Mazapán

Just a few weeks ago I had the privilege of travelling with a team of medical students and physicians to a rural village in Honduras known as Taulabe.  The Kaiser Napa Solano Family Medicine Residency Program has partnered with long standing local NGO – ENLACE to help provide much needed care for villagers in this area. We concentrated our work in the villages of El Diviso and Pal Michal Carmen .

I was immediately taken by the warm welcome we received by our hosts. We were immediately fed after being picked up from the airport. I found the Honduran food quite enticing and this was certainly one of the many highlights of this trip.  Our meals were prepared fresh daily by two kind and amazing women, who one night took the time to teach me how to make handmade tortillas. My favorite dishes included breadfruit and plantains, not to mention fresh passion fruit juice.

           

                     (Bread fruit is round green fruit just above the bunch of bananas)

(fried plantain and fried breadfruit)

(Left-My ugly handmade tortilla, Right- plantain canoe)

Another highlight was working with the medical students who hailed from various medical schools within the United States and working with local Honduran physicians. Our three medical students were quite experienced in global health having spent time in the Peace Corps or doing global health projects in Asia or Africa. They were enthusiastic bright and very hardworking. I learned from them and I hope they were able to learn from me as well.  The partnering of our team with local physicians Dra. Floripe,  Dra. Lillian and Dr. Fabricio is what I believe to be one of the strengths of this trip. On our first day we were given a presentation on the Honduran healthcare system which set the tone for how we would practice while we were there. It was also much easier to coordinate follow up care when working with local physicians.

 (Global Health Sub- I's, Tyler Trang, Bethany Jackson, Alyson Davidson)

Last, but certainly not least the reason for it all and the source of my passion for global health, the patients. The patients I worked with throughout the week were some of the most kind and grateful people I have ever met. Though the chief complaints were quite similar to my patient population in the United States, headache, stomach pain, asthma etc the defining difference was the lack of resources to manage some of these issues. For instance, in the village of Pal Michael Carmen, many residents mainly women and children suffer from chronic respiratory illness such as asthma and COPD due in part to the use of wood burning stoves in the home. Over the past 7+ years ENLACE has been working to replace these stoves with eco stoves designed by ENLACE lead Israel Gonzales. However many of the homes in Pal Michal Carmen are still in need of these new stoves. I congratulate ENLACE on all their efforts in this regard and their approach to addressing healthcare upstream. Downstream however there is still work to be done as the patients cannot afford inhalers and there is no nebulizer in town. Thus many are treated orally and are not under good control.

In spite of these challenges the patients were optimistic and hopeful as well as grateful and I was happy and humbled to have served them.

Francine Frater, MD

Mazapán

Just a few weeks ago I had the privilege of travelling with a team of medical students and physicians to a rural village in Honduras known as Taulabe.  The Kaiser Napa Solano Family Medicine Residency Program has partnered with long standing local NGO – ENLACE to help provide much needed care for villagers in this area. We concentrated our work in the villages of El Diviso and Pal Michal Carmen .

I was immediately taken by the warm welcome we received by our hosts. We were immediately fed after being picked up from the airport. I found the Honduran food quite enticing and this was certainly one of the many highlights of this trip.  Our meals were prepared fresh daily by two kind and amazing women, who one night took the time to teach me how to make handmade tortillas. My favorite dishes included breadfruit and plantains, not to mention fresh passion fruit juice.

           

                     (Bread fruit is round green fruit just above the bunch of bananas)

(fried plantain and fried breadfruit)

(Left-My ugly handmade tortilla, Right- plantain canoe)

Another highlight was working with the medical students who hailed from various medical schools within the United States and working with local Honduran physicians. Our three medical students were quite experienced in global health having spent time in the Peace Corps or doing global health projects in Asia or Africa. They were enthusiastic bright and very hardworking. I learned from them and I hope they were able to learn from me as well.  The partnering of our team with local physicians Dra. Floripe,  Dra. Lillian and Dr. Fabricio is what I believe to be one of the strengths of this trip. On our first day we were given a presentation on the Honduran healthcare system which set the tone for how we would practice while we were there. It was also much easier to coordinate follow up care when working with local physicians.

 (Global Health Sub- I's, Tyler Trang, Bethany Jackson, Alyson Davidson)

Last, but certainly not least the reason for it all and the source of my passion for global health, the patients. The patients I worked with throughout the week were some of the most kind and grateful people I have ever met. Though the chief complaints were quite similar to my patient population in the United States, headache, stomach pain, asthma etc the defining difference was the lack of resources to manage some of these issues. For instance, in the village of Pal Michael Carmen, many residents mainly women and children suffer from chronic respiratory illness such as asthma and COPD due in part to the use of wood burning stoves in the home. Over the past 7+ years ENLACE has been working to replace these stoves with eco stoves designed by ENLACE lead Israel Gonzales. However many of the homes in Pal Michal Carmen are still in need of these new stoves. I congratulate ENLACE on all their efforts in this regard and their approach to addressing healthcare upstream. Downstream however there is still work to be done as the patients cannot afford inhalers and there is no nebulizer in town. Thus many are treated orally and are not under good control.

In spite of these challenges the patients were optimistic and hopeful as well as grateful and I was happy and humbled to have served them.

Francine Frater, MD

Cambios Incrementados

Though a week has passed since our return to California, I've found myself with precious little time for reflection on the innumerable experiences we shared in Honduras. Within three days of our return, I was again jumping on an early morning flight en route to Kansas City to join our Kaiser Napa-Solano team at the AAFP National Conference. Chatting with prospective applicants, whose passion for righting the wrongs of health disparity was so often worn right on their sleeves (or occasionally just below their name badges), perhaps I shouldn't have been surprised to find our conversations looping back around to Honduras so often. As such, these discussions became an unexpected, and welcome, venue for reflection.

Into each short clinic encounter, every family and patient brought with them untold experiences, tales and stories of their own - informing their lives, medical conditions and the prism through which they understood their own health. That I was able to share in just a day of so many of their lives is a privilege I will always hold in a special place. And yet among all of these encounters, my mind - and with it my conversations in Kansas City - continues/d to return to one particular instance that in many ways exemplifies the incredible difference our partnership with ENLACE can make in the lives and communities we seek to reach.

Tuesday in El Diviso, my second patient of the morning strode to the table from the church pew on which he had been waiting. My translator and I both greeted him before we all settled into our seats at the fly-covered table, our hands absently swatting them away. I reviewed his vitals; wnl, confirmed his name; Biblical, and his age; appearing quite a bit younger than his stated 23 years, something I can certainly relate to. It took only a few pointed questions to discern what had been troubling the young patient. He went on to describe "un dolor del estomago que duro much anos... tambien me duelen los testiculos - pero solo en el lado izquierdo." To paraphrase, he had been suffering for ~5 years with intermittent LLQ abdominal pain, with radiation to the testicles/scrotum worsened/exacerbated by lifting, bending, or any significantly tasking physical activity. On further conversation, he mentioned he had been unable to find work due to his limiting symptoms. Finally, with a resounding affirmative response when asked if he had recognizes any mass or protrusion in the groin or testicles, I let him know my initial assessment straight away. "Sospecho que tenga una hernia / I suspect you have a hernia." Undaunted, he responded with a vigorous nod - "Creo que si."

After running the story by our ever-ready-wonder-Doc, Javier, we escorted the patient to the lower level of our makeshift Church turned clinic for a private exam. It took only a moment to confirm the suspicion; a large, left-sided sliding inguinal hernia. Thankfully no evidence current or historical of incarceration, but it was clear that he needed surgical correction. However, within the Honduran health care system, he would no doubt encounter significant - if not precluding - barriers. If he were able to come up with the money (a big IF within such a socioeconomically depressed community), Javier explained it would likely be months to a year before the surgery would likely take place. Having already lost 5 years of labor and income with his first child on its way, and in distinct danger of an emergent incarceration, we all agreed months to a year was too long to risk.

As such, Javier sprang into action. Recalling that our indefatigable team member Gaby (a highly skilled and generous Honduran Dentist currently practicing pro-bono in the surrounding communities) currently happened to be hosting an American, Pediatric Surgeon friend and colleague, Javier wasted no time in tapping Gaby on the shoulder between her many extractions that day. The Pediatric Surgeon would be performing surgery all week at the local hospital, a ways down the main highway once descended from the hilltop village (a many hours long walk, all told). Within 15-20 minutes, Gaby had spoken with her friend, who agreed to the surgery despite our young patients decidedly non-Pediatric age range (his youthful appearance once again serving him well :). A few additional minutes later and the patient was climbing into the passenger seat of another of our team members truck, and they were away down the winding road to the hospital for consultation.

Less than 24 hours later, the hernia repair was completed at no cost to the patient (thanks to the benevolence of the Surgeon and some added donations from our amazing team). What could have been months of continued pain, risk of emergent and potentially life threatening injury, and continued lost wages for a young, newly forming family had been averted. Had our ENLACE and Kaiser team not been present to see this young patient, it is impossible to predict how differently this story could have developed.

Although I was only a small cog in the wheel that brought positive change to the lives of this patient, his family and their community, I am proud to have been provided the opportunity to do so. Most lasting change is made in small, incremental steps. That day, however, what was a small step for our team engendered a life changing difference.

We continued to receive updates on his recovery over the course of the week; all positive.


Taking the time now to reflect on our short time in Honduras, I am struck by how many similar stories and instances must have occurred of which I remain unaware. In some ways, our experience is not unique - indeed, I would prefer it not to be - and rather live in the knowledge that small steps and incremental changes being made throughout the world by like minded people and teams such as our own can make such significant, and continual, positive differences in the lives of those who need it most.

Until next time Honduras! ... in the meantime, here are some more photos to keep the memories fresh.


~ Geoff Winder, MD ~
Family Medicine PGY-3
Kaiser Napa-Solano

Un toque de Honduras

While climbing the road to El Divíso yesterday morning, our little silver bullet of a rented van sputtered its wheels against the rocky ruts worn deep into the ruddy soil. 15 eager volunteers from across Honduras and the States (and one from Switzerland) had packed in shoulder to sweaty DEET-soaked shoulder. Violeta dug her fingers into Eric's arm as the momentum around a now familiar curve weighed heavily across our back (the fifth) row. Moments later Lago Yojoa made its brief appearance below, framed amid sloping hillsides and, at the northern horizon, the hazy peaks of one of two transcontinental mountain ranges.

At some point along this daily trek, I've no doubt that each of us contemplated in some manner the beauty of the countryside around us... I suppose Violeta may have spent more time contemplating her mortality, but clearly there's value in that too ;).

Un toque more than five days in, we've collected more memories, moments and marvels than one could possibly hope to record with pen, paper or blogspot. And at least in my case, I'm learning to deal with a certain amount of (happy) fatigue after long

mornings seeing patients in our pop-up clinic within the El Divíso iglesia and full afternoons throwing our hands, minds and sometimes dance moves (in Tessa's case) into an incredible array of projects already transforming the under resourced village.

Amid the nonstop clamor - and this will be no surprise to those who know them - I continue to be amazed at my co-residents innate adaptability and the intuitive ease with which they connect to patients and their families across cultures, across linguistic barriers, and across fly-strewn tables covered with handwritten visit summaries of a family of seven. A sample smattering of memories might include Elise wetting and packing soil into a newly installed high(er) efficiency stove, Violeta riling up a class of elementary school ninos in with a lesson about preventing los piojos (lice...), or, of course, any hundreds to thousands examples of Tessa's limitless energy and enthusiasm acting as both the pilot light and DuraFlame (secondary shoutout to a Joelle obsession) when the last licks of energy begin to flicker in the late afternoon lull.

I count myself fortunate to be surrounded by a unique, varied but singularly dedicated crew of providers - and not simply in the medical sense, though they are most certainly that too.

With that, and with fatigue creeping (and a nice helping of my trademarked run-on-sentences), I'll just go ahead and leave you with a certain other classic toque of Honduras - shamelessly adorable nino portraits. Hasta el proximo.

~ Geoff ~

Un toque de Honduras

While climbing the road to El Divíso yesterday morning, our little silver bullet of a rented van sputtered its wheels against the rocky ruts worn deep into the ruddy soil. 15 eager volunteers from across Honduras and the States (and one from Switzerland) had packed in shoulder to sweaty DEET-soaked shoulder. Violeta dug her fingers into Eric's arm as the momentum around a now familiar curve weighed heavily across our back (the fifth) row. Moments later Lago Yojoa made its brief appearance below, framed amid sloping hillsides and, at the northern horizon, the hazy peaks of one of two transcontinental mountain ranges.

At some point along this daily trek, I've no doubt that each of us contemplated in some manner the beauty of the countryside around us... I suppose Violeta may have spent more time contemplating her mortality, but clearly there's value in that too ;).

Un toque more than five days in, we've collected more memories, moments and marvels than one could possibly hope to record with pen, paper or blogspot. And at least in my case, I'm learning to deal with a certain amount of (happy) fatigue after long

mornings seeing patients in our pop-up clinic within the El Divíso iglesia and full afternoons throwing our hands, minds and sometimes dance moves (in Tessa's case) into an incredible array of projects already transforming the under resourced village.

Amid the nonstop clamor - and this will be no surprise to those who know them - I continue to be amazed at my co-residents innate adaptability and the intuitive ease with which they connect to patients and their families across cultures, across linguistic barriers, and across fly-strewn tables covered with handwritten visit summaries of a family of seven. A sample smattering of memories might include Elise wetting and packing soil into a newly installed high(er) efficiency stove, Violeta riling up a class of elementary school ninos in with a lesson about preventing los piojos (lice...), or, of course, any hundreds to thousands examples of Tessa's limitless energy and enthusiasm acting as both the pilot light and DuraFlame (secondary shoutout to a Joelle obsession) when the last licks of energy begin to flicker in the late afternoon lull.

I count myself fortunate to be surrounded by a unique, varied but singularly dedicated crew of providers - and not simply in the medical sense, though they are most certainly that too.

With that, and with fatigue creeping (and a nice helping of my trademarked run-on-sentences), I'll just go ahead and leave you with a certain other classic toque of Honduras - shamelessly adorable nino portraits. Hasta el proximo.

~ Geoff ~

Infrastructure - lessons from the field

Infrastructure—lessons from the field.

Recently I traveled to Central America with the Honduras ENLACE Foundation whose mission is to support existing health services through inter-professional and community collaboration to improve the quality of life for underserved populations in Honduras, especially those at risk, such as children under five and the elderly. Two medical teams joined together, one from Indianapolis, Indiana (home of ENLACE), and one from Kaiser Permanente-Vallejo, California.

As a charter ENLACE board member, I knew the projects they have been involved in for years, and as a Professor of Spanish, I have taught numerous medical interpreting classes and trained healthcare personnel how to use medical interpreters. I was asked to accompany these teams—which grew to be “the team”--to serve as an interpreter for the doctors who set up mobile clinics in the mountainous villages around Taulabé, Honduras, with our home base at the Clínica Las Lajas, one of the successes built and run through the Honduras ENLACE Foundation. My second task was to teach a foreign language methods class for teachers who would become the core educators for Spanish as a Second Language for medical personnel who served the clinic through the establishment of an on-site language school.

I knew my trip was going to be logistically complex, but I looked forward to the experience. I could never have imagined the robust and diverse scenarios that awaited me, as well as the sense of accomplishment and friendship that resulted. I already had extensive travel through Latin America and Spain, numerous trips as a study abroad director and professor, and experience interpreting in hospitals and clinics in Spain and Mexico. Honduras reinforced my fundamental belief that as humans, we want to both give and receive.

On the giving end, I witnessed a sense of dedication from doctors, dentists and nurses who worked twelve-hour days to meet the medical needs of rural communities who had limited access to basic health care. Beneath their observable passion to assure they met the main clinical requests presented, I realized the solid infrastructure healthcare providers work under proved by these particular individuals as stellar providers. Many factors were unknown:  How many patients would there be, what medications would be the most needed, what would be the main issues regarding communication and medical attention, how accessible were the facilities, how would recommended follow up visits to a clinic or a doctor take place? The list could go on, but there was nothing stopping their goal of making an impact on the communities they were there to help. Everybody on “the team” and everything that was planned through daily briefings and debriefings highlighted the fact that everyone felt a sense of accomplishment, a true bonding, and a heart.

The second component of the giving were the teachers who learned methodology and spent hours preparing for classes for dedicated doctors who not only spent an entire day seeing patients, but then spent extra time learning Spanish to be able to communicate at some level on a personal basis with their patients. It’s hard to brainstorm as one individual preparing a methods class for teachers who are going to be thrown into a class with students at different levels of language proficiency, not to mention trying to prepare them in such a limited time frame. All rose to the task, both teachers and students, and observing these classes was music to this professor’s ears.

From the receiving side, several items could be mentioned, but two stand out: the doctors and me. Did the doctors feel they had received professional recompense and success for their hard work? Unquestionably. Did the doctors learn what they could teach others who went on similar medical brigades?  Undeniably. Would they do this again or recommend others to experience practicing medicine in a cultural and linguistic environment they didn’t know? Undoubtedly.

On my side, which may sound bizarre to some, but maybe only healthcare interpreters could possibly understand the angst I experienced as the code of ethics and standards of practice were like computer chips I couldn’t shut down at night when I turn off my laptop. These questions arose: How is the positioning going to work, will there be terminology I don’t understand and a small medical dictionary won’t have the word or a there will be no signal to access the dictionary app on my cell, will I be able to interpret non-stop for an extended period of time without suffering from interpreter fatigue? Again, the questions could be endless. The bottom line, as a trained professional interpreter, we cannot have all the resources we might need at our fingertips all the time, but we have an infrastructure also, parallel to the infrastructure healthcare providers use to move them forward and to practice medicine in the best way they know. My infrastructure pulled me through, showing that interpreting is a profession, and that “the team” not only got the job done, but the accomplishment felt wonderful.

Muchas gracias a todos, por el trabajo hecho, y por la oportunidad de haber tenido esta experiencia inolvidable.

Enrica J. Ardemagni, Ph.D.

Professor Emerita, Indiana University Purdue University Indianapolis

President, National Council on Interpreting in Health Care

June 2016

Post Medical Mission to Honduras

Let me begin by expressing my continuous gratitude to Dr. Sarah Jones for inviting me to join the KP Napa-Solano Global Health trip.  In addition, I am thankful to Drs Symkowick & O’Connell for allowing me to participate in this amazing experience.  Drs Stecker & Chen for being yourselves, which is fabulous, OF COURSE!  Indiana University team (Dr. Javier Sevilla-Martir, Dr. Daniel Gomes, & Enrica), ENLACE, Interpreters (Enrica, Carole & Ivan), Honduran residing in Texas (Dr. Juan Vasquez), our 1st Global Health Sub-Intern Medical Student, Angela Rodgers,the beautiful local Hondurans & last but certainly not least, Dr Symkowick’s wife, Leigh (an Art Teacher) & kids (Marta, Gabe & Louisa).  It was an honor working side-by-side with a multidisciplinary team, (Physicians, Medical Student, Dentists, Periodontist, Interpreters, Teacher, Kids & myself, an admin), assisting in any way possible for the short time we had in Honduras.  

In the beginning of the trip, I was hesitant in regards to how may I help during the trip since I’m not a physician, medical student, Dentist, etc.  My primary role was to take photos, (which I love doing), however, one can take so many photos in a day.  The first village was busy and Dr. Juan Vasquez, a Honduran who lives in Texas slowly asked for assistance, then the Periodontist, Dr. Gomes and the local Dentists asked for my help as well.  My hesitation was over!  I felt very useful after the first village.  

Our hosts, Israel Gonzalez, Clinic Resident Administrator & Dr. Floripe Hernandez who runs Clinica Dr. David Randall Williams were extremely hospitable, welcoming & helpful.  Israel provided in depth education to our team about the village communities every evening.  Love him!  

Chicho offered his lending hands with a smile throughout our entire stay.  And Ivan, (Israel & Dr. Floripe's son), and wife, Carole were excellent interpreters.  

The 4 outlying villages our team visited are beautifully located up on the mountains which ranged from 20 - 45 minutes from home-base, (driving 5-10 mph in a narrow uphill dirt road).  The communities were welcoming and very friendly.  

We made 4 home visits to patients who were unable to make it to our location & assisted with 3 home stove installations.  Soccer clinic with the local kids were led by the Symkowick kids & Dr. Vasquez.  Final day in Taulabe were physicals with eye exams & dental screens to two very big group of school kids in the clinic.

Our multidisciplinary team worked very well together as if we’ve known each other for several years.  For me, the trip was bonding & highly rewarding.  

I look forward to future invitation(s) with the KP Napa-Solano Global Health Program, especially Honduras!

- Jojo Delacruz Garces (Gilberto)
  Family Medicine Residency Assistant
  Kaiser Permanente Napa-Solano  

Por los ojos de los niños

When asked about this trip to Honduras, Marta, 14, shared that it had been a "really great experience".  She and her brother Gabe and sister Louisa, had never traveled out of the U.S. before now.  They were skeptical that they could help the medical team and nervous about their Spanish. Marta noted that "lots of people I know talk about helping the people of the third world, and we got the chance to actually meet people in poor villages in Honduras."

Marta, Gabe and Louisa helped organize the medicines for the physician that was dispensing them.

They helped Leigh (their Mom) draw pictures with the children of the villages.  From the smiles on their faces, both the local children and Louisa, Gabe and Marta understood each other well and really enjoyed their mornings.  Tessa started a game of "Pato, Pato, gonzo" (duck, duck, goose).  Everyone had fun with and laughter could be heard throughout the village.

Marta said she really enjoyed playing soccer each day with the children near the clinic.  She felt that everyone playing really loves the game.

Everyone, local kids, visiting kids (she and Gabe and Louisa), clinic staff and local ENLACE workers (ChIcho and Ivan), and adult team members, united in a common purpose.  Everyone laughed, joked, cheered, high-dived, and hugged.  She felt "close to all of them" in these games.

Marta, Gabe and Louisa all hope to return to help a "Brigada" team in Honduras "soon".  Overall "this has been a really great trip Mom and Dad".

- Matt