Friday, June 30, 2006

La Mascota

The official name of the hospital where I work is “Hospital Infantil Manuel de Jesus Riveras.” But that’s a mouthful to say, and so it is instead referred to as “La Mascota” which means The Pet. There must be a story behind this name, so I’ll have to do some investigation to figure it out.

“La Mascota” is one of the best public children’s hospitals in Nicaragua, and children from all over the country come here for treatment. The doctors are knowledgeable and well-trained. It is a teaching hospital, and serves as a major training center for the medical students who attend the public university in Managua. On the infectious disease ward there are two senior residents, four interns, and six medical students who work under the supervision of the attending physicians who are infectious disease specialists. Each morning the entire medical team visits each of the patients on the ward. They call it “La Visita.” Each patient is presented to the group by a medical student or resident who gives a summary of the patient’s history and physical exam. Then the attending physician questions the child or parent to fill in any gaps in the history and afterwards briefly examines the patient. The final step before leaving each patient is to come up with a plan of what needs to be done for the patient. The entire Visita usually lasts about an hour, and writing up the orders for tests, external consults, discharge summaries, etc. usually keeps the interns and residents busy until 3pm or so.

Everyone arrives by 7:30am. The medical students leave by 11am. The attending physician leaves around 1pm. The interns leave at 3pm. And the residents stay until evening. Night call starts at 6pm and involves one resident and one intern. They call it doing a “Turno” and it comes every four nights.

I’ve been going on the Visita each morning, and then afterwards I work on the ultrasound data analysis project on my computer. Sometimes before the visita I’ll take a history and physical of one of the patients but thus far I haven’t worked up the courage to present any patients to the team. Once I get more comfortable with how things work then I’ll present a patient.

Thursday, June 29, 2006


One of the children hospitalized for dengue went into shock today. His blood pressure was low, his heart rate went up, and his extremities were cold. What happened was that his blood vessels were leaking fluid so he didn’t have enough blood in his circulation to maintain a healthy blood pressure. The doctors gave him fluids by IV, but his blood pressure failed to respond. The only option left was to put a catheter into one of his large veins (a.k.a. a “central line”) in order to both increase his blood volume and give him medicine that would increase blood flow to his vital organs.

His parents were both in tears as the resident informed them of the procedure that needed to be performed. Within minutes, a surgeon arrived in the infectious disease ward, and they began the procedure. I observed from the back of the room as a resident and two nurses held the boy firmly in place to keep him from moving during the procedure (which was done under local anesthesia, so the boy was awake for much of it).

After injecting the anesthesia, the surgeon made an incision to the right of the groin and then set about to locate the femoral vein (which leads in to the Vena Cava – the route by which all blood returns to the heart). However, the procedure did not go smoothly, as the first catheter did not go in correctly and had to be removed. A second surgeon then arrived on the scene and after much effort was able to succeed in inserting the central line. The entire process lasted over an hour. It was made the more difficult by the fact that every now and then a nurse would relax her grip of one of the child’s limbs and he would kick or flail his arms. There was a collective sigh of relief when the whole thing had successfully terminated. Poor kid. He´s only three years old.

Boys Playing on the Street

Tuesday, June 27, 2006

One of the biggest surprises I encountered on my trip to the beach this past weekend was the preponderance of real estate signs – in English. Seems that the Gringos have run out of cheap coastal properties to purchase in Costa Rica, so they’re now buying land in Nicaragua. Many of the real estate signs are Century 21 or REMAX.

A quick internet search for real estate in Nicaragua will yield quite a few hits such as,,

And the prices are good. You can’t buy beachfront property in Florida for less than a million dollars, but here the same parcel of land costs a fraction of the cost. We met a lawyer from Texas who decided to move down to Nicaragua to make a living selling real estate to foreigners. She surfs in the morning and works in the afternoon – not a bad life.

Getting Around Managua

I’ve already mentioned that Managua is not the most accessible city. There are no street names or numbers, so if you don’t have a good sense of where the main landmarks are, you’re absolutely helpless. And that’s how I’ve felt for my first week here. I tell the taxi driver the directions for where I want to go, but I have no way of knowing if he’s actually taking me where I’m supposed to be going. Yesterday, I took a taxi back to the house from the Health Center, and I told the driver to take me to a house “Two blocks south, and half a block up from the Bar Los Rostros.” He took me to an unfamiliar street, and told me that we were at the location I had requested. I told him that this wasn’t the street, but I had no way to know where we had gone wrong, so I paid him the fare and decided to find the house on my own. After circling the block, I realized how I had gone wrong: the house was one block south of the Los Rostros Bar, and I had told the taxi driver two blocks south.

However, there are some landmarks that I am beginning to recognize. Whenever I go to the Health Center the taxi will pass by Stadium Denis Martinez. When I go to the laboratory, there is a Pizza Hut along the way. Plus there are the Redondas (traffic circles) that serve as major landmarks. Any time you go from one side of the city to the other you end up on one of the major roads, and these roads all intersect each other at traffic circles – usually with a statue in the middle.

For my first two days I was driven everywhere by drivers who work for the Dengue Project. This was great since I didn’t know my way around the city and was worried about being robbed. But the problem was that I’d have to wait to go at a time that was convenient for the drivers. By my fourth day, I got tired of waiting for them to pick me up and started taking taxis. They cost about $1.25 to $1.50 to go almost anywhere in the city – but that’s if I pay the Nicaraguan price rather than the Gringo Price. Before getting into a taxi I ask the driver, “How much to X neighborhood?” And usually he’ll quote me 30 or 40 Cordoba (2-3 dollars). But since I know it shouldn’t cost more than 25 Cordoba, I’ll tell him so, and sometimes he’ll drive away (probably out of pride/spite) and sometimes he’ll agree. From my experience thus far, it’s about 50/50.

Monday, June 26, 2006

A Surfboard Encounter

I went to the beach yesterday with Sara, a public health student from Berkeley who is also working on our dengue project for the summer. Sara is working with CIET, an organization that promotes community health by mobilizing community members to educate their neighbors. In this project, CIET is working with various neighborhoods in Managua to help promote the eradication of the dengue vector, the A. aegypti mosquito.

When I arrived at the bus station at 7:30am on Sunday, I asked for the bus to San Juan del Sur. I was then physically pushed onto a bus by a group of four men who work for the bus company. I told them that I was waiting for a friend named Sara and they told me she was already on the bus. However, the problem was: 1) this wasn't the direct bus and 2) Sara wasn't on the bus.

Once this was sorted out, I got off the bus and found Sara. Then we found the correct bus and had a pleasant ride to the town of Rivas. Once the bus was en route, a man came around to collect money from passengers. When he came to my seat I handed him a 100 Cordoba bill, and he then gave me back a ticket and also gave me back my 100 Cordobas. So in the end I got a free bus ride.

From Rivas its a twenty minute drive to the beach. Sara and I planned to take a bus, but while we were waiting for a bus to come, taxi after taxi came by to offer to take us there for 100 Cordoba. We waited a bit and then asked a shopkeeper how much a taxi should cost and he told us 25 Cordoba per person, so after a bit of negotiation, we found a taxista to offer to take the two of us for 50 Cordoba.

However, there were complications with this taxi ride:
1) Sara had brought her surfboard and the taxi did not have a roof rack. Turns out we were able to fit the board diagonally from the backseat to the passenger seat.
2) He had a big dent in the back right corner of the car. When we asked him about the dent he told us that just the day before a group of Gringos had crashed into his taxi from behind.
3) The road was full of some of the worst potholes I've ever seen. It was like navigating an obstacle course at times. We'd periodically slow down and swerve left, right, left, center, left, right, to try to avoid the worst holes.
4) En route, the taxista found a local woman with two kids who wanted a ride to San Juan. So the three of them squeezed in alongside the surfboard that was already taking up most of the back left seat and front right seats.

We got a ride from San Juan del Sur to the beach with Nana, the Japanese Surfer Girl. Nana works at the Japanese embasy in Managua, and surfs every weekend. First Japanese surfer I've ever met. The beach was at the end of a twisty dirt road, and it was beautiful. There was a simple shack selling food and drinks, but otherwise it was just sand and surf. The waves were big and the water full of surfers, mostly foreigners.

I spent a couple hours just swimming in the warm water, but then this guy Robert offered to let me try his surfboard. However, it was a short board which is really hard to balance on, so I was unable to stand up. Then in the afternoon, a girl who had rented a long board was leaving and she agreed to let me use her board for the rest of the day. I tried my best, and was able to stand up maybe 4 times, but it was exhausting. The hardest part was trying not to get knocked over by the waves that I did not want to ride. Eventually, a wave caught me unawares, and I banged my head on the surfboard. It didn't hurt much, but it left a nice little cut on my forehead. I like to think of it as a war wound. I may not have dominated this battle, but I'll be back on the lines, fighting the board and the sea. It's a fun sport, especially when the water is warm.