NicaDayz - Rescate 911!

Date: Wed, 5 May 1999 19:44:13 -0300
From: jberman@xxx.xxx.xxxxxxxxxxxxxxxx)
Subject: Rescate 911!
>From: Emseditor@aol.com >Date: Tue, 30 Mar 1999 00:33:13 EST
>To: jberman@ibw.com.ni >Subject: Article >

>Dear Joshua:

>Thank you for your recent e-mail. I would be very interested in receiving an article from you based upon your experiences in Nicaragua and the medical system in the country. Maybe you could angle the piece from the perspective of your background in EMS in California, as well as offer readers a glimpse into volunteering in developing countries. In terms of length, our articles typically run between 2000-3000 words. Color prints are always appreciated. Article will most likely be slated for publication late this year or early next year. I look forward to working with you.

Sincerely, Nancy Perry Editor, EMS Magazine

[EMS Magazine is a national trade journal for ambulance workers and paramedics]

Rescate Novaciento-Once! EMS (and lack thereof) in the Third World, by Joshua Berman

I received my firefighting and EMT training in a poor, rural community. Fort Jones, California. Elevation 2,741 ft.; Pop. 550. Although our Fire/Rescue rig was relatively modern, our engines were veritable antiques-complete with rounded corners and convertible cabs. The office wasn't much to look at either, and much of our equipment was used and worn. It was pretty easy to complain, especially knowing how much better-off departments in the big cities were. It's all relative, however, and after spending the last year in Nicaragua, I realize just how good the people of Fort Jones have it.

When I first arrived in country, I asked my Peace Corps Medical Officer about EMS in Nicaragua and how I might be able to get involved in it as a possible secondary project to my main environmental education duties. Even though my EMT-1 would expire during my two-year service here, I didn't want my skills to dry up. Her answer was simple: "There is no EMS." She went on to explain that I should seek out the local health center once I got to my site, and that depending on where I got placed, there might be an ambulance. "Don't get your hopes up, though," she told me. "Most of the time their only option for pre-hospital care is to throw the patient in a beat-up old pickup truck and go."

Her answer was prophetic. After my three months of training were up, I found myself in the northern cowboy town of La Trinidad, two hours north of Managua on the PanAmerican Highway. Elevation 714 meters; Pop. 12,546. La Trinidad actually has its own hospital, a rarity for a community so small. Most towns here have nothing more than a health center, located by the central park and church, and run by the Ministry of Health, or MINSA. El Hospital La Trinidad had seen better days, but nevertheless there it was.

Their ambulance? A beat-up old white pickup truck, with a bent IV tree sticking up over the cab. It was used primarily to transport trauma patients who were brought in to the hospital to better equipped facilities, either north to Estelí or south to Managua. I also discovered that our Health Center had an actual ambulance. It was a part of the small fleet of '98 Toyota Land Cruisers donated by UNICEF last year. These vehicles, distributed across the country, are a big step up from an open bed pickup-they have a stretcher bed, a light, a siren, and four-wheel drive-but they don't come close to the modern facilities seen in the First World. No oxygen, no suction, no highly-trained ambulance staff.

The first few months in my site were pleasant, or as they say here, tranquilo como Camilo. It was the rainy season and the hills that rise up around La Trinidad were green and fresh-an enormous contrast to the hot, dry smoke and dust of the dry season, el verano. I took plenty of time to settle in, find a house, and improve my Spanish. At the same time I was getting involved in the community, teaching in the schools and seeking out the more motivated community members with whom I'd want to work. As the rainy season, or invierno, came to a close though, things got kind of exciting.

The last week of October, 1998 was a wet one in Central America. Hurricane Mitch parked itself over the north coast of Honduras and dumped something like three feet of rain in nine straight days over much of Central America. The water accumulated quickly, soaking deforested hill slopes to their saturation points, and gorging rivers into violent torrents. Bridges that weren't outright smashed and washed away were left standing in the middle of enormous new water channels, connecting nothing to nothing. 9,000 people died that week, washed away, buried in mud, sick and cut off from all medical help.

Dr. Victor Blandón, the Director of the hospital in La Trinidad, was worried. His hospital and nursing school sat at the base of a rock-strewn, treeless hill, and the little rivulets of water running off it were getting bigger and muddier. He had some 40 patients occupying about 50% of the hospital's beds and, as always, he was dealing with extremely limited resources. Now he was faced with the problem of moving all of his patients before the hill collapsed and crashed down on his building. In the meantime, reports of landslides and destroyed bridges up and down the PanAmerican Highway meant that La Trinidad was becoming increasingly isolated.

Blandón called up a friend who owned a couple of old American yellow school buses which normally served as public transportation to and from Managua. An emergency evacuation of the hospital was performed as efficiently as possible, taking the patients, their families, and a limited supply of drugs and equipment to the town's Catholic Church. Pews were pushed together to form beds, makeshift IVs setup, and hospital staff worked around the clock to keep things under control.

The evacuation was on Wednesday. On Friday, the hill came down.

Boulders the size of Volkswagon Beetles, huge dead tree trunks, and millions of gallons of mud rushed down in a single roar. Three of the nursing school buildings were immediately crushed and buried and the main hospital building was filled with two feet of mud. It would take nine days to dig out, with hospital grounds staff and community members working continuously with nothing but shovels while the patients remained in the church. Two baby boys were born on the church pews during that time, and everyone jokingly wanted to name them both "Mitch."

"It was terrible," says Juan Gurdian, one of the hospital's three ambulance drivers who alternate working in 24-hour shifts. "Gracias a Dios, nobody died." Although he has been driving vehicles for a living for 22 years, 21 of those years was spent behind the wheel of a chicken truck until he was hired last year by the hospital.

Hurricane Mitch was an ordeal for El Hospital La Trinidad, its staff and its patients. The reality however, is that Nicaraguans are accustombed to suffering such crises with sub-standard resources. They survived for decades under a crushing, self-serving (and U.S.-backed) dictator, they endured a revolution, and then the subsequent civil war and U.S. trade embargo, and they've made it through numerous economic crashes and natural disasters. Nicaraguan history has instilled in its people an incredible ability to make due with what they have, or more often than not, what they don't have.

If a serious headwound and multiple-fracture MVA patient is brought to the doorstep of La Trinidad, staff must take action without the benefit of a trauma center, an orthopedist, or an ambulance. Headwounds need to get to Hospital Lenin Fonseca, two hours away in Managua as fast as possible. What can they do? Throw the patient in the back of the pickup with a doctor or nurse, run an IV, and hit the road. "Load and go" at it's simplest.

La Trinidad is not completely without resources. Internal medicine, a bare bones operating room, and one gynecologist. If he's not on duty though, says another of the hospital's drivers, Felix Salinas, the woman is transported 20 km north to Estelí where a hospital was just donated by the Spanish government. Also, emergency surgery can be performed on some of the trauma wounds that come in. Although mostly MVAs (La Trinidad is located on a dangerous stretch of the PanAmerican Highway), gunshot and machete wounds are fairly common. "Usually from fights in the cantina," smiles Felix. "Lately," he reports, "there has been an unusual number of suicide attempts with something the people call the 'love pill.' It's actually a kind of rat poison for protecting sacks of stored grain. They call it la pastilla de amor because it's usually used because their girlfriend left them."

Felix, 42, is a nine-year vet at the hospital. Although he never received any official training, doctors taught him how to stick an IV years ago. As we spoke in my living room on the complete opposite end of town from the hospital, about 3 km away I brought up the subject of communication.

"The truck doesn't even have a radio, does it?" I asked him. "No," he said gravely, sipping his coffee. "So what would happen if there was an emergency right now in the hospital?" "They know I'm at your house, en la casa de Josué, and they would probably send a kid over on a bike to come and get me."

If he was away on an assignment though, hospital staff would call up the town's Health Center and see if the ambulance was available to borrow. This is usually a long shot though, as it is the Center's responsibility to cover all of La Trinidad's surrounding rural communities as well as the town itself. That's a lot of ground.

Roger Garcia, the sole driver of La Trinidad's sole ambulance, never received any emergency medical training from MINSA either, but by observing doctors and nurses from his center, and by watching the EMTs and paramedics on television, he has learned how to perform CPR and stick an IV. "Mouth-to-mouth," he says, "appears much in the program Rescate Novaciento-Once [Rescue 911]. I like watching it because you see so much. I've also learned about treating burn wounds. It's very good, my favorite program to watch. Muy bonita esa programa." Rescue 911 appears on TriniCable, dubbed in Spanish. Like many Triniteños (as the people of this pueblo affectionately refer to themselves) Roger splurges for a nice entertainment system and cable, even though he may live in a house with a dirt floor.

Roger's salary for being on constant call and working as much as 15 hours a day, six or seven days a week is 1,300 córdobas, or just over U.S.$100, a month. Over at the hospital, Juan and Felix receive 1,100 córdobas each month. That's less than U.S.$100 for working three, sometimes four, 24-hour shifts a week. Felix has to feed six children on this salary. "It's very difficult," admits Roger. "Some months I can hardly pay my bills." He says this with a resigned look on his face. When asked if he likes his work, he shrugs. "Even if I didn't like it, I'd have to do it. There is no other work here, so one has to animate onseself. At least it is good to be helping the people."

I thought about Roger's statement and about what it was like trying to get a job on an ambulance in Boulder, Colorado, where I lived before coming to Nicaragua. EMTs' starting salary there was barely over the minimum wage, and still there were long waiting lists to sign up. "One has to animate oneself," I repeated to myself. "At least it is good to be helping the people." Apparently, this is a sentiment felt by EMS workers across borders.