Since we didn’t leave the clinic until after 9 and didn’t eat supper until after 10 and didn’t get back to our hotel rooms until nearly 11, we didn’t get much sleep until nearly midnight. When the alarm went off at nearly 7, Ashley and I were in no mood to actually get up. We’d both been worked to a frazzle the day before and had very little sleep in between, so we just could barely face getting up at all. I don’t know how we managed not to growl any more at one another than we did, but we arose and got showered and dressed with very little griping.
None of the rest of Team Gringo were especially bright or chipper, but I don’t think any of us dreaded the day itself. We just wished we had more energy to give to it. As for me, though, I needed not only more energy but also a better attitude. I was a right cranky man, for no real reason, and it seemed like everything was irritating me. That attitude, unfortunately followed me all the way to the clinic site.
In the pharmacy, we had a little down time before patients began showing up so we bagged more and more medicine. We could hardly keep up with the demand for vitamins the day before, so that was a primary goal for pre-bagging. For much of the day, whenever any of us had a spare moment, we bagged vitamins. Unfortunately, it was difficult for any of us to do this without taking up valuable counter space and generally getting in the way. And you could only bag meds for so long before the swell of patients with prescriptions called you away to help with the filling, leaving a mess behind from the stuff you were bagging before, clogging the counters and other spaces. I began to get growly—never a good sign.
We also bagged a bunch of other meds, trying to stick to the doc’s new favorite dispensing amount of 30 pills, instead of 20, only this time to have prescription after prescription arrive in amounts of 20!!!
“Porque? Porque? Porque?!!!!”
I also began to become further irritated with my fellow pharmacy staffers, particularly Mary Ann, who kept insisting on doing everything the correct way instead of my the semi-half-assed method I preferred. (I fully admit to being wrong here.) I can’t even recall the exact details of what I was irritated about, except to say that it was over a medicine, probably Amoxil, that we had to instruct the patients how to pre-mix, but the way I wanted to do it required them to put 2 ml less water into the powered Amoxil than the dose actually called for. I think this was because we’d run out of the syringes that were easy to mark, or maybe we’d run out of our 250 mg Amoxil and were having to recalculate doses from the 400 mg Amoxil we had plenty of. I don’t recall. What I do recall is that Mary Ann insisted, as well she should have, on getting the dose exactly right, instead of having a dose with slightly less water in it, as I was trying to do. This was probably the pinnacle of my ire for the day, but even as I was fuming inwardly and sometimes outwardly about it, I realized that Mary Ann was only trying to do the right thing for the patient, and that no matter how little the differences in out methods might actually matter, I should defer to her experience in these things, especially considering that I’M NOT A MEDICAL PROFESSIONAL and SHE IS.
After that realization, my attitude became quite a bit better. It often takes embarrassing myself with my own bad-behavior for me to recognize how badly I’m behaving and make the necessary adjustments to stop it.
One of the major patient pharmaceutical requests was insect repellant. In a country with the kind of large and aggressive bugs that this one seemed to have, it stood to reason. However, the pharmacy did not stock bug dope of any kind. In some cases, however, there were children patients who had enough bug bites on them that it seemed like some sort of repellent would be good to prescribe. This is when Ashley had the idea of concocting a 1 percent solution of Deet in water. Deet is one of the most powerful insect repellents on the planet. Unfortunately, it is also quite dangerous when it comes to killing off brain cells in children and is not recommended for use with children. Her idea was to create a very weak solution of it to use on the child’s skin to ward off bity bugs. I let her mix it, so as not to screw it up and put too much in it myself. But I didn’t feel good about it. Most of the meds we had in house wouldn’t kill a person if they took too much. And even though the Deet solution was given out in a child-proof bottle that I’d drawn a skull and crossbones on, I didn’t feel safe that the kid we’d prescribe it for wouldn’t find a way to open it and drink the stuff. Later in the day, Ash prescribed another bottle of it, which I mixed up and labeled, but then went to her and let her know that I didn’t feel good about giving such poison out. We wound up nixing it from the prescription.
We did do some far safer mixing when it came to creative prescriptions. Because we were seeing so many skin rashes, the docs had been prescribing lots of hydro-cortisone cream. So much that we ran out of it pretty early in the day. Dr. Allen suggested that we make our own cream solution by mixing 1 part Triamcinilone Cream (a far more powerful skin ointment than Hydro-cortisone) with 4 parts hand lotion. We mixed it up in tiny little baggies, labeled it as to what was in it and in what ratio and then gave it out as prescribed. I wound up mixing quite a few of these throughout the day.
Dr. Grace was back with us for most of the day on Thursday, so we kept a pretty steady patient rate.
On Thursday, Ashley had to leave for her first house-call. A woman had come to the clinic and explained that her son had suffered a severe burn to his leg and was unable to walk to the clinic for treatment. So Ashley, Butch and a translator took some supplies and some meds from the pharmacy that would be good for treating burns and headed out by vehicle with the mother to visit her home. Ash told me later that she didn’t know what to expect. For all she knew, the boy had just burned himself horribly that morning and she didn’t have the know how to do much, other than tell his parents they needed to get him to a hospital. Or if the burn had happened some time ago, she would likely have to deal with improper bandaging and infection. She prayed that God would give her insight.
They drove for a couple of miles until they were in a wooded area where they came upon a house. The boy himself was seated on the front porch of the house waiting. The boy was wearing long trousers and didn’t seem to be in any obvious pain. Ashley, through the translator, asked if she could see his burn and he lifted up one of the legs of his trousers, which had been split along the side for easy access. The leg had what looked like a fairly fresh dressing on it. The boy removed the bandages for her to let her see the burn itself. Upon seeing it, Ashley was confused, because she couldn’t figure out why the burn had a crosshatched pattern. It was also not in nearly as bad condition as she was expecting. Then she realized why it had the crosshatched pattern. The boy had received skin grafts on the burn already. This burn had been treated by physicians who had shaved skin from elsewhere on his body and applied it to the burned leg, to help grow new tissue there. The reason for the crosshatched pattern is that skin heals far better from lots of smaller wounds rather than one large wound. So before the shaved skin is applied it is first cut into a latticework-like pattern that facilitates faster healing. Not all of the skin graft had taken, so there were burn patches showing through, but Ashley said the whole thing seemed to be healing fairly well. Since she was there, Ashley applied a burn bandage infused with silver which would help in the healing process.
In the afternoon, we were brought more nifty snacks purchased at a local neighborhood store. Butch returned from the store bearing a large roll of snack bags, the kind chips usually come in. I say they were in a roll and what I mean by this is that instead of individual bags of chips, these bags were still attached to one another, as though they’d missed a key process at the packaging plant in which they were to have been cut apart. At a mere 5 cents American per bag, though, these rolls of chips were actually a pretty neat idea. After all, it’s much easier to transport a long coil of chips than 20 mini bags. Butch had also bought three different varieties so we could each get a good sample of the kind of snack junk-food El Salvador had to offer.
One of the varieties was basically Cheetos. They weren’t called Cheetos, but that’s what they were. And unlike my experience with El Salvadorian Oreos, these Cheetos actually tasted like real Cheetos. In fact, they were almost better than real Cheetos. Almost.
The next variety were a kind of bacon flavored puffed snack that had a similar texture to Funyuns. They were quite tasty. We don’t really have an equivalent in this country, so next time you’re in Central America you should pick up a bag of them. Sorry, I don’t recall the brand name.
The last variety was my favorite, though. They were salted and deep fried plantain chips. Yesiree, these were the best of the bunch. They were sweet and salty and crunchy all at the same time. Just Mwah! Goodness! I ate two bags of them without breaking a sweat.
“You know, fried plantains are a breakfast food here,” Jo Ann said. She didn’t mean the fried plantain chips, but actual plantains deep fried and coated with powdered sugar. I suddenly found I had a hankering for just such a creature and was looking forward to ordering them as soon as possible. Jo Ann even told us that she knew of a good place that did fried plantains and that if we wanted to we could go eat there on Saturday. Sounded like a plan to me.
The thing about the chips that continued to amaze me, though, were their price. Five cents American. I just marveled at it. Sure, it’s not like we were getting a Big Grab, or anything, but these bags represented the size you usually find with a child’s lunch. Not a bad size for a quick snack. And you couldn’t beat 5 cents. Jo Ann asked how much one would cost in America.
“Oh, fifty cents, easy,” I said.
They were appalled.
Unlike Guatemala, where the currency is Quetzales, El Salvador now runs on the American dollar. However, as you can see with the example of the chips, the dollar goes a lot further in El Salvador than it does back home.
Thursday afternoon we were joined in the pharmacy by two new translators, whose names were Rosio and Claudia. They were very sweet young ladies who were very good at their job of translating. Some might say too good. So far Jo Ann had pretty much stuck to our standard prescription instructions of telling each patient how often to take their medicine and for how many days and circling this frequency on our graphic-based instruction slips, or, if the instructions were more complicated, she would write them out, but for the most part she kept it as simple as possible. Rosio and Claudia, however, felt it necessary to not only explain all instructions in graphic detail but to write them all down in graphic detail as well. This might not have even been an issue, except that we still had Dr. Grace with us and she continued whipping through patients at an astounding rate. Soon the pharmacy had a line of patients fifteen feet deep and it stayed that way. Mary Ann and I were filling prescriptions as fast as we could, but then these filled prescriptions had to get in an ever-lengthening line to have their instructions notated, which–as the “pharmacists” on hand–we also had to be present for to make sure they were done right. It was gumming up the works and was beginning to put me into another foul mood.
I tried to explain to them that this was not a productive or efficient way to run a pharmacy. Sure, it was very nice that they wanted each patient to have exact instructions on when and how often to take their meds, to the nearest hour, but this wasn’t rocket science and our former method of telling patients “Uno por dia” and “Dos diarias” worked just fine for telling patients to take pills once or twice a day. Now, granted, if a prescription was more complicated than taking a pill a specified number of times per day, we did then have a medical obligation to explain it and write out the instructions accordingly. However, for the vast majority of prescriptions we could just circle the little pictures on the instruction slips.
Rosio did not agree with this at all. I don’t know if she didn’t think the people were smart enough to follow the graphs or if she thought they would forget what we told them, but she did not like it that I wanted her to stop writing out all the instructions. I tried to explain that we’d been using the graphs and simple instructions quite successfully for not only this week, but a four clinics in Guatemala before this and had no known problems. Taking the amount of time we were with each med was slowing everything down to a crawl and causing the patients who had been waiting to be seen for most of the day to have to wait even longer before they could leave. All we needed to do, as I saw it, was fill the prescriptions, circle the correct pictures on the instruction slips, explain each slip in regards to each medicine to the patients and then put those slips into the individual med baggies or otherwise attach it to the med bottle itself so that they wouldn’t be confused with other meds.
Rosio didn’t like it, but she and Claudia agreed to do it my way. Of course, the first patient Rosio tried my method on was a kid in his late teens who gave us the blankest of looks when Rosio told him the instructions for his pills. He looked at her like she was speaking English, or something. She told him the instructions again, very simple instructions that he was to take one pill three times per day until they ran out, but again his expression spoke volumes about just how much he didn’t get it.
“Uh, maybe you’re right after all,” I said. After that we kind of met in a middle ground of our two methods, altering it on a case by case basis.
At the end of the day, one of the last patients to be seen was an elderly woman. She explained to Dr. Allen that though she had been waiting for much of the afternoon, there wasn’t actually anything wrong with her. She said she lived nearby and had several children and grandchildren living with her. Due to circumstances, the grandchildren were largely unable to work, so she was the primary bread-winner for the household in her job as a housecleaner. Her family was understandably very poor and had little money to spend on anything fun for the kids. She had been told that our clinic had been giving out toys and candy and she had walked here and signed up to be seen on the off chance that we had some toys and candy we could give to her to take home. Dr. Allen was very touched by her story and loaded her up with toys and candy and vitamins for her whole family.
Our clinics ended around 7 that evening and we were able to head on back to WOL headquarters for a much earlier supper than the night before. Some of the translators from our week would not be returning for our Friday half-clinic, so we had something of a tearful farewell with them Thursday night.
EL SALVADOR CLINIC DAY 3 STATS
Patients Seen: 218
Prescriptions Filled: 586