Journal notes

Over the years many of you have become extended family to me.  So I decided to share edited excerpts of letters I wrote my own family in the past months.  Since it’s hard to condense so many excerpts into a letter of reasonable length, I make no guarantees that this is fully representative of our recent lives here.  If you want to know the rest of the story, write and let me know!!

11/20/04: This was the week of interminable school  board meetings, trying to decide who would be allowed to enroll based on last year’s school performance.  With 6 grades and 2 teachers, we can ill afford unmotivated students. It is difficult refusing admission to new pupils but there is no more space for more desks.

Feb 23, 2005: Our community’s new water committee decided to clean our community`s water source, a fountain flowing out of a mountain 45 minutes from here.  They thought we`d be without water for one day.  Today, the hottest day of the season so far, was the third day without incoming liquid and the clinic was completely waterless.  We cleaned our hands with a cleaning solution, used bleach to disinfect exam rooms, traipsed through the mass of waiting patients to use the latrine when we needed those facilities, and felt hot, hot, hot.

The patient I was most worried about today was a 16 month old weighing 14 pounds who came in with vomiting and diarrhea  He had the non-focusing eyes and whimper that I have come to dread in malnourished, dehydrated children. When I started talking with the young mom about the need for hospitalization, she just started crying.  [Mom’s tears do not hydrate a dying infant!].  Then she started explaining why she couldn’t take the next out-going vehicle to the hospital.  Both this child and his twin were completely dependent on her breast milk for feedings so she could be separated from neither of them for long periods of time.  The twin, at home in a village 2 hours uphill from here, had also started vomiting that morning and she had no idea how he was by now. Besides, there was no money for hospitalization

I gathered my trusty staff around me; they are adept at uncovering social solutions that elude me.  This time they just looked at me blankly.

I talked to Marietta and she arranged to take the babe to the hospital while mom went home to gather up her husband and the remaining twin and join Marietta.  When we wanted mom to give us written permission to admit the child for her we discovered that she could neither write nor did she bring any legal documents which could verify her agreement to the arrangement.  Marietta finally wrote a permission slip and had the mother add her thumbprint while I sent along the professional referral.

When Marietta returned home after dark (by now I was fearing she was stranded without transportation from Santa Ana) she told me her story.  Upon leaving the clinic a bus loaded with people was ready to go to Santa Ana.  But now the mother didn’t want to give Marietta the patient.  Marietta kept reminding her of the urgency of immediate hospitalization, of the danger involved in exposing a dehydrated child to a 2 hour walk in the noonday sun, of the immediate need of IV fluids, and of the unavailability of transportation later in the afternoon.  The bus driver started honking at the two of them, wanting either for Marietta to get on the bus or for them to get out of the way.  The infant was ill enough that the bus passengers were talking about him in hushed tones.  Finally a passenger called to the mom out of the bus window, “Give him to her!!  You know how terribly sick he is and he has to get to the hospital right now!!”  That persuaded the mom and she handed the child to Marietta and took off running up that steep road to get the rest of the family and head to the hospital.

Marietta received the hospital’s entrance guard’s permission to enter with the child.  (Wish you could see that blue and white monster of a facility sprawled over several city blocks, masses of milling multitudes, squeaky cots for beds, bare basics for equipment, but sometimes an amazingly efficient and helpful place.)  Amazingly,  the interns in the emergency room attended the child immediately without paying much attention to the mother’s absence (or the lack of a referral note, which Marietta had forgotten in the shuffle).    Between various exams Marietta tried to wash the child’s face and hands; it had been a while since that had been done. The hospital personnel requested that his dirt-caked clothes be removed so Marietta was carrying him around with just a sheet from our clinic.   Yes, he still had profuse watery diarrhea.  Yes, he was without a diaper.  Yes, Marietta and another person waiting in the ER had to wash out Marietta’s skirt.  (When she came home that night she thought she might not bathe in bleach after all but the idea was tempting).  But within several hours he was admitted to the pediatrics ward, and IV’s started.  The parents came in with the other sick son and were actually able to find Marietta and assume the care of their child.

—————————————————————NEW LETTER

Fall, 2006

Whoa! I think I’m back in El Salvador!  (Which brings me to an apology.  In my computer is a draft of a letter labeled ‘Spring 2006’.  That letter was to tell you about recent events and my summer travel plans.  Spring 2006, however, brought some of the most chaotic months of our lives and the letter never left the computer.  Though I tried to contact many of you while I was in the US, I missed some of my friends.  You are certainly in my heart even if I couldn’t see you personally!)

This first week back in El Salvador calls to mind the gamut of international adjustments: funny, red-faced, or purely delightful.  Don’t you think one is adjusting to different cultures and climates when:

–One hand scratches a left-over Kansas chigger bite while the other hand reaches to relieve the new itch of a Salvadoran sand-flea?

–One can’t figure out what to do

with the shopping cart in the check-out line?  (In the US I felt so silly to be  pushing back through the line of bewildered shoppers to retrieve the cart which I [by habit] had left in the store while in El Salvador I blush to see eyes glaring at this would-be thief when I start taking the cart to the parking lot).

–One is speaking ‘normally’ to a North American friend and suddenly senses that things are out of sync; that this friend is backing up instead of reciprocating the multiple light touches on the arm during a conversation?  Ah, yes, North Americans seem to need so much personal space in conversation and Salvadorans seem to feel so much more comfortable when there is physical closeness.  (Eeeks!  They probably think I’m weird where ever I go!)

–Within 36 hours one goes from a cattle-starving Kansas drought to a sudden tropical deluge which so floods the road that we trespass a neighbor’s property in order to walk to church?

–The moment one hits the community a neighbor says, “Go right now, bring a plate and tea towel and a kettle; I’m going to send tortillas and soup home for you and your guests.”?  And when within 7 hours one is fed 3 meals of love and welcome (and eats 3 different forms of corn in these 3 meals!)?

Speaking of wondering about things: How is it that I can eat ribs (if I could afford it!) at Tony Roma’s in San Salvador but can’t get a chest x-ray on a child with a possible lung abscess?  Resources are such a puzzle here.

Resources: El Salvador has reaped Western lifestyles from its connection with the North, especially with the US.  People who earlier only heard of tap water now live in homes with tiled floors and painted walls and enjoy electrical conveniences.  In San Salvador one can eat at KFC or Wendy’s and can buy microwave ovens.  People in our small village now own cameras and talk to their relatives in Los Angeles by cell phone.

Resourcefulness: If Salvadorans are anything, (besides exquisitely friendly and warm and hard-working), they are resourceful.  Our friend builds us fences out of freshly harvested bamboo and plain wire.  Farmers, owning no horse or vehicle, cheerfully bury themselves in the grass-stack on their back when hauling feed for their cows.  Pleasant outdoor chairs are made of bent iron and thin plastic rope; barbed-wire fences double as clotheslines.  Gardens spring up with no investment except for the neighborliness that shares plant slips.  Road washouts go from impassable to passable within 30 minutes as a dozen men pile branches, boards, and leaves over the hole.

Resourceless-ness: Usually, I love living in El Salvador.  Moments of irritation occurs, of course, when the village’s only incoming water line has again been broken by a cow.  Or when the neighbor’s free-roaming chicken chooses to nest—and lay her eggs!– in a potted ivy.

But there are times when I am downright grieved, particularly at the medical system.  Recently a rash of incidents left me pulling hair.  Diego can’t speak for himself so the rest of us feel a greater need to do so.  He is 9-years-old and weighs 30-pounds due to his cerebral palsy.  He has spent much of his life in a supine position; there are weeks when he cries day and night.  His neurologist, rather than investigating possible sources of illness or pain, merely increases his daily dose of carbamazepine.  He is receiving this potentially-dangerous seizure medication only for its sedative effects and is already taking more than an adult-size dose of the drug.

But the neurologist is not the only one in the hospital system who disregards this child.  Recently his mother asked me to evaluate him after several weeks of unabated crying and fever.  His right chest once again had crackles so I sent him to the public hospital for a chest x-ray and probable admission.  It was only after several trips to the emergency room that he was finally admitted, despite my referral note.  I asked his dad about the x-ray results.  “Oh,” said dad, “the government keeps telling us that their hospitals are fully stocked.  While it is true that the hospital owns an x-ray machine, they have no film”.  Diego left the hospital after a week-long stay for presumed pneumonia and possible lung abscess without a single chest x-ray, even though the family would have paid to go to a private facility to obtain one.

The family of another patient called me one evening to evaluate their feeble grandmother.  As they lifted her from the creaky pickup I was unhappily certain she had sustained a hip fracture.  They decided to take her to a private hospital so she could obtain an x-ray promptly and receive appropriate care.  While awaiting surgery she developed complications and went into cardiac arrest.  When the hospital personnel wanted to intubate her, the ventilator didn’t function. (Isn’t  such equipment meant to be immediately available in emergencies?)  So the staff started calling around to other hospitals in town.  Yes, the public hospital did have ventilators but they were all in use.  When a machine was finally located, the patient was transported—still coding—to the opposite end of town.  She didn’t survive the technical breakdowns.  The family, who wasn’t fully in agreement with the resuscitation efforts in the first place, is left with large bills from both hospitals and the ambulance ride and larger questions about the methods and motives of the code.

More recently, a friend was being followed for a twin pregnancy.  The level of  prenatal surveillance reminded me of medical care in the US in the late 60’s and worried me.  This week the mother went into preterm labor.  She was in the hospital a number of hours before she gave birth.  Soon after delivery the smaller twin developed respiratory distress.  When they tried to connect her to the ventilator they found it to be malfunctioning.  No, no one had checked the equipment in the hours when the mother was in labor, despite this being the best hospital in this area of the country.  Although the child was born early morning, it was late that afternoon before they could borrow a unit from another hospital.  Thankfully she survived the lack of preparation; not all do.

One last story.   Five years ago a dear friend with deep wrinkles and bare feet came complaining of  red and burning eyes.  I noted a basal cell cancer at the corner of her eye and gave a referral for removal.  The family delayed for a while but eventually saw the public hospital’s only ophthalmologist (he serves the city of 60,000 and the entire surrounding area).  For months the physician merely prescribed a cream for the lesion but eventually admitted that the patient had skin cancer.  But, said he, there was no way he could operate on her because his schedule was too full.  When she finally was seen at the country’s largest public hospital several months ago she was told that the cancer has now penetrated so deeply that her only hope of cure is removal of the entire eye.


OK, many of these stories were written 5 months ago.  Since then I have taken Family Practice Recertification Exams and visited family in Virginia and Pennsylvania.  I have joined most of my family in a caravan of failing vehicles, tired toddlers, and hot (but delightful!) adults while helping a brother and family move from New York City to Kansas.  I have visited family and friends, eaten like crazy, enjoyed the Kansas skies and rural roads, retreated in the Ozarks, collected meds and supplies for the clinic, and have now  returned to El Salvador.

In the meantime, while we were gone:  dear trusty Marta placed pans to keep the leaky roof from ruining the ceiling and killed rats which were chewing into medicines. (She stands only 4’11” tall but managed to chase one rodent into the clinic’s tiny bathroom and killed it with her shoe.) Moises slept up by the clinic to frighten vandals.  Anabel fought off leaf-eating ants and persuaded a neighbor not to chop down one of our trees just because she saw a snake in it.  (Thank God for my staff!!)  The road crew continued preparing ourinfamous road for pavement while the phone company procrastinated on repairs to the community’s only land line (hence, once again we have had no communication with the outside world).

Within our first 2 days back in the community we have joined our staff in unpacking and shelving mountains of medicine, removed a 2-inch long twig from the back of a 7-year-old’s nostril (an unhappy result of tripping and falling on his face; the rest of the branch broke off with the impact) and sewed up a machete cut.  Ah, yes, those machete cuts.  This cut had occurred 11 hours earlier but was still dripping blood; though a tourniquet had been tied at the wrist, the bone-deep cut of the palm was unprotected and a small artery intermittently spurted blood. However, this time I didn’t have to dig hair, dirt, or dried lime from the wound (all of which are frequently used to control bleeding), so who am I to complain?

Smiles: Chickens are the main meat source here.  Chicks are brought back from Santa Ana in ventilated boxes which are squeezed between passengers’ feet and spend the first weeks of their lives eating a flaky tan-colored feed called “concentrate”.  Recently a mother of a 3-year-old came into the clinic with complaints of constipation.  After determining that the cause was probably lack of dietary fiber, I handed her a small plastic bag that contained a sample of Metamucil.   “Mommy!” squealed the youngster excitedly, “here they give you chicken feed for medicine!”

Thanks so much for sharing in our work and world (even to the extent of reading through these letters!).  You have enriched our lives in so many different ways.

Jana Nisly