Pharmacy in El Salvador

Sorry for the delay, as Emily has said, the internet situation is not ideal on the ship. In addition, google had decided that because I am in Central America, I must be able to speak spanish. So all of my google pages load in spanish...I'll do my best to continue posting!

18 Julio 2011

Last night at dinner I met up with Emily after our day out at the separate MedOps sites. She had just come to the Galley from the pharmacy and told me that I might be going on a pharmacy tour in a nearby town the next day. After a few phone calls by the pharmacists, I was cleared to go. The four of us left at 0745 in a taxi with a Police escort. I really never thought I would be in a position to have a police escort, but it happened today! I was with two doctors form the US Air Force and a pharmacist from the Netherlands. After a 25 minute ride, we arrived at the Sonsonate Hospital in one of the nearby towns. The hospital itself was actually very beautiful. There were lots of folering plants on the property and the building was one of the cleanest I have seen in the country thus far. However, some of the larger rooms with 10-20 patients each were not air conditioned and you could tell that some of the patients were uncomfortable. We made our way down to the pharmacy to ask them some questions about their products and services. This particular pharmacy actually had a substantial variety of medications, but they often experience shortages.

We had a chance to sit down with the pharmacist and go over some questions with her. Members of the USNS Comfort crew tour pharmacies in each country to see what medications as well as what services are abailable for citizens. This information is given to the providers who prescribe medications at the MedOp sites. This allows them to make proper recommendations so that their patients can continue treatment after the Comfort's mission here is complete.

After our hospital tour, we went across to a retail pharmacy. These are completely different than anything in the US. Patients can get nearly any medication without a prescription. They simply walk inside, tell the individuals behind the counter their symptoms, and walk out with what is deemed to be the proper medication. It is definitely an interesting system with fewer regulations than what we have in the United States. Below is a picture of just a few of the drugs available at the retail site, with the previously mentioned Dutch pharmacist in the background.

We left the retail site and had lunch in town before heading back to the ship. We invited our police friends and taxi driver to eat with us. I really have to say, everyone we have met in El Salvador has been wonderful. Even with the language barrier, you can tell the people are very friendly and really are happy to see us here. The policemen recommended a Mexican restaurant and it was delicious. I have attached a photo of my fajitas. It was nice to eat a meal outside of the noise and bustle of the ship's galley. Tomorrow I will be out for another MedOp and will try to blog about the experience soon!

Buenas Tardes....from El Salvador and Costa Rica!

Hello! Finally an opportunity to update everyone on our adventures! Unfortunately the entire Internet was down from July 21-28! We were told that there was an issue with the modem and we needed a part that we would be picking up in Costa Rica. So we have been anxiously awaiting its return to post some updates! Additionally, the connection makes dial-up look lightening-fast, so it is nearly impossible to load any websites with pictures or large files. So our apologies, and we are now posting from the most wonderful local coffee shop at the end of the pier in Costa Rica.

Below are previous posts written but unable to be posted (dated when written)....

Written: July 16, 2011: Yesterday after a long bus ride from San Salvador we embarked on the USNS Comfort in Acajutla, El Salvador. Our general impressions of ship life are very positive; yet, it is extremely different than to which we are accustomed. To be effective you must understand military time, learn to eat quickly, and learn to shower even more quickly. We have had the extreme pleasure of meeting a wide variety of healthcare professionals from many different organizations and countries! We have met nurses, dentists, hygienists, veterinarians, surgeons, pediatricians, and pharmacists representing several different organizations and services including the Canadian Army as well as the Dutch Army and Navy. Additionally, all the members of the U.S. Military or Military Sealift Command have been exceedingly helpful to assist us in navigating the ship, answering questions, etc. We have also had the opportunity to take a walking tour throughout the ship as well as onto the flight deck and see the “helo”. After speaking with many of the deck crew we are beginning to decipher the color system of their fire-retardant uniforms: red – ordinance/fire crew, brown –captain/inspection, blue – chains, etc. It is fascinating and a complex operation up there. I hope that I can get the chance to ride in one to a site in Costa Rica.

Today was our first full day on the ship and we went through indoctrination (shipboard training) and were introduced to mostly all of the pharmacy personnel. Both Alisa and I will be going out on two separate MEDCAPS (clinical mission) tomorrow.

Written July 22, 2011: Yesterday I was out on site again for a MEDCAP at a different location, Pollide Portivo, a type of small stadium structure in El Salvador. There is a “roof” but semi-open sides, and has endearingly earned the name as the, “bird sanctuary.” Because of the open sides and tall roof with supporting beams many birds have made it their home. Though interesting to see, it is dangerous to stand underneath in the “kill zone”. Both Alisa and I,as well as many others, took at hit from our feathered friends. Each site offers a new organizational challenge to route patients through the care process to the correct places. In comparison to the first site at the school with individual rooms, this site featured all of the different disciplines and practitioners setting up in a semi-circle on the edge of the building, and staging patients in the middle. The day ran very smoothly and we had at least 2 translators at all times. However, whenever I felt able and/or the translators were otherwise occupied I would try my hand at distributing and counseling on medications in Spanish. Everyone I spoke with was very patient with my less than perfect verb conjugation and pronunciation; and appeared pleasantly surprised and grateful. On a few occasions after a few brief counseling points in Spanish the patient would respond with a long (very fast) story, question, etc. at which point I called in reinforcements. Communicating in Spanish with these patients felt wonderful and consistently challenging.

A few highlights from the day were jump roping with the children waiting at the site, as well as watching service men and women enjoy Pizza Hut (a far cry from the chow served on the mess deck) after being away from typical American take-out. I was also particularly touched when a young girl whispered for me to come over to the fence in front of the pharmacy and then gave me a rainbow-colored bracelet. It seems like a small silly thing, but it was an enormous gesture. It seems that most aboard agree that El Salvador has been one of the most enjoyable of all the countries that the Continuing Promise mission has visited.

Puntarenas, Costa Rica (our next stop) is a liberty port, everyone may get off the ship and duty for a short period. Alisa and I, like many many others on the ship, have planned to go zip-lining during liberty! For the military and civilians that have been on the ship for the entire mission this is a long-awaited occasion!

Today I had the amazing opportunity to visit and observe the OR. I was able to see a laparoscopic cholecystectomy, pediatric inguinal hernia repair, and an umbilical hernia repair. The surgery was fascinating as well as the complete protocol and procedures of the operating room in general, as I have never been in one. The laparoscopic work was very easy to view in detail; however, it was difficult to get close enough to the hernias because of sterility to see the intricacy. During these I was able to speak with the anesthesiologists about the different drugs, dosing, and disease considerations. He did an excellent job of describing the general regimen facets and many of the considerations based on the pharmacologic properties of the drugs.

Written July 26^th 2011: We have finished in El Salvador and are underway to Costa Rica. We watched the ship leave from El Salvador from the flight deck; consequently also the best place to see the sea or the stars. Because the Internet is down, so are the phones. The IT department has been providing satellite phone use (with a 2 minute limit) on the flight deck each night.

Once underway I have had a few fun and fascinating experiences. The first was a complete hospital tour with a Commander. He is both a radiologist and a helicopter pilot! We learned about the ship’s history, current capabilities, as well as future upgrades. We were able to see the intricate workings of the Casualty/Receiving (CASREC) area, ICU, CT scanner and Radiology, the patient wards, as well as the general “patient flow” as the ship was designed.

We were also given the opportunity to do a presentation on the requested topic, “Parasitic Disease and Treatment.” The audience was largely Project HOPE personnel (doctors, nurses, etc.), many of the pharmacy staff, as well as a variety of other doctors and nurses. We were fortunate to have the time, help, advice, and input from Captain (Dr.) Martin, an infectious and tropical disease specialist. The reviews and reception of the presentation were positive. We covered mostly the lesser-known parasites and those endemic to the area. We also included a case from the local MEDCAP site with pictures of Leishmaniasis. The presentation overall was particularly difficult, as we were putting the finishing touches on it without the assistance of the Internet.

Last night Project HOPE volunteered to help on the mess deck in the galley or scullery. I was in the scullery receiving trays. It is hot, wet, and dirty with uneaten food, but very fun! I imagine it would wear thin for those doing it from 0400-2000 everyday; but for me it was a race against the incoming line. There was also music, handmade signs, cowboy hats and a super soaker.

This morning has also been eventful. The ship is receiving replenishment from the USNS Lewis and Clark. This is one of the most skillful, highly engineered, and completely awesome operations I have seen thus far. The fuel line is strung between the two ships, as they continue to move at what I am told is 5-7 knots. The ships maintain ~200 meters in between and continue in perfect parallel. Pallets are delivered via line between the ships, and also transported via helo. The picture below shows the help ops, fuel line, and direct line delivering pallets across the ships.

Getting closer to 'shipping' out!

It's been a while since I've posted, due to having few updates.
I'm glad to see my classmates, Andy & Andrea, who shipped out to Southeast Asia have returned safely and have great blogs about their trips!
So far in Cameroon things are going good. Project HOPE has gotten volunteers on the ground and working in the hospital. There are always logistical issues with missions such as this, but things are progressing positively. I'm very excited to arrive and 'get my hands dirty'. It looks like I'm a few immunizations short of my early September trip.

Next update will be closer to fly date.

*Make sure to follow our group, Alisa & Emily, who have recently gone to Latin America!

Pohnpei, FSM

Well, all good things must come to an end, but we saved the best for last. Pohnpei, of the Federated States of Micronesia (FSM) was our final stop. The island, a lush, tropical garden situated in the Pacific about 500 miles north of the equator and a few thousand miles west of Hawaii, where it rains on average 17.5” every month, was a gorgeous location for our final mission with Project HOPE. Needless to say it rained regularly, sometimes more than four times a day, but between each quickly moving rain shower, the sun would shine and keep things nice and toasty-warm.

This weather made for interesting transport to and from the ship on the LCU (Landing Craft Utility), which has no roof or covering, so we were always praying that we would miss the rain, unfortunately it didn’t always work out how we wanted. We did get to watch a bunch of gorgeous sunrises and sunsets though. So, there were more than a few days, where if you didn’t soak your clothes sweating in the heat, you were rained on and soaked anyway.

The locals were used to the rain and heat of course, and again like in Timor Leste, despite the weather thousands of people made their way from all over the island to visit our clinics. The first week, I worked at Nanpei High School, a complex where for the first time our pharmacy was set up inside a building, and occasionally we were blessed with electricity and ceiling fans. During the second week, I was at Pohnpei hospital, where we worked alongside the Micronesian pharmacists and techs. They were great, and went out of their way to serve as translators for us, which was reassuring in that they already had some experience and training in counseling patients.

The people in general were very friendly and grateful, and many of them spoke English, which made all our jobs a little easier in that we didn’t have to rely on the interpreters as much as in Timor. The main health issues I saw were musculoskeletal problems, and so the pharmacy dispensed a lot of ibuprofen and acetaminophen. Apart from treating back and knee pain, we sent out a lot of de-worming regimens, which made up a good deal of the rest of the prescriptions. I suppose that was a good sign, but with a diet mostly consisting of fresh fish, fruit and vegetables, it is not hard to see why they were a generally healthy people.

After the clinics work was complete, the ship’s schedule changed and had to head back to San Diego a day early. As this was the last part of my rotation, quite a few people left the ship for good a day early to fly out of Pohnpei and head back home. But because our planed flights and accommodations didn’t coincide with this recent change of schedule, we were provided with other lodging. The lodging came as a surprise to the ten of us departing from Pohnpei though, as we were put up by the U.S. Ambassador and his wife at their residence. They fed us dinner with vegetables from their own garden, set up the rooms for us to sleep in, made us breakfast, and even drove us around for some souvenir shopping. It was quite an experience, and was a very special cap on the end of our time with Project HOPE. After a few more days on the island and after catching a tour to visit some waterfalls, some ancient ruins and swimming with manta rays, I did a bit of unwinding from, and finally boarded the plane and enjoyed a wonderful 33 hours of travel before arriving back at home in Virginia.

It is amazing how quickly the trip has come and gone, but it is an experience I will always remember. The wonderful people I was privileged to work with, all the people helped, the different and interesting cultures I interacted with, and the time working and living with the Navy are all irreplaceable experiences that will travel with me wherever I go. It was such a great time and I recommend it to anyone. I especially want to thank Project HOPE and Shenandoah University, but to everyone who made this possible, I want to thank you so very much.

Andy

Timor Leste

Bon Dia!

That means good morning in Tetun- the language of Timor Leste! It was an amazing experience that has taught me so much.

We had really long days with transfers off the ship as early as 0530 (or O-dark-thirty as we like to call it!) but they were well worth it. Riding on the LCU (the transfer ship that is inside the USS Cleveland) was awesome but a real try for patience on those early mornings sometimes.

You wait for the Cleveland to fill with 9 feet of water (doesn’t sound right I know but it works!) and then the LCU backs out. It was an AWESOME thing to see though, just a little time consuming. It was well worth it when you got to see the patients we helped and become part of the community.

In Timor Leste I worked at various MEDCAP sites distributing medications, got to run a 7K that got routed incorrectly and turned into a 13K, and went to a COMSERV to paint a school that was built by a pervious mission, unload donations for the school and play with the school children.

I marked dosing cups, syringes, and medication vials with a Sharpie to show dosing, I would give all the children their first doses of azithromycin in order to make it easier on the parents for the remaining days (even though it sometimes induced tears) and I would simplify the directions as best I could. For other types of meds like inhalers and creams “show-and tell” worked great. I know it’s not the biggest of things, but any little bit that I could help them understand better made me feel great!Each experience has helped me grow as not only a health care professional, but as a person as well. I’ve met some amazing health care staff and military personnel and become great friends with the people on the ship I otherwise would never have had the chance to meet!

The people of Timor were very kind. Even though there was a language barrier, if you just explained something to them and organized them in the lines through the MEDCAP sites, they soon got the program and followed suit. Being a part of this mission has taught me many things. I have learned I can take the lead on situations and can become very creative to try to simplify things for patients. Many of the people of Timor can’t read English so I started creating different things to help the patience with compliance.

The kids of Timor loved it when you took their pics and getting to see them- it even helped some of them stop crying after an unwanted check-up. I will miss seeing their faces change as they see the pics and the curiosity in their eyes as they approached the pharmacy tent. At each site we say about 600-1200 patients and completed a plethora of scripts, but to me the satisfaction wasn’t in the numbers of patients we saw or scripts we filled; it was in knowing that maybe with my help I made at least one persons day a little better.

Welcome to El Salvador!

We arrived without issue a few days ago to the El Salvador airport outside of the capital city, San Salvador. We decided to come a few days early to see a little bit of a new country and experience a different culture. Yesterday we visited the National Anthropology Museum as well as the Museum of Modern Art.

We have found the food to be excellent and the people to be extremely gracious and helpful. We have been generally able to communicate with our limited Spanish and their limited English. Hotel staff speak fairly fluent English; however, this is not the case in the general population.

This morning we were able to meet our preceptor, Dr. Earl Rogers, for breakfast and discuss our work to come. He encouraged us to see the country and enjoy a day before beginning some long and hard, yet, rewarding work.

Later, we took a taxi ride with driver, Romeo, to El Boquerón (literal translation to “Wide Mouth”) a volcano and national park. It was approximately a 40-minute drive from the city ending with a steep climb to the rim of the crater. The park was lush and beautiful with flowers and vegetation. We saw hummingbirds and butterflies on our trek to the top.

We found the crater surprisingly symmetric, steep, and preserved. Romeo informed us that the last eruption was in 1917, and although the country boasts 12 volcanoes only two remain active.

After the exciting stop at the volcano, Romeo drove us to Joya de Cerén, a recently discovered (1970’s) anthropological site exemplifying Mesoamerican culture and life around the 6^th century. It was buried by volcanic ash and rock, but rediscovered in the 1970’s by a bulldozing project! Today the World Heritage Convention through the United Nations Educational, Scientific, and Cultural Organization protects this site. The intricacy of the construction and the seemingly advanced techniques and artifacts were fascinating.

Although we saw both interesting as well as beautiful sites today, our travels also exposed us to the great poverty that this nation experiences. Some of the most unsettling or difficult visions were of starving animals (dogs, cows, horses), dilapidated and unsanitary living conditions, as well as many people walking, sitting, and living just on the road-side on the way up to the volcano. Homes are primarily made out of scraps of metal, plastic, and wood. We were ultimately left feeling although the country is full of beauty and rich history, it is clear why we are here to help, and there are many challenges this population faces for the future.