normal discharge tomorrow.

In PACU, I found Amy and Elizabeth bringing a patient up from anesthesia. He had come in to have his cataracts removed, and was just a step away from moving down to visit Elie at the ICU. His body temperature was 96.5—0.3 degrees lower than the regulations consider manageable enough to move away from the OR (PACU). Cataracts usually come in pairs, so the floating hospital will usually do the surgeries over two days (to keep the patients from having to undergo two surgeries in one day), so Jose Diaz and his wife will be with us through the weekend.

I then went to the front of the patient flow (and, incidentally, the front of the ship—Comfort was designed to streamline the receiving process: CASREC is in front of the Hotel is forward of the OR’s are forward of PACU, and all on the same level. Only ICU and Discharge are one floor down, but patients will only go there after time has ceased to be critical). At the Hotel, I found Addy Wakeman holding down the fort. A Medical Telemetry (post-op) nurse by trade, she’s just getting the feel for the rhythm and needs of the Comfort pre-op ward. The Hotel was only about half-full today, though the nurses there have seen a patient in every rack, plus as many cots as they could put out as well. That week, the surgeons operated on 241 people in 10 days—a record even by Comfort standards.

Thanks for reading-Jacob

HOPE Volunteers Saving the World—One Coloring Book at a Time

Today found Project HOPE volunteers Sarah Angelo, Carrie Reichert, Elise Chamberlain, and Tina Weitkamp heading for the Jose Pantoja Hijo School, the current main site for Continuing Promise ’09.

Sarah quickly found work tag-teaming the front door of the General Adult Medicine room with HOPE volunteer Marley Gevanthor. After their initial screening process, patients are sent to the appropriate specialists—Pediatrics, Ophthalmology, Dentistry, OB, Adult, or whatever the case may be.

Outside of the specialty room, though, the screening continues: “Are you in pain? Where? How badly?” Prescription sheets must be filled out correctly. All of the patients information must match on each piece of paperwork. Marley and Sarah saw to it that all these details were smooth, getting each patient to see their provider that much quicker—which means more patients were seen today.

In the meantime, Carrie, Elise, and Tina set up a preventive medicine/health information booth near the initial triage area, and began teaching dozens of children how and how often to brush their teeth and wash their hands—using crayons and colored chalk as their lesson plan. By the end, I don’t know how many little artists put their masterpieces in Project HOPE’s coloring books, and everyone seemed happy: the educators saw the children learning, the kids were having a blast, and the mothers worrying over sick loved ones had one less thing to worry about for a few hours. Sarah even got a Spanish lesson or two from some 5-year-olds. What better way to teach a child than to have them teach you?)

Thanks for reading-Jacob

Health Education in El Salvador Proves Timely

I spent most of the day today with Project HOPE volunteer nurse educators Meg Candage and Tina Weitkamp. Together with two U.S. Navy nurses, they took over a classroom at the military secondary school located on the Naval Base in La Union, El Salvador.

There, they met 20 doctors and nurses from local hospitals and clinics in the La Union area (some from nearly 2 hours away) to train on ACLS (Advanced Cardiovascular Life Support) and CPR. Working through translators (I even got to jump in to translate at one station!), they set up four different stations—defibrillation, CPR technique and airway opening, types of arrhythmia, and tachycardia—and began training.

The Salvadorian medical personnel were quick to catch on—and equally quick to point out where U.S. procedures and regulations differed from those in their hospitals.

By the end of the day, these nurses who were just now getting portable defibrillation devices in their hospitals, were able to demonstrate exactly how to diagnose and use the portable defibrillator on a cardiac patient safely and quickly.

I was also able to sneak in a tour of a Navy project site with Capt. Jim Hudson, the man in charge of all ashore transportation. He showed me around the project site of the Navy Construction Battalion (CB—or SeaBee’s). They’re partnering with the El Salvadorian SeaBees to completely redo a local playground—right now it’s a prime hang-out of some distinctly non-family people once the sun goes down. New roofing on the toilets and main picnic area, new basketball hoops and backboards, and some 660 feet of new fence, topped by concertina wire to keep the place safe for kids after sundown are all in the plan. It’s an amazing project, and just one of the ways that NGO’s, the U.S. Military, and foreign militaries are all working together towards a common goal.

The training and that side-stop took most of the day—but we were able to get back to the ship while there was still daylight. It was the first time I’d really seen El Salvador in the sun, and it is an amazingly beautiful country. The jungle, mountains, and ocean all come together in exactly the same spot. All in all, a great day.

-Jacob

Volunteers Work Busy Medical Sites in EL Salvador

Within five minutes of our arrival at Jose Pantoja School, now converted into the staging area for Continuing Promise 2009, Project Hope volunteer nurse Peggy Goebel had canvassed the site, finding out where the Pediatrics, Radiology, Dental, Ophthalmology, General Medical and Pharmacy were located (all in rooms that, until two days ago, had been elementary school classrooms), found what was needed at each station, and began filling in the gaps. She sent a translator here, a triage nurse there, a corpsman to yet another area, and then began seeing to patients herself. A trained labor and post-natal nurse, she naturally gravitated to pediatrics.

The patients she saw had already been screened from the thousands still waiting outside the gates. She began to further prepare them to see a primary care provider—in this case, Project HOPE volunteers Ken Iserson (PH’s Medical Director) and Faye Pyles. She made sure their paperwork was filled out correctly, asked deeper screening questions that would speed up their process, and—with the help of their parents—generally kept dozens of children occupied, entertained, and mostly under control.

There were a lot of unusual Pedi patients today—a girl with probable cerebral palsy, another wheelchair-bound girl with two dislocated hips, a boy with a club foot. I followed Mirare Andrades and her mother from her initial screening to the end of her time at the triage area. Mirare, a 7-month old girl, has syndactilism—an extra thumb on her left hand which, though now is merely strange to look at, could cause her significant problems down the road. After coming through initial screening, she saw Doctor Iserson almost immediately, who sent her to Radiology.

At X-ray, Project HOPE volunteer Marina Rivera got her to sit still for just long enough to take 3 X-rays of her tiny hand. She checked the images—yes, the sixth digit was clearly visible. Back to Doc Iserson, and then the case had to be forwarded up to higher authority.

Because Mirare is less than a year old, she cannot be operated on aboard the Comfort. However, because of the partnership and cooperation in place between the U.S. and El Salvadorian governments, we were able to forward her on to the El Salvadorian Ministry of Health, and she is scheduled to be operated on in the General Hospital at La Union on Monday.

More tomorrow on health education training-Jacob

Project HOPE Volunteers Get to Know the Comfort

More Project HOPErs streamed in late last night, and this morning, as the patients rolled in to Casualty Receiving (CASREC), the main staging area for incoming patients, our new volunteers began to get the lay of the land.

I tagged along with the Project HOPE nurses as they got the lowdown on all of the equipment in CASREC that they will be working with for the next four weeks. Even though it floats, Comfort is still a hospital—and every hospital has its own quirks, routines, and regulations. And though all of our nurses had worked with similar equipment before (IV monitoring devices, for example, or heart monitors), its tough to use a device if the “On” button is in a totally different place than what you’re used to.

Some of the equipment I recognized—the EKG and defibrillator—but it was a learning experience for others. The “bear hugger,” for instance, which is used to get post-op patients’ body temperature back to within manageable range—above 96.8F—or a Doppler ultrasound pulse reader, used to check fetal heart rate, or the pulse of patients with lots of swelling.

More tomorrow-Jacob