(The following was submitted by RMU senior nursing student Lee Folk, who recently returned from Nicaragua, where a group of nursing students travel twice yearly to provide basic health care to residents in the barrio around the capital of Managua. The trip is led by Carl Ross, university professor of nursing at RMU.)
The ferry eventually reaches the dock, and it continues to bob on the waves of Lake Managua as we make our way down the plank. Having spent the past forty-five minutes on the top deck of the boat, leaning into the fierce wind, I am glad to be back on solid ground. We climb the vibrantly painted steps of the pier toward the parking lot where our driver is guarding the van. It’s late afternoon on our first full day in Managua. The murky brown waters of the lake are now disguised by the growing radiance of the sinking sun. I snap one last picture of the rolling waves behind me and climb into the van.
The driver takes us directly across the empty parade grounds of Managua. While these grounds now lie silent, they have been witness to many magnificent celebrations in recent decades. Dr. Ross directs the driver across the square and points him toward the Old Cathedral and La Casa de Los Pueblos. The Old Cathedral was the grandest church in all of Nicaragua until earthquake and revolution stripped it of its glory and left it to the winds to decay. Now it stands as a bullet-strewn skeleton of concrete and glass. The construction is still magnificent, with lofty arches and two great bell towers stretching toward the sky. A clock on the right tower remains frozen at 12:35, never to move again.
On opposing sides of the square lie the executive residences of the Nicaraguan president. There is the traditional Casa de Blanco, whose name is taken directly from America’s own White House. Upon his ascension to power, President Daniel Ortega decided to construct his own mansion, despite widespread public outcry. He called it La Casa de la Pueblos, or “House of the People.” The high gates that surround the perimeter seem to contradict that title.
The children are everywhere. From the moment we step foot in the square, kids are all around us, trying to sell us little crafts made out of fern leaves of some kind. I watch a young boy working fiercely to finish the construction of one such leaf. He fashions the leaf into an incredibly accurate replica of a grasshopper. I know the consequences of such an action, but I take out a dollar anyway in exchange for the boy’s unique work of art. He smiles and takes it from me quickly. Sure enough, three or four more children instantly appear on either side of me. “Sólo uno más?” they plead with me. Just one more?
I remember Dr. Ross’ advice. Sometimes you just have to say no. But there is one little girl who is extremely persistent in getting my attention. She never stops working with her leaves as she follows me across the square. I decide that my first grasshopper will get lonely without a friend. I ask her to make me another. She immediately goes to work crafting another grasshopper. She tells me her name is Ruthia. I pull out a dollar bill and hit ‘record’ on my camera to capture her amazingly honed talent. The competition for tourist’s spare change is fierce in this city square. Several boys stand off to the side and try to divert my attention from the industrious girl. I notice that Dr. Ross is standing behind me, watching closely. “Those boys will beat her up for the money she makes as soon as we are gone,” he tells me under his breath. I look up at him in disbelief.
“She won’t be able to hold onto this money?” I ask him.
“Not likely. And what’s worse, if she doesn’t return home with a certain amount of money, she will be beaten again by her parents.”
The tone of the unfolding scene has now shifted from merely curious to absolutely heart-wrenching. Ruthia’s hands continue to fly over the leaf, and the shape of a grasshopper emerges. She holds it out to me with pride, and smiles. I hand her the dollar, the dollar that will be taken from her as soon as I walk off the square. And she hands me grasshopper, the grasshopper that is now sitting beside me on the nightstand. To her, I was just another American tourist with a dollar. To me, she was the girl I’ll never forget.
It’s been quite a long time since I’ve enjoyed a peanut butter and jelly sandwich. I guess I had forgotten how good these sandwiches were. I’m eating one with my classmates out on the veranda of the UPOLI health clinic. Today is Tuesday, our second day in the barrio of Managua, Nicaragua. The sun is high above us, and I am filthy, sweaty, and tired. The dirt from this morning’s soccer match on the road is clinging to every inch of me. For all of the laughter that I had with the children during the game, my dirty clothes are a small price to pay. Right now, we have a brief respite to rehydrate and gear up for the afternoon at the clinic. The day is only half over. There is still much work to do.
Our mornings here unfold out in the barrio, with each of us spending time with the family that has been assigned to us. We work in teams, assessing patient’s health conditions and evaluating their living conditions. Our goal here is simple: to give these people the most help that we can in the time that we have. Their health issues are basic: conditions like arthritis, gastritis, urinary tract infections, asthma, malnutrition and dehydration. Though most of these ailments are relatively simple to treat, they cause far more damage than they should in the barrio due to a complete lack of simple education and basic care. By developing a personal connection to a single family, we are able to ascertain the most effective route to an improved quality of life for them. That is why we are here.
Yesterday morning, Ashley and I were introduced to the family we were assigned to on Friday. Our family consists of two grandparents, along with their granddaughter, a nineteen-year-old and her little toddler, a three-year old girl named Nicole. The place they call home is nothing more than a makeshift hut. The walls are made of scrap metal and wood planks; the floors are mud. The grandparents live in one room, while Nicole and her mother live on the other side of the wall in the same structure. There is an open area outside of their dwelling where they spend most of the day sitting under a filthy tarp, their only protection from the unrelenting sun. A clothesline made of barbed wire runs the length of the common area, and in the middle of the small yard sits an inflatable children’s pool. The pool water is a wretched shade of green, lying stagnant unless little Nicole stirs it up for fun. A washtub stands next to two giant metal barrels of water. The containers are rusty and the water inside remains exposed to the passing mosquito. The scent of rotting garbage hangs heavy in the air, stymied only by the pungent stench of human refuse that leaks out from the holes in the cardboard door of the outhouse. It is unbearably hot. Flies land constantly on anything and anyone in their search for a still surface to rest their weary wings. With no white picket fence in sight, it is indeed a far cry from my idea of a home. And yet, as difficult as this may be to understand, this family is quite proud of the place where they live. As I began to spend time with them yesterday and again this morning, I have discovered that they have just as much to be happy about as I do. Why else would they smile so brightly and laugh so often?
Now lunchtime is coming to an end. I finish jotting down some notes about this morning, and stand up to stretch my tired legs. There is a renewed sense of energy among us after we finish eating. Nurses, by nature, are happier on full stomachs. Andrea is hard at work near the entrance to the clinic, unpacking and organizing the pharmacy that she will be running out of a large suitcase. I can tell she is tired, but a little fatigue is not going to stop her from dispensing the medications that these people desperately need. The rest of the students are rallying as well, soaking their bandanas in cold water in an attempt to beat the heat. I feel a sudden wave of cool air hit me as Dr. Ross opens the door of the air-conditioned Pepto Room. I have dubbed this small examination room the Pepto Room because of the Pepto-Bismol shade of pink that covers the walls. The room is not much larger than a walk-in closet, outfitted with a primitive examination table, a small desk, a sink, and two stools. This is where Dr. Ross will be seeing his patients throughout the afternoon.
Before we open the gate to the villagers, Dr. Ross and Andrea want to take a walk down the path to visit a family that Andrea had taken care of the previous year. They ask me and Anne if we’d like to join them. The family lives nearby in one of the comparatively spacious dwellings of the barrio. They are excited to see us coming. Anne and I are introduced by Dr. Ross at the entrance, and we are welcomed inside. Chickens dance out of our way as we move deeper into the dank alleyway. It is a joyful moment for Andrea, and a relief for her to see the family’s children alive and well and standing taller on a year’s worth of growth. The people of the barrio may not have much, but they do have each other. It’s an encouraging sight.
Ten minutes later, we say our goodbyes and head back down the path. As we near the clinic, it is clear that something has happened while we were away. Leigh, our graduate student with ER experience, comes running to meet us. “Dr. Ross! We need you in the clinic right now!” In a flash, we are all racing up the street to the clinic. Leigh fills us in as we go. A man had been dropped off just a few minutes earlier. His wife was with him, and she explained through our translator that her husband had advanced cancer and he was having seizures. Leigh got the man into a wheelchair and wheeled him straight into the Pepto Room. He was febrile, dehydrated, and only semi-conscious moments ago. His blood pressure is dangerously low.
As we crowd into the room, the man seems to have come around a bit. Dr. Ross immediately assesses the situation, retakes the vitals, and then turns to the man’s wife. “Can you tell us about your husband’s cancer?” he asks. The woman explains through the translator that her husband has penile cancer, and he was operated on several months ago. She produces a photo of her husband lying in a hospital bed. His sheet is pulled back, exposing a massive lesion in the left inguinal area. The penis had to be removed as a result of this aggressive form of cancer. Dr. Ross listens carefully to the woman and then turns toward her husband. “I will need to take a look at the site of the cancer,” he tells the man. The man nods weakly. The room is tiny, but more and more people keep filing in to offer help. I do a silent head count. Eight people now stand in the tiny office: Dr. Ross, Leigh, the patient and his wife, the translator, another nurse practitioner, another nursing student, and me. It is a good thing that the air conditioner works. I am standing in the corner, simply observing, and wondering what the man’s name is.
Dr. Ross gently loosens the man’s belt and opens the pants to expose the cancer. Everyone in the room takes a breath. The penis has been cut away, leaving only a small hole through which he can urinate. And the open wound to the left looks terrible. The hole bores deep into the man’s body, making it a prime site for infectious agents to enter the bloodstream. Dr. Ross begins to carefully irrigate the site with betadine swabs, then listens to the man’s lungs. The expression on his face tells me that the prognosis is not going to be good. He looks up at me. “He’s most likely septic by now. If he develops pneumonia, his body won’t be able to fight the infection.” He turns to the translator, who relays the findings to the wife. She has shrunken back into the corner with her face in her hands. “Tell her that he needs to get to a hospital now. We can’t treat this here.”
“What is his name?” I ask softly. No one hears me over the hum of the air conditioner. The wife has received the message, and is now quietly sobbing. Marie, the other nurse practitioner, pulls her into her arms. The translator taps Dr. Ross, who has gone back to cleaning the gaping wound.
“She says that she does not have the money for a cab to get to the hospital.”
“Tell her not to worry. We will pay for the taxi.” But the woman is still crying, telling us more of her husband’s story. He has been sick for so long. The burden has fallen completely on her. She is exhausted and doesn’t know what to do. The hospital sent him home before. Why would they do anything different now? Dr. Ross nods sympathetically.
I tap Michelle, another student, on the shoulder. “Did we get his name?” I whisper. She hands me the slip of paper with his vitals written on it. His name is Eddie.
There is a pause in activity as Dr. Ross decides what to do. There is little we can do for him here other than keep him in the air conditioning. If we send him to the hospital, they will not do much more than give him IV fluids. Leigh speaks up. “Why don’t we ask him what he wants to do?” We all nod. Dr. Ross bends down on a knee with Marsala, our translator.
“Ask him if he would rather go to the hospital or back to his home.” Marsala knows that either decision is a likely death sentence for Eddie. And she has to be the one to say it to him in Spanish. She is fighting back tears as she asks him. At first, there is no response. Then Eddie mumbles something. Marsala can’t hear. Dr. Ross looks to me in the corner of the crowded room. “Turn off the air conditioner, Lee. We can’t hear him.” I push the button. The room falls silent. The temperature instantly starts to rise. Eddie speaks again, and Marsala presses her ear close to him. She looks back at Dr. Ross.
“He’d rather go home and wait until tomorrow.” Dr. Ross asks one of us to take the wife out and call for the cab. Discussion breaks out again. The medical minds in the group are afraid that is too risky to send him home septic. If we send him out now, the hospital can begin IV fluids and triple antibiotic therapy to ward off the pneumonia. There is a chance that we can give him more time. But we need to act now. Every minute counts.
The temperature in the room is now nearly unbearable. Too many people in too small of a space. Marsala interrupts the discussion. “Dr. Ross, can I tell you what I really think he is saying? I think he really believes that if he waits until the morning, then things might be better. I really think he would rather go home.” Dr. Ross is looking at Eddie. Then he turns away to face the wall. His shoulders are shaking. He is crying. I watch him take a deep breath and turn back around. He looks at me with tears in his eyes.
“They know what will happen at the hospital. They know that the hospital won’t do anything.” At that moment, the door opens. It is the wife, and she has brought along their daughter. She is nineteen years old, and nine months pregnant. Eddie’s grandchild is due to arrive in less than two weeks. She is here to convince her dad to go to the hospital.
“Please, Dad. Come to the hospital. They can help you,” she tells him. The door opens again. The cab is waiting out front. Someone needs to decide. It is Eddie who finally relents. He will go to the hospital. Dr. Ross begins dispensing orders to the crew. The room empties quickly. As Eddie is wheeled out, he takes my hand and says something to me softly in Spanish. I look to the translator. “He said, ‘God bless you.’” Then he is gone.
The Pepto Room is empty now. I am sitting alone on the exam table. The only sound is the steady hum of the air conditioner. And now it is my turn to cry.
In this moment, the reality of death is so disturbingly clear. Sickness is a part of life for these people. Suffering is their daily burden. They know there is no help for things like this. They know that death can take them at any moment, from something as simple as an infected papercut. This is the harsh life of the barrio. This is the plight of the Managuan.
A few minutes pass by. I sit alone with my thoughts and my notebook. The door opens. It is Dr. Ross. We don’t speak to each other for a moment. We can only cry. He carries a burden for these people, and it breaks his heart to face a problem that he can’t solve. “How can he say ‘God bless you’ to me? How do they do that?” he whispers. I put my arm on his shoulder.
“You did everything you could Dr. Ross.” He nods. This was just our first patient of the day. The waiting room is now jammed with patients to be seen. Dr. Ross tries to fill his water bottle with trembling hands. I reach in to help steady it. He takes a long drink, and catches his breath. This is what we do as nurses. Care first, cry later, then take a deep breath and keep moving forward. We have to move forward. These people need us.
Dr. Ross puts his hand on the doorknob of the Pepto Room. He takes one last deep breath, looks at me, and nods. He opens the door. “Estoy listo!” he calls out to the sick. I am ready.