Corre Como Loco

week after the brigade was quite busy, as NDI was getting ready to help out with the children’s race that is tied to the Fuego y Agua Ultramarathon. Each of the runners that would be coming for the ultramarathon were to bring an extra pair of shoes to be donated to a child running in the 5 km race the following Sunday. My co-worker Angela was the main NDI contact to organize for the race and to prepare the shoes, shirts and medals for each group of children that would be coming. Not only was NDI working on the children’s race (the calzada) but also Tabby was a Medical Director for the Ultramarathon and most of the NDI team were volunteering in some capacity that day in case of any medical emergencies, or just falls and scratches.

The Ultramarathon was set as a series of 3 races: a 25 km loop that ran up 1000 m of Concepcion, a 50 km race that ran from Moyogalpa to Volcan Maderas and up it, and then the 100 km race that combined the two shorter distances so the runners would have be running up both volcanoes. Since August I have been running on a semi regular basis when I have had people to run with, with the idea in the back of my mind of trying my hand at the 25 km race. After my return in January I started running between 3 and 5 times a week with two friends of mine, both local guides, who were also thinking of doing one of the races. I had been keeping a little quiet about the idea of running in case it turned out I couldn’t complete the training or the race. When the time actually came to sign up I just couldn’t pass up the chance to run it, who knows I may never be by this way again. So I signed up for the shortest distance I could, and then set off to convince my friend Arcelia to do the same.

I am more of a social runner than a competitive runner, but because of my background I do know how to train properly. Unfortunately due to circumstances and work schedules we did not do the full training. The longest distance we likely ran before race day was 12 km, and once I looked at the actual route the distance creeped up to something closer to 30 km. Needless to say the couple days leading up to the race I was a little nervous, knowing what might happen if I were to have trouble with my asthma or a fall while running with the medical resources on the island.  Race morning arrived and I had extra water for the both of us because it was going to be a hot one with the 25 km race starting at 7 am with the sun already out. Tabby, Trish, the kids, the three interns that were working with NDI at the time, Gary and Laura all came out to see us off. The route was more akin to trail running than actual road and within the first 5 km we had been passed by the same bus 3 times kicking up smoke and dirt and chased by 6 dogs. I was most nervous about the volcano part as the last time I hiked Concepcion, I clearly remember it kicking my butt. It turns out the hardest part was getting from the main road at a town called La Flor to the base of the volcano as it was nothing but large, loose volcano rocks mixed with sand and then the odd cow and toros roaming through. Going up the volcano there was a lot of walking and dodging those with speed making their way down. The view at the aid station was incredible, as was the fact that we had ran so far and then up the volcano. By the time we decided to make our way back down Arcelia was in top form and ready to rock down and I did my best to keep up. There was quite a bit of walking once we got back to the main road because of rolled ankles and the sun beating down on us. We finished together, happy and a bit sun baked in about 4 hours and 17 minutes.  Then it was time to relax a bit, find some food, have a shower and then head back to the main office to see if I could help out with anything. Fortunately there were no major injuries, mainly just scrapes, bruises and rolled ankles.

   

    

   

 

                          

The next morning was a busy one getting all the volunteers on the Moyogalpa side ready to have anywhere between 300-500 children running from Esquipulas to the cancha here in town. There were lots of people to organize and we all did our best to keep things calm while getting each town together so they could receive their shirts, medals and then come over to get their juice and sandwich. Handing out food at any event with numerous people here is always a bit of a gong show, but things went really well and the kids ran faster than most expected.  The weekend ended with a dinner at Charco Verde with all the runners still in town and then a good nights sleep before giving my legs another workout to ride into Los Angeles Monday morning for work.

The Last Brigade

Our first brigade of the year, and the final brigade I will work with during my time here arrived early February.  It was a primarily Canadian group from CCNM in Toronto, with a couple from the United States joining as well.  We also had the pleasure of having another good friend of NDI join us for this brigade, a nutritionist who I had the pleasure of working with on my student brigade back in 2009. As our previous meet and greeter for brigades has gone back to school, I was designated to be the one to come in and pick up the group. Fortunately for me the nutritionist would also be meeting up with us at the airport and would be able to help me get everyone fed and organized as the brigaders were to arrive on 3 separate flights. Nineteen brigaders were to arrive, which for us is quite a large group and aside from one missed flight and a mixed up bag, both of which were fixed up by the next day, everything went quite smoothly.

The next day was a very early day for everyone, as we had to be up and on the road by 4:30 am to make it to the island in time. Usually once we get onto the island there is time for a relaxing breakfast at the Cornerhouse and a welcome class. This time for some reason breakfast was as quick as possible, which for me is always a bit of a challenge, and the class was held back at the rancho in Los Angeles. After lunch we did the usual clinic and hospital tours, followed by putting away the donations brought in and getting the clinic ready for the week. As is with the majority of the brigades companies and sponsors were very generous and we were able to fill up our dispensary with a lot of new and very needed products, including some great multivitamins. As the Fiesta Patronal was happening in Esquipulas, just 2 km away from where the brigaders were staying in Los Angeles, several of them decided to stop by for a while that night. I decided to stay home in Moyogalpa as I knew the week would be busy and I was still catching up on sleep from the travel to and from Managua.

The clinic days went by very quickly and as is usual were very busy. There seemed to be a few bugs going around with some of the brigaders feeling under the weather as well as Tabby had to step out for several days as she had a bad chest infection. With Tabby getting rested up to regain her health, the groups got divided again between Trish and I, and everyone really worked hard to see any extra patients that came. This grouped worked extremely hard and during the brigade we each saw almost the equivalent amount of patients that we would see in a regular clinic day, which is no small feat. Each group also had its share of very difficult cases, which the brigaders handled with grace and empathy. Due to the challenges of access to further medical testing or specialists on the island, as well as other challenges that are bred within this system, the NDI clinic tends to see more than an average share of very severe or advanced illnesses with limited options for treatment, as well several cases that are often very emotional. The final day of the brigade Tabby was back in form and word has seemed to spread around the island about our DIOSA room for PAPs as there was a line up of women who had just come in for an exam.

       

      

       

       

The week came to a close with the entire group choosing to hike Volcan Maderas, and everyone made it to the top and down which after a long week in the clinic and in the heat doesn’t always happen. The couple from the U.S. were staying on the island and then going to come help NDI for the next week after the brigade, but most of the group were traveling on to the coast. This time Trish came to join me to bring the few brigaders catching earlier flights to Managua. We were a small group, but still a bit on the large side for one taxi so the ride to Managua was rather squishy and unfortunately started out with a slight altercation with the police in Rivas. It was sorted out in not too much time and then we were on our way back to where we started at the hostel in Managua before dropping off the girls at the airport the next day. For me the end of the brigade was a little bittersweet as I felt very fortunate to have the chance to meet with and work with a great group of people but I was also a little sad knowing that it would be the last brigade this year for me. I want to take a little moment to thank all those on this brigade for making it a very memorable one for me, and wishing you all the best on your own journey.

Second Homecoming

The start of this year has been busy. January has flown by in record time and by the looks of the calendar February is likely to do the same. This year has brought quite a few changes to the NDI team. My colleague Tony finished his work with NDI in December and has returned to the States to finish his studies and continue his journey with cinematography. He will certainly be missed in the office and on the island. The new volunteer ND, Dr. Patricia Beck, arrived two days after I did. We had met before on a brigade in April where she came down to see the island and get a feel for what it is like down here and working with NDI. I stayed in Managua to be able to meet up with her at the airport, it turned out to be necessary that I stay to deal with some legal paperwork for my license to be approved. Unfortunately this approval was not that easily gained. Tabby and Nestor had come into Managua for other reasons and on the Saturday we all made our way to the island.

          

Monday morning as I was on my way in to work I received a phone call informing me that my license and paperwork had not been approved and that I couldn’t see patients until I met certain requirements. Unfortunately the majority of these requirements were extremely challenging to fulfill and ideally would require that I be in Canada and have several appointments with a lawyer and the CNPBC. This meant that clinic would be stalled until we got my papers, and other NDI paperwork sorted out. One of the main goals of NDI is to work both sustainably and legally in the host country and so even though some of what was being asked of us seemed unnecessary or confusing we all worked together to get it done. I was also fortunate once again to have some amazing people working on my behalf and on my side back home to get papers sent/copied/faxed/signed and notarized so that I could get back into clinic as soon as possible.

By the second week of January we had what was needed and the clinic was re-opened. I had also been working a lot with Trish, helping to train her in the administrative office tasks, and she was going to start with me in the clinic to get an idea of what it is like and get comfortable with the language.  Once we got back into the hospital she chose when and whom to shadow the other doctors or when to sit in on consults with me. The last week which was just before the brigade, was time for her to start to dive in on her own and she took over the consults while I shadowed her in case she needed any help with the translation. It was a very interesting experience for me to introduce many of my patients and hospital colleagues to ‘la nueva doctora’ as in many ways it was quite bittersweet to think that I won’t be there to follow their cases and work with people in the hospital. There has been more than one person who has told me that I won’t be leaving the island and that they will find a way to keep me here.

          

Already this year NDI has been quite busy with it’s community programs. An intern who stayed on from the last brigade in December helped to spearhead an organic farming project in Los Angeles with the help of a Nicaraguan organization out of Esteli called Fedicamp. From what I have heard the project has been quite a success and the farmers who were part of the original course have formed a group with regular meetings and are speaking with other farmers to grow more interest.  Another new NDI team member, a friend who lives on the other side of the island, has reignited the DIOSA program. Since I have been here the DIOSA program has mainly consisted of doing PAP exams and work with International Women’s Day; as there just wasn’t enough manpower to be able to set up and run the classes for a group of women. Maria has taken charge of organizing the classes and after a few days of rather intense door-to-door surveying of the majority of houses in Los Angeles a group of women was selected to participate with classes set for every other Thursday plus participation in the International Women’s Day event. As Maria lives on the other side of the island near Volcan Maderas she also found a way to bring DIOSA to them and so classes will alternate between Los Angeles and Santo Domingo.

         

On a more personal note it was easy to slip back into life here on the island. The first Sunday after I arrived I went with my neighbours to the beach and we all had a great time swimming and chatting. There were a few surprised faces that didn’t realize I was coming back and it has been really great connecting with friends I have made here. The weekends have seemed to slip by and there have been the occasional fiesta or two thrown in there as well.

       

       

Reflecting on a Year Gone By

Here we are at the start of a new year, which also happens to mark the one-year anniversary of me coming to Nicaragua to work with NDI. The end of 2011 flew by, with me falling quite out of the habit of writing.  I was lucky enough to have another good friend of mine come down for a visit in early October and took some time to travel around with her to San Juan del Sur for some surfing and Granada for some relaxing.  For Thanksgiving Laura, Gary and I got together a little after the fact and they put together a delicious meal, complete with a pseudo-pumpkin pie that would fool anyone! My contribution was an apple crisp and my mothers stuffing recipe.  October came to an end with us going out to a Halloween party where Tabby took top prize: a fan.  November came and went quickly and was quite busy. The elections here on the island proved fairly quiet and seemed to go by without any large demonstrations. I went with my neighbours in the morning and then when I tried to join Donna and her family in the afternoon we weren’t allowed in the gate. It seemed that we as foreigners might provoke a fight. November also marked Donna’s despideda or going away as her time with the Peace Corps here had come to an end. As it was the Fiesta Patronale in Alta Gracia, I joined Tabby and her family there for the hippica and to watch the Baile de las Ramos – where people walk and dance with branches behind the horses to the church. It was a very busy end of the month for Tabby and her family as it seems within the span of a few weeks there were 4 birthdays: first little Luna turned 1, then Maximo turned 3 and then both parents had their birthdays.

          

         

                                              

         

         

Work continued to keep me quite busy with the patients, although things began to slow down through November and into December. I was able to attend another birth in the hospital. This one was the first where the partner decided to be in the room and it was quite moving to see how supportive he was, which can at times be rare due to the ‘machismo’ that is common here. I was able to attend a couple different conferences. One on the island about Dengue, Leptospirosis and H1N1 which was very informative as it showed how all the protocols and regulations are layed out from the mainland but that due to lack of resources and support are almost impossible to apply here. The other was in Managua for Living Waters for the World the organization NDI is working with on a water project here on the island. Unfortunately in the NDI clinic November was a bit of a frustrating month. Rats had decided to make a home in our lovely clinic and after having to do 3 deep cleans it was decided major renovations needed to take place. This meant that the clinic was closed for about two weeks, but was ready in time for the last brigade of the year and is far better organized and much more animal proof. The final brigade was a first for NDI as it was an herbal brigade with two very well known herbalists coming to teach and share their knowledge and the return of well-loved NDI doctor.  Also joining this brigade was a psychologist and flower essence practitioner from Northern Nicaragua who was a pleasure to meet and work with and an unbelievable resource for patients that came through.

                                           

The year came to a close with the marriage of my neighbour and landlord Rubenia. The service was small and intimate, held right in front of my house and I was not only an invited guest but also able to be part of the preparations. Unfortunately that same night there was an accident on the island involving several friends which ended up taking the life of one, who was dearly cared for and whose presence will be deeply missed in Los Angeles and elsewhere by all who knew him. My last few days on the island were a mix of feelings, from those that came up just that week to trying to assimilate all I had seen and learned from the year. Getting ready to come home to spend the holidays with close family and friends was exciting as I had not been back for a year, but also I felt sad to leave these new friends and this life I had become used to here. Being home for Christmas was a much-needed break, that helped me to feel rejuvenated and catch up on some much needed sleep for the first week at least. The time flew by getting together with various friends and making sure to see as much family as I could.  Before I knew it I found myself on a plane on my way down to Nicaragua, but this time it felt a little more like coming home than going into the unknown.

         

         
                                     

How Time Flies

Here I am, once again playing catch up. September has flown by and I now find that the calendar is almost through October. September was a month to start fresh, beginning with a new fitness routine with my co-worker Tony as well as changing the system we use in the clinic for organizing patients. Tony and I started running during the last brigade and have managed to keep a fairly regular schedule since then. We have only cancelled our morning runs a few times, mostly due to weather or off island travel. At first we stirred up enough interest that some people asked to join us, most notably my neighbors. Unfortunately my excitement in having a local running group was short lived as no one has actually came with us in the mornings and thus far have only talked of doing so. I still have hope that one day we will convince others to join us, other than a couple of kids and their dog who were curious when we ran past them. The little boy without shoes even beat us to the end of the path.

          

Clinic has stayed steady throughout the month. After some discussions with my co-workers in Los Angeles it was decided we needed to change the system of how we see patients back to “first come first serve”. This was hard for me as there are often many people who arrive later in the day and whom I have to send away, asking them to come back another day to try their luck again. As I mentioned in my last post there has been a lot more patients coming to the clinic from the other side of the island and from the more remote communities. Angela and her mom have been seeing patients arrive as early as 5 or 6 in the morning to wait to be put on the list to be seen. It still surprises me that people make this much of an effort to come to the clinic, and I cannot imagine having to do this anytime I needed to see a doctor as this is the same system that is used by the other health centers here.

Independence day for Nicaragua fell mid-month, which meant another few days where day-to-day work is interrupted and the hospital would be closed. In the hospital I still use an sort of appointment system (citas), so I decided to work at the hospital the day before Independence Day as I felt it was better that the doctor show up and not the patients than the other way around. For a half day during a holiday I was kept quite busy, especially as I was called in to assist the on call doctor a few times during the morning. It was while working with the other doctor that I had one of my most challenging days this year. It started with a birth just as I arrived at work. I was excited to be able to assist as I felt a little more comfortable this time around, however this would not be in any way the same as my first experience in the delivery room. This time the mother was having quite a difficult labor and from the look on the doctor’s face I was sure that there might be an emergency boat trip to Rivas that morning. Fortunately a healthy baby girl was born to a very happy and relieved mother. Shortly after the birth I received another knock on my door, requesting I return to the emergency room to help the doctor once more. Not sure what to expect I found myself in the other surgery/ delivery room with a patient who would not have such a happy morning. My role was to prepare the medicine tray with sterile gloves and supplies, and then to hold a headlamp so that the doctor could see to do their work. When I asked what was happening I was told that the patient has lost her pregnancy earlier that morning and had been bleeding quite heavily. The nurse returned shortly to help the doctor to make sure the patient would not have an infection and to hold the light for him, and all I could do was hold the mother’s hand as she lay alone in a stark surgical room after her miscarriage. I had no words that I could think of to say to her, and I had a feeling that even if my Spanish were better I still might not have words to say. It was the hardest thing for me to leave that room, as she stayed there alone, resting after all she had been through. I pulled myself together to finish seeing my patients, and then I retreated for a little coffee and chocolate to help me process the feelings that I could not articulate.

The next day, which was Independence Day, I had off. In the morning I joined Ashley and the family at the park to see the school awards and the marching bands. In the afternoon I met up with Tabby, Angela and a bunch of the family for a day of swimming at the beach in Santo Domingo. For having lived here for 9 months and having driven past Santo Domingo many times it was actually my first time to the beach there. As we are now well into rainy season there was very little beach to speak of but the water was cool and inviting and we spent most of the afternoon splashing about with the kids and having little diving or swimming competitions.

     

September marked my ninth month being here, which also meant it was time for me to renew my visa. I was hoping to avoid another trip to the border and so decided to try my luck at the immigration offices in Rivas. It turned out to be a much smoother experience than most of the others I had, even if I had to make the 6 am journey to Rivas two weeks in a row. By the end of the month I was all set to stay another three months, whether or not the island is ready to keep me that long. It was important for me to get my visa settled mid month as not only did I want to avoid any fines but also I was expecting another visitor at the beginning of October.

    

The end of the month brought some clinic excitement as well. While Tabby was in Managua dealing with more paperwork, she managed to locate a medical supply store. This was great news to me as we running exceptionally low on Pap supplies, and after all the generous donations to our DIOSA program I was worried about how we could continue to offer exams to the women on the island. I had been hearing from many women that they were being turned away from the local health centers as they too were out of the supplies needed to be able to do the exam. Fortunately, with the discovery of this store, we would not be in that situation and so with the help of many who donated to DIOSA recently, we restocked our supplies and even purchased a new light for the exam room. I cannot express how excited and happy I am with this new light. The light we had been using before was quite literally a desk lamp that took a fair bit of balancing and luck to be able to position it well while doing an exam if you were working alone. We are now back on track to reach DIOSA’s goal of improving the experience women receive during their Pap exam and increasing the number of eligible women who actually have the exam done.

                                         

               

 

 

 

 

Look How Far We Have Come

Sunday morning and it was time to meet the newest brigade. Usually Tabby and I meet a little earlier to make sure everything is ready and in place. This time when I got to Cornerhouse, where we do our welcome to the island accompanied by great coffee and breakfast, Tabby was already there with a group of students. It took me a few moments to realize that I was not late, which was my first thought as when the power goes out my clock sets itself to a whole new time zone, but that some students had gotten in early as they were already on the island. Shortly after I sat down, the rest of the group came in. The majority of the students were from Tabby’s Alma Mater, NCNM in Portland. Along with the NCNM group, there was one student from CCNM and two practicing ND’s, one of whom had been here many times and had been in my position a few years ago and so for her it was more like a homecoming. The group was smaller than the other brigades and with four doctors working in the clinic there would be a lot of one on one time with students.

The first day of the brigade was the usual welcome to the island, introductions to the team and their homestay families, followed by tours of the hospital and the clinic and then clinic set up. As the Fiesta Patronale was still going on in Los Angeles and as most were tired from a long day of travel, it was decided class would be done another day so that the brigade could rest or stop by the fiesta to see the bulls or go dancing. Angela and I went to the fiesta later to see if the brigaders were still there but as the torro’s never got started they had all had left, which was for the best as a good nights sleep is just what the doctor ordered for a fresh start in the clinic.

This brigade had a really interesting energy. We started out with three doctor stations inside and the physical exam station outside. The fourth doctor bounced between the other stations for the first couple of days before setting up on her own. Having four stations really speeded things up and we were able to see a lot of patients while not having to be rushed. It was also interesting to work more one on one or with two students at a station and I felt I got to know more about their own style and which modalities they were interested in better. As with all brigades, this group brought down a lot of knowledge, new ideas and much needed medical donations to the clinic. Another thing that made this brigade really special were the patients. Almost all of the patients came from the other side of the island. Although this is a small island relatively speaking, it can be quite a challenge to move about between the different volcanoes due to road conditions and minimal bus service to the various towns and communities. There were people coming to the clinic from towns that even Tabby had not heard of, and she has lived here for over 6 years now. It still surprises me how many people are finding out about NDI and making a very long trek to come and be seen by us.

My favorite day was our third day in clinic. I had a patient come from Alta Gracia, the town on the other side of the volcano, whom I have seen several times. She is a very charismatic and interesting patient, who always makes me laugh and this time she brought her family as well. The relationship she had with one of her children was what really brightened my day. They spent most of the consult teasing each other back and forth and making myself and the brigader working with me laugh the entire time. As is typical during brigades we had several challenging cases come through the clinic. One involved a young child with a fairly severe burn that just as it was getting better got infected as the family thought it was too painful to clean and dress the wound daily. Another was an extended family from the other side of the island that were a challenge to treat due to communication challenges and who were all very malnourished. It is cases like those that really create lasting memories in terms of how basic access to food and education affect health. I still take it for granted that people here don’t eat vegetables, as all I see are fields and fields of farms. I figure that they might not get a variety of vegetables but at least a few basics such as onions, tomatoes, peppers and plantains. However most patients when asked what they eat just laugh and say food, and when pressed further say rice and beans. That is it. It is not a wonder that so many children are undernourished, many look several years younger than they really are, and that everyone who comes into the clinic asks for a vitamin for themselves and their family members. 

Special Delivery

With August coming to a close it was time to prepare for the next brigade. Which meant making sure all the paperwork was signed, sealed and delivered from MINSA. Unfortunately for me, as I found out the Friday before the brigade was to arrive, my papers were not signed nor sealed. Some changes had been made regarding the requirements for licensing documents, and my papers no longer met the requirements needed. So early Monday morning Angela and I set off to Managua to see if we could convince the powers that be that my papers are in fact legitimate and that I am a licensed Naturopathic Physician. I had spent the night before working to make sure I had all that I needed in terms of my license, my acupuncture certificate, my transcripts, any letters, copies of internet pages, copies of requirements for my licensing jurisdiction. I was sure that once I presented my case things would go smoothly. I would not be so lucky. The new requirements were to have my license notarized, in the United States or Canada, which as I was in Nicaragua posed a slight logistical problem. Also they weren’t happy that my license did not have an expiry date written on it. So it was back to the drawing board, or in my case contacting my licensing jurisdiction to ask them for documentation that states I am in good standing. Fortunately I had some great people on my side who were able to produce such documentation in record time, as we had to get back to the office before it closed at 1 pm. Angela and I got into the office just in time, only to find the people we needed taking lunch and not interested in doing much as the electricity had just gone for the entire sector of the city. This meant we would be returning the next day to see if they would accept our papers, which fortunately they did.

As I had just taken a couple days off of clinic to make sure MINSA would still let me work and as the month was about to come to a close it was time for another turno. With the brigade coming on the weekend I felt a good day would a Wednesday night, as I could come in a little later to the office to do brigade prep after a quick catnap. Wednesday was busy with longer visits and fewer patients but I felt full of energy, which would prove very important as the night went on. I was just finishing up with my last patient when there was a knock at my window beside me. Typically I try not to pay too much attention to distractions and focus on the patient in front of me, this time was much harder not to be distracted as all I heard was a man’s voice “Doctora Kyling hay un parto, vienes ahora”. For reasons I have yet to discover my name seems to end with “ing”, but the message was clear – there was about to be a birth and they wanted my help! So I finished up my patients and made it in more than enough time, excited and very, very nervous. It turns out the nurse that had worked with Michelle and I on my last turno remembered that I had never seen a birth and so she sent someone to find me when a patient went into labour.

After a rather brief rundown of what my role would be we were all ushered into the delivery room: the doctor, a nurse, the patient, their mother and myself. It was an incredible experience, one in which I gained even more respect for those who deliver babies on a daily basis (doctors, midwives, dulas) and especially for the mothers. The love this mother had for her newborn immediately following a rather uncomfortable and at times very painful birth was seen all over her face as soon as her little one was placed in her arms. I managed my role with as much calm as I could, with the doctor and nurse laughing at me only occasionally for my evident lack of experience in this particular situation. I was actually the second person to hold the newborn as I placed her on her mother’s stomach to warm and dry her. I also was in charge of moving her to take her vitals, during which there was a constant stream of  “don’t drop her, don’t drop her” running through my head as I am known to be mildly klutzy. It was an unforgettable experience for me and for anyone reading this please give your mother a big hug for everything she went through to bring you here and the love that that takes.

It seems that would not be my only first for the evening. After fobbing off a few chances to practice my minor surgery skills it seemed only time to bite the bullet and give it a go. And so later in the night I got try my hand at stitching up an elbow, with the on call doctor right by my side giving me tips and pointers. Because of the location and depth of the cut the doctor had to do the first stitches and then let me take over for the outer stitches. Due to the surgical set up in the hospital how he was teaching me that night was a little different and a little more awkward for me to start. With lots of help I managed to stitch it all up and near the end the patient was looking less and less nervous about being the first Nicaraguan to be stitched up by me. After the stitching was done it was time to help the nurse with rounds, something I know is important but seems so cruel as often it is right when people are drifting happily to sleep after the last time we woke them up. Midway through I was back in the emergency room as there were some tourists that the doctor wanted me to speak to in regards to the rabies shot after one was snapped by a dog while leaving their hotel. After that it was back to rounds, helping the nurse where I could and trying not to make the littlest patients cry. Perhaps it was because of all the activity that night, or perhaps it was because I was getting used to doing turnos and sleeping when the nurse and doctor recommended it but I actually got a couple of hours of shut eye.

       The rest of the week went by quickly. Some brigade prep on Thursday with Angela to make sure we had signs up advertising in the community and making sure the houses where the brigaders would be staying were ready. Friday was much calmer than I was expecting. It may have been due to a mix up in the list of patients I had written down for earlier in the week and partly due to the rain but it was really nice not having to turn a lot of people away for a consult. It was also nice to be able to tell people that soon there would be four doctors all working in the clinic to see them and their family if they could come back the next week.