Panamanian Clinical Experience-

preparing vaccinations

So I will once more throw up a personal blog  that I wrote on the trip at an earlier date. This was during week 2. So today we were in the clinic and HAD PATIENTS. Woo hoo. Doctor Erick promised us pt’s and they totally came. I don’t know if he actually went into the community and brought them in or what lol…... But when we got there, there were pt’s lined up outside waiting for us. So cool to see considering the past few days the clinic has been almost empty on arrival. So we split up into 2 groups - first myself, Kayla, & Olivia were in the vaccination room where we worked on flu shots, penicillin shots, & oxycillin shots with our Nurse Adelina. We gave a penicillin shot to a little girl in her tush. It was a preventative most likely for STDS. It is sad to see such a young girl (10 years old) get an STD shot….but also smart of them to be giving it. Back home we are often oblivious to the fact that younger generations are involved with sexual activity. For ex: we preach abstinence in the school, well that’s great & all……but we should also equip them with other knowledge if they choose to have sex (birth control, condoms, etc.). That is one thing I have noticed here in Panama, their use of vaccinations is awesome. Better than the US in many ways. Doctor Erick mentioned that he is also big on antibiotics. Every time a person comes in with a cough, they get an antibiotic to prevent pneumonia- which is often the end result of their cough.



One of the shots I gave today was to a young boy who was both very skinny & very timid. He hopped up onto the table and pulled his pants down just a little bit for his wittle cheeks to show. For this, I was nervous. I have never given an IM injection in the gluts before. When I put the needle to the skin, the poor little guy tensed up & the muscles tightened so much the needle wouldn’t budge. I started to panic  sitting there like uhhhm, am I doing something wrong?! Thankfully our nurse came over and helped me relax the boy (by speaking his language lol … now that I think of it I would be nervous too. One large needle, some foreign girl, sticking me in my butt) Eventually it slid in & I released the medicine (oxycillin for an infection of some type). It’s cool to get a lot of interaction with children out here. Back home it is many older individuals in the hospital I have clinical at.

Dr. Eric stitching up a machete injury...



One thing I noticed while working in the clinic, is that how great our nurse with the patients. Not in a sense that she was really compassionate or anything, but she was a great teacher - which is so crucial to nursing. Even though I could only pick up on a few things that were being discussed, what I could hear was good teaching. One big thing she educated every pregnant woman on was the importance of having their baby at the health clinic as opposed to their home (due to the complications that could arise). Even with all her teaching, a lot of the mothers were set on having the baby at the comfort of their own home. Here in panama they often times just have the local medicine lady come to their house to aid in the birthing process. I think it has a lot to do with the culture- a lot of Panamanians are opposed to western medicine (the clinic). Adelina also educated patients on the importance of breast exams and general health checkups. It is crazy to think some of these people walk 8 hours to get to the clinic: barefoot, holding their baby, and any overnight supplies needed….



Another thing I noticed was how many of the people here suffer from respiratory conditions.  It is related to the living conditions, cooking in closed areas with all the smoke. So we saw a lot of nebulizer treatments related to respiratory issues in our clinic. It is also obvious that HIV, blood borne diseases, and communicable diseases are a huge problem in this camarca. It’s interesting to compare that to the United States where a lot of our health concerns are related to obesity, smoking, cardiovascular diseases, etc. Here in Panama they eat relatively healthy and are walking basically everywhere so that doesn’t seem to be a concern here. Their issues arise from their living conditions, lack of water, lack of cleanliness , etc.  



Another exicitng thing I got to do was MY FIRST BLOOD DRAW. My first time ever sticking someone with a needle for blood! Dr. Erick was such a great teacher. He kept telling me to be one with the vein. To close my eyes & feel. He even whipped out a pen and drew on the lady’s arm to show me where to stick the needle lol that may have been a bit extensive-but it helped. There was no way I was going to screw this up. Bevel up, I pushed the needle in at a very low angle and after shifting it to the right a little bit I saw blood! When I began to pull back the plunger Dr. Erick kept saying Mas, Mas, Mas.. I need more blood. I’m pretty sure he even made a twilight reference and told me to pretend I was a vampire….lol Needless to say, He was a great teacher. And the pt was a great pt! It was not as hard as I had expected, as are most things in life. I now feel much more confident going back home ready to do a blood draw of an IV.

We have walked around in the community a few times and it is interesting to see the way these families live out here. The living conditiongs, the cleanliness (lack there of), the small living area, etc. The homes are made out of mud, straw, and sometimes cement. The roofs were zinc. The floors were hardened mud. No electricity. No air conditioning. Running water was a rare find.

We saw a little baby chillin in a hammock. I think

it was her crib

Feeding a deer out in the community

one of the nicer homes we saw

I couldn’t imagine living like that and yet to some of them they consider their home luxury compared to the family sleeping in a shed. It is so funny how you can just walk onto someone’s property out here and they don’t even mind. Back home someone would call the cops if they saw someone strolling around their backyard. I think they are used to people randomly crossing on their property considering how many of the doctor’s, nurses, promotoras knocking on their doors on a regular basis to check their vaccination records…educate them on coming to the clinic…. However, as welcoming as they were, they are very shy. I remember when we asked them a few personal questions relating to their health, they would oftentimes not answer, hide behind their hands, or step away in a guarded manner.

A lot of people out here grow their own vegetables and fruits. I’ve always wanted to grow my own vegetables. It’s kind of cool to go in your back yard grab a few things for a salad and go back in the house to prepare lunch- knowing it is so fresh. However many people in our community aren’t really aware of how to grow their own crops so they are working on educating the community how to do so. At our local highschool you can graduate in a degree with agriculture. (The other degree you can graduate with is housekeeping….. quite the options).

I have learned a lot from just walking around the community and experiencing a little bit of what they experience day after day....

-Brittany Brewer

My clinical group and I on our way home from Beunos Aires...

Last day

            Our last day in San Felix/David began with a presentation of our findings from our work in each of the three communities in the Comarca.  Each group had a particular focus such as childhood development, women's health, or traditional medicine, and incorporated statistics and photos from each region.  It was probably a little longer than needed, but I think we managed to hold the audience's attention through most of it!
             Next on our agenda was an evening at the hospital in David, working alongside the Unachi nursing students doing their clinical rotations.  The first half of the evening was pretty uneventful.  There weren't a ton of patients on the floor, but my student, Cristela, and I got to hang blood and I did a head-to-toe assessment (in Spanish).  Despite lack of hands-on work, I did learn a few things:

- Nurses (and students) hand write everything!  They don't have any electronic charting, it's all on paper.
- Mercury thermometers are really hard to read
- Counting respirations/pulses for 15 seconds and multiplying by 4 doesn't fly here
- Students sometimes have to work doubles (7a-11p!)
- And then they have to go home and do homework for their morning classes
- There is only 1 nurse per unit which means each one can have 30-40 patients at once!
       (In the US, nurses complain when they have more than 5 patients)
- Nurses here make an average of $3/hour
       (Meanwhile food, gas, and many other things are priced equivalently to the US)
- Students are required to wear makeup and have their hair up in a neat bun
- All nurses wear little caps, and the various colors on them indicate where the nurse is from
        (i.e. green = Panama City, yellow = Chiriqui)
- Regardless of where they're from or the language they speak, nursing students have the same sense of
       humor :)

            I really enjoyed my time working with the girls in David, and I wish we had more time to spend with them!  They are held to such a high standard both academically and professionally, and I think they set a great example for nursing students everywhere.  They were incredibly patient with us, taking the time to explain things several times in order to make sure we understood, and never seemed to mind that we couldn't speak their language.  I, and I think we all, felt so welcome here that I can't wait to come back someday!

Hospital in David

               On Thursday, June 7, we went to the hospital in David to work alongside the Unachi nursing students (the hospital's full name is "Hospital Materno Infantil Jose Domingo de Obaldia in David."

Nursing students :)

I was assigned to the labor/delivery unit, which we will be rotating through next semester, and found that it was not like anything I had experienced yet as a student.  First we were brought into a waiting room where all of the women in labor were awaiting transfer to the delivery room.  After observing several measurements, one was finally ready to go and we were allowed to follow her.  This was her third child, so apparently things moved relatively quickly, but the entire procedure was performed by a nursing student!  We don't get the opportunity to do that as students in the US, so that was really cool to see.  There were a number of differences between US and Panamanian deliveries:  first, the mother showed no emotion during the entire thing, including when they handed her child to her and the nurse had to place the mother's hands on her child because she kept them by her side.  Second, they do not use epidurals - not just in Panama, but largely anywhere outside of North America (apparently we are just wimpy in the States).  Third, the doctor poked his head in once to make sure everything was running smoothly, but was more or less absent otherwise.  Evidently they are only called in if surgery is required (i.e. c-section), but any minor sutures are, again, done by the nursing student.  Lastly, there were four USF students and an instructor, five Unachi students and an instructor, plus on-duty nurses in the room with the poor woman, and they were all standing around educating us on various aspects of the delivery process, taking pictures, laughing, but not really paying much attention to mother and baby.  It was great for us, but I felt rather bad for her.

It's a girl!

               I suppose that the nursing students here are required to have this type of experience because it occurs more frequently here, especially among the indigenous people.  In the United States, most families have between one and three children and the parents are getting older with each generation.  Here, however, more than half of the population is under 19 years old (at least in Chami, our community), and many of the women have their first children before the age of 20.  I realize that part of it is cultural, but after seeing so  many women struggling to feed themselves I'm wondering if there ought to be a better effort to promote education on birth control.  In our clinics, Dr. Barry and his staff were very good about making it a point to mention the various implements and injections available, but most of the women I observed were reluctant to discuss it.  

A family in Hato Chami

All good things come to an end

As our journey in Panama comes to a close, I have only good things to say about the people I have encountered and the experience I have had. I have been lucky enough to have experienced many new "firsts" while in Panama, including witnessing the births of two baby boys, assisting with an STD check, and listening to a doctor spend nearly an hour solely on education regarding safe sexual practices. This last facet was very nice to see; in the United States, it would be nearly impossible to find a doctor who was willing to dedicate that much time just to teach a patient about condoms. The last few days spent in Buenos Aires and Chami have only reinforced the importance of cultural competency. Healthcare for the people of Panama is much different than in the States. I have had to adapt to my environment and work through the difficulties that arised. Despite this, I feel like my experiences have been extremely fulfilling. It has been enlightening to see how much responsibility the community nurse takes and how many duties she or he must perform. The scope of practice for a nurse is much wider here, yet the nurse does not seem to get overwhelmed. Perhaps we have much to learn as American nurses. I am so happy to have met so many kind and welcoming people and I hope that I will have an opportunity to revisit them and the communities again at some point. I have learned so much from this experience and will truly miss the people I have come to be friends with. I will always treasure the time I spent here.

A baby is born

At the hospital on Thursday, I was afforded the opportunity to spend time in Labor and Delivery.  From the moment we walked in, a young woman was crying.  I immediately walked over to hold her hand.  I asked her how old she was and whether this was her first pregnancy.  She is 20 and this was her second pregnancy.  She seemed very scared and nervous.  She told me she was in a lot of pain.  I didn't know what to do other than hold her hand and try to comfort her.  She gave birth to a healthy baby boy within about an hour.  I was able to hold her hand and stay with her the entire time.  After the doctor finished assessing the baby, I asked when the mother could hold him.  The doctor informed me that I could pick him up and give him to his mom immediately.  It was a very moving experience to hand a newborn baby to his mother for the first time. The mother informed me that her first child had passed away.  At that point, my heart broke for her and I understood the level of fear she was experiencing during labor.  I tried to reassure her that her son was healthy and everything was fine.  Unfortunately, I'm not fluent in Spanish.  Dr. Cadena asked Jessi to assist us in explaining to her that her son was fine. I asked her permission to have a photograph with her and her son and she agreed.

Culturally Competent Care

At the clinic, the head nurse was providing immunizations to a lot of the community members.  We participated and administered the injections.  I introduced myself to my patient in Spanish before drawing up the influenza vaccination.  She seemed confused when I spoke to her.  The nurse explained that the patient understands Spanish but speaks mainly Ngobe, the native language of the indigenous people in the area surrounding the clinic. The nurse helped me translate some basic sentences from Spanish to Ngobe.  The nurse was fluent in both Spanish and Ngobe.  She explained everything to the patient.
One of the doctors, on the other hand, claimed that Ngobe is a useless language.  He could not understand why the people do not just learn Spanish.  He has refused to learn any words in Ngobe and communicates with the patients in Spanish only.
I was very impressed with the level of care the nurse provided and confused by the doctor's comments.

The Trip is Coming Close to the End!

Now that I truly understand that general nurses practitioner most often care for one patient at a time, but community health nurses care for entire populations. For instance, Soloy clinic nurses work with entire Comerica Noble Bugle community. They are able to educate community about health issues, improve health and safety, and increase access to care. Panamanians community health care has implemented health education campaigns and disease prevention activities, such as immunizations and screenings. They tell the community they serving about locally available health care programs. They also provide direct health care services to vulnerable and those at risk populations.

Last week, we visited at the hospital (Hospital Materno Infantil, Jose Dmingo De Obaldia) with UNACHI faculties and working with students side by side. We have given a brief tour and have introduced different departments and their staff members. We have divided in to six groups and assigned to three or four departments.  First few hours our group spent emergency triage pregnancy and then moved to labor and delivery. According to UNACHI students state that they deliver three babies per semester as part their curriculum. The students are prepared to handle any primary care may arise from the community they are serving except when things are complicated.

    
So far I have had a wonderful experience. It has been an interesting trip in Panama. Panamanian gave us warmest welcome to their community. I was with friendly the faculties, students, and the hospital staffs members. I have found it easy to communicate with the faculties, students, and the community in general. I had a great time interacting with the UNACHI students and communicating with mixed Italian, Spanish and English. It was a great experience being at the hospital and I learned a great deal about the differences in culture at the hospital and language barriers between us.  


 

Yesterday we went back to UNACHI and the hospital one more time. We worked with faculties and students in GYN department. We also said with final goodbye with faculties and students. Our Panama trip is coming to close and soon we will back to the states. I am feeling that being in Panama has increased my skills and awareness of different cultures that exist within Panama. I am very thankful that I had the opportunity to be with Comarca Ngobe Bugle community for this trip.  


Muchas gracia!