Wednesday, August 14, 2013

Alum Molly Palilonis '05 on a medical service trip to Nicaragua

Molly with one of Timotea's many grandchildren.
Timotea is the health promoter in San Onofre,
which is one of the strongest AMOS programs
Alum Molly Palilonis ’05 is a medical student at Duke University. She spent much of this past spring in Managua, Nicaragua volunteering with AMOS. An organization rooted in community health projects, AMOS seeks to empower small, rural communities to take ownership of their communal assets and difficulties and works alongside them in health education and development in order to improve the lives of members of their communities. Below is an excerpt from a blog on their trip.

One manner in which many communities operate with AMOS is via a health promoter. This person has been chosen by the community to facilitate the healthcare for the people living there. The health promoter has resources from AMOS - including manuals on symptoms, diagnosis and management of common problems - like anemia, respiratory disease, and diarrhea - because these leaders have no medical background. Our project is going to focus on an assessment of antibiotic usage in several communities. Like in the States, many health promoters over-prescribe amoxicillin (the only antibiotic they have) and we plan to compare the rates of antibiotic usage in the various communities around Nicaragua. This is such a limited resource, it is important from a cost perspective as well as a health/resistance perspective to better train the promoters concerning the use of antibiotics.

We met the AMOS crew at the gas station near our house early Monday morning. We loaded up the land rover and rode out to San Jose de Los Remates. Here we had some breakfast with John and Desiree - two AMOS employees working on projects this week too. Then we rode down a long dirt road and finally arrived at Fatima's house. Fatima is the health promoter in this community - she has been trained by AMOS to provide for specific healthcare needs of the people who live there using medications and following protocols designed by the WHO. Dr. Carlos, an AMOS supervisor, came with us, and he worked with Fatima first, because he was introducing her to prescribing antibiotics for the first time. Later in the morning, we presented our make-believe cases to her so that she could practice using the new protocols she and Carlos had been reviewing. Our cases were a child with cough, and a child with pneumonia. We presented the cases as if we were each a mother with our child who was sick. While discussing the cases, we were assessing her ability to use the protocols to diagnose and treat these pretend children accordingly. She did really well with the cough, but struggled some with the pneumonia, missing a few key points about the child's breathing. We discussed the important things to remember about pneumonia with her, but I think she was just nervous, too!

One of the highlights of Fatima's house was her four-year-old daughter, Tatiana, whose birthday was the day we arrived. She was dressed like a princess, in a long flowy white dress with ribbons and all. She was easy to get along with - constantly chatting and offering us stickers, and watching movies like The Jungle Book.

Fatima's house (and the AMOS clinic)
That afternoon, we walked to a neighboring house where a recent patient of Fatima's lived, to discuss her recent clinic visit. We wanted to learn about her experience, if the clinic was helpful and useful, etc. Later that evening, this woman visited Fatima's house, coming with a bucket of bananas fresh from her garden. She is pregnant, in her first trimester, and she was having a headache. Fatima checked her blood pressure - 90/70 - and the patient suggested she might take ibuprofen for the headache. Fatima read through her protocols, and with our help, understood that ibuprofen is contraindicated in pregnancy, and therefore acetaminophen would be better.

It gets dark very early out in the campo, and that night, after dinner, we went to bed pretty early. There were so many bugs - the sansbug is essentially the best thing ever!

I woke up at 4am to the sounds of Fatima and her daughters making tortillas - slapping them out on a large stone. After our breakfast, a few hours later at a more reasonable hour, we went over a third case with Fatima, pretending Molly had a son with diarrhea (an extremely common problem for kids in Nicaragua). She knew everything to do, including the recipe by heart for an oral rehydration solution. Soon after, Dr. Carlos arrived, and we all hiked up a mountain to get to the schoolhouse - we were there to hand out toothbrushes and paste to all the kids, and Dr. Carlos taught them how to brush! It's amazing what simple things we take for granted are so crucial to teach out here in the campo.

On our way back to Fatima's house, we visited one of the seven pregnant women in her community. She had been having high blood pressures, so Fatima had wanted to check in on her. A part of every visit with the pregnant women is to review their plans for el parto, the delivery. The health department in Nicaragua is making great strides in the health of mothers and newborns by requiring that they deliver in the local hospitals (more like birthing centers). It's important to review with the women the signs of labor - because they live so far away!!!

That afternoon, we hosted the health committee meeting at Fatima's home, and about 10 women from her community came as members. They went over some data - the rates of flu, pneumonia, and diarrhea over the past year - and they also discussed fundraising for more water filters and emergencies (an ambulance is expensive and not many can afford it). Dr. Carlos concluded the meeting by gathering ideas of topics the committee wanted to learn more about on future visits from AMOS, things like anemia and breastfeeding.

Following the meeting, the women gathered in Fatima's kitchen to make "anemia patties" - little fried patties made of green leafy plants, roots, and peppers, and probably other things I didn't catch - all of which grew in Fatima's garden! They are sweet, and muy rico, delicious, which is perfect in that they are made to fortify the diets of their children! I loved them!

Then we rode over to Cumaica Norte, another village in the same province. Here we met Catalino, a funny and distractable man who is the health promoter for his town. After he worked with the supervisors, we went to visit a pregnant woman in his community. We made a second visit at another house, and Molly and Socorro (one of the supervisors with AMOS) went alone so that our crowd wouldn't be so intimidating. These went really well, and when we returned, we helped Socorro go over the protocols with Catalino.

Dr. Carlos teaching the kids how to brush properly
Later that morning, after we had returned from the school in Cumaica Norte to hand out our toothbrushes to the kids again, Catalino was ready to go over our cases. We completed the first, same as we had with Fatima, about the child with a cold. Just as we finished, an actual patient came in - a 2-year-old girl with her mother. The little girl, Aida, had had a fever for the past 2 days. She had been sick several times recently in the past few weeks with colds, but this fever and cough is worse. Catalino took her temp - 39C. He counted her pulse at 99, but I had checked it too, instead at 144. We suggested that he count for a shorter time, like 30 sec, and then to multiple to get it per minute. And again we counting her respirations, Molly demonstrated how to rest a hand on her shoulder to help with the counting. He took to our suggestions kindly, and seemed to appreciate the little tricks we knew.

He continued with asking the mother questions about her daughter's illness. He listened to her lungs (we did too), and he then went over her symptoms with us as he determined her diagnosis. We walked him through the protocol and helped him understand that her diagnosis would be pneumonia. We talked about why her case could be treated at home, but other children who were sicker should go to the hospital.

We then helped him prescribe amoxicillin - the two-year-old gets 7.5ml of a 250mg suspension every 12 hours for 5 days according to his protocols. He retrieved the bottle, we mixed it there, and she received her first dose there in the clinic. Catalino went on to explain how to take the medicines (he gave for acetaminophen for the fever too), why it was important to give the antibiotic as directed. And finally, he told her what to look for in case her daughter got sicker, and when to return to his clinic. He did beautifully. This was a big deal - he only started providing antibiotics a few weeks ago! We were so proud of Catalino, and so appreciative of the mother's patience while we all were learning. She seemed very thankful for her daughter's care, and we hoped Aida would be well soon. So cool - we were doctoring and teaching in Spanish in the middle of the jungle!

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