Las Islas de Nicoya 11/17

Sunday 11/17

Dra. Moya, my preceptor this past Thursday at the pharmaceutical lab, followed up with me regarding the trip to the islands of Nicoya and insisted that I come, and that she pays. I told her I would come only if I could pay for my own ticket.  She repeatedly said no to this and would not even hear me out. She is such a mom, I love it. So I finally agreed after a little arm twisting by her in which she explained I'm a student and I don't have money for trips like this one, and she's a pharmacist. So I spoke with the coordinator of the trips, "El Chino" who in reality is not Chinese or of any Asian decent but, like me, has smaller eyes and is there for called Chino. When we spoke over the phone I asked him his real name and he said Miguel but he said he hasn't heard that name in years! Anyway, we arranged to meet at a bus stop near Mama Ticas house at 5:45 AM the next morning. 

I went to the spot at 5:30 AM, paranoid to miss a bus 2 days in a row. A few minutes after I got there, a girl named Joaneigh and her family joined me. We started chatting and I learned her aunt moved here to Guadalupe from Vancouver about 40 years ago, and they have a family business here.  They live less than a minute away from Mama Tica's house! Their family is originally from Taiwan, but Joaneigh currently lives in Vancouver. The bus came a bit after 6:0 AM, right on time if not early according to "Tico Time". We picked up more people in San Jose including Dra. Moya and her friend is also a pharmacist of La Caja! In the group we had everyone from professional photographers, to mother-son/daughter pairs, to hard-core hikers.  A few of the people had been on the trips with Chino before in the past and learned how great he was and came back for more!  Joaneigh and I were were the only 2 not from Costa Rica.  When we picked up the last 2 passengers, we stopped to pray that God blesses our trip and all the people on it. We began traveling with Abel driving and Chino directing the introductions. We all went around and introduced ourselves and then were handed our bagged breakfast and we were off! We stopped for water because there is no drinkable water on the island and real breakfast because you can't put gallopinto in a bag.  

After we started up again, we turned onto a dirt road and everything changed. Houses were totally different and made of corrugated metal and wood. We arrived at the water front in the very poor neighborhood.  We walked out to the boat since it was low tide and got on an "ancha" (type of boat) and off we went into the ocean! 

We learned that there are about 16 islands in the Gulf of Nicoya.  We passed many of the islands and the guy driving the boat told us about the specific island and how many inhabitants there were and what they do for a living. 

Below is the view from San Lucas onto the gulf, after we got off the boat.

(I have many more pictures but my computer is being a bit slow at the moment and does not wish to upload them, so I shall do so at a later date!)

We arrived to San Lucas to see the old island where there once was a penitentiary. We toured the old church there and then the newer looking building and the rooms in the back where the prisoners slept. There were many "drawings" on the walls that made it rather clear that this was most likely an all-male prison. Our tour guide told us he was in this jail 30 years ago for 3 months and when he left he stayed on the island and started working. After we toured the old buildings we followed the hiking trails to see "cocos" and did we ever! It was almost like walking on a floor of old coconuts. We had 2 professional photographers in the group, one of who noticed the monos in the trees! See pictures. We also saw a beautiful beach that kids were playing soccer on. After viewing the scenery and Chino taking a photo with Los extranjeros (Joaneigh and I), we headed back to the dock. You can tell Chino does this for a living because he took some great pictures of me before we boarded the boat again. 

From San Lucas we went to the Isla Chira where we had an interesting greeting by the local drunkards...Anyway we had an amazing meal of either arroz con camerrones (rice w/ shrimp) or pescado entero frito (full fried fish). I tried ceviche for the first time as one of the group members insisted I try hers when she learned I hadn't tried it yet. For a drink I had a beer with freshly squeezed limes and salt, something else new to try! I ordered the pescado entero, and I was sure happy I did! It was amazing. It came with white rice of course, a salad of pepino y tomate, and tortillas de platano which was also new! We only had to pay for our drinks because everything else was included in the cost of the trip. 

Next we all piled into a taxi that was pretty similar to taxis I've ridden in Mexico. It's basically a pick up truck with a tarp through over the back and raised by poles. "Chiribús" The seats were removable wooden benches. We drove from one side of the island to the other in about 20 minutes. There were beautiful views on this side of the island. Once we reached the other side of the island we saw a fish market that was closed because it's Sunday. After a dog almost joined us in our taxi, we headed back to the other side of the island to get back to our boat! We left Isla Chira and headed back to the mainland, noting Isla Caballo, which got its name for its shape, not because there are horses there. We got back to the mainland in our boat and thanked our trusty friends of the islands and headed back to our 15 passenger van. 

We drove back to the same rest stop and I had an empanada de pollo - one of the best I've had thus far and it was at a rest stop!  Got back to moms house and 2 surprises awaited me: 1) they decorated the arbol of Navidad! and 2) the second Canadian student had arrived earlier in the day! Mama Tica said they took pictures with the arbol of Navidad that we have now and she and I must take one. She made me wear my "gorro de turismo" for the first photo because she can't stop laughing when I have my hat on. I met our newest housemate, Marie-Julie, who was finishing up her residency applications, and we all went to bed. Such an amazing day I can't believe how blessed I am to continue to meet such amazing people on this whirlwind of a trip.

Volcano Poas!...Almost. 11/16

Saturday 11/16

I slept in a bit this morning, got up around 7 to go see Volcán Poas!  I followed the directions Yuri gave me perfectly, but when I got to the intersection where the bus to Volcán Poas was supposed to be, there was no line of gringos that I could see anywhere.  Yuri explained that it's mostly just tourists/gringos who go to the see the volcanoes.  I asked a few random people where the bus that goes to Volcán Poas forms a line, but no one seemed to have any clue.  Finally I saw a bus across the street that said it was going to Alajuela.  I knew that Volcán Poas was in Alajuela, so I went over to ask the driver if he went to the volcano.  He responded he didn't, but the bus station that he drives to in Alajuela has a bus that leaves from there to go to Volcán Poas   I jumped on, and off we went.  We arrived at the bus station, and I asked around for the bus that went to Volcán Poas, and finally found the bus that was in the lane labeled as such.  The driver was really nice but explained I just missed the bus and the next one doesn't coming until tomorrow.  I was crushed for a brief second before calling Yuri for some truistic advice.  There were buses in the station that seemed to go all over Costa Rica, so surely I could hop on one of these and salvage the day in another great spot.  He advised me to take a bus that goes to Grecia and Sarchi as there is some great artesenia there and I have been looking for a good spot to buy some gifts for everyone back home.  I enjoyed the ride to Sarchi, it was beautiful and through the mountains. As soon as we entered Sarchi, at all the stops we made, the people were even more friendly than they are in Guadalupe! Everyone knew everyone else and everyone was wondering what I was doing here and where I was headed and where I was from.  It was great!

I easily found the stores of artesenia since every store that wasn't selling artesenia was selling "muebles" or furniture.  I explored the beautiful town a bit and learned there was a bus that was going back to San Jose at 1:15.  I waited at the bus stop where I met the cutest little boy of 3 years old whose name was Sebastian.  We played together on "la concha" (the soccer field) behind us as we both waited for the bus.  In true "Tico Time" fashion, the bus arrived at 1:30, but then didn't leave until 1:45 because the driver hadn't had afternoon cafe yet.  The ride back was just as beautiful as the right down.

After arriving home and working on the residency search the rest of the afternoon/night, I anxiously awaited the arrival of one of my two future "family members."  Her name is Genevieve, and she is one of the two students who will be staying in Mama Tica's house with me.  She is one of the four medical students who is coming for a month from McGill Med School in Montreal, Canada.  She arrived around midnight with Yuri, and she is AWESOME! I love her already.  She's 23 as well and in her last year of med school.  She lived in Cuba in the past and speaks Spanish fluently so she will be working at a hospital in Grecia while here for the month.  Unfortunately, because Grecia is about 1.5 hours away from Guadalupe, she will only be living in our house for a few nights before she transitions over to her house in Grecia.  However, I will be going to Manual Antonio next weekend with her and the other Canadian students and to Isla Tortugero with them the week after! 

And then I ate a worm 11/15

Friday 11/15

I arrived at La Carit at 7 like usual and Mari (my Mama Tica of La Carit) brought in "pan casero" for all to enjoy.  It's basically fresh rolls with some honey on top of them which you then eat smothered in butter - delicious!  In the morning I helped fill for the outpatient clinic side of the pharmacy until our breakfast break which I always take with Dra. Ovares. Today when I went to "El Solito," the take out restaurant that I always eat at across the street, they had "budín," my favorite breakfast treat, which is basically really dense sweet cake, shown here.

After breakfast I helped fill on the inpatient part of the pharmacy until lunch time.  We often eat lunch in the beautiful courtyard of the hospital and when we do, Dra. Ovares is constantly on the lookout for "cas," a sour fruit that is delicious! I tried it once in the "fresco" that Mama made, but never raw before. Dra. Ovares found a bunch of cas today and insisted that I try it raw with a dash of salt.  I broke it open and ate a bite and it was delicious! Almost as sour as a lime.  Then Dra. Ovares taught me about the tiny, tiny worms that grow inside the cas and can only survive when in the cas.  I nearly dropped my cas when she said the word for worm in Spanish which is "gusano."  Then she proceeded to tell me I needed to eat the gusano she dug up from inside her cas, right off her knife.  Dra. Ovares snapped this picture right after I ate the worm from the knife. I must say, I love cas, worm and all! The picture on the right is a close-up of the knife, and the small thing on the right of the knife is the worm I was so concerned about.

At the end of the day, Mari, Dra. Ovares, Carolina (the secretary) and I were talking about what I have and have not tried yet in terms of Costarricensen cuisine.  I told them I keep seeing signs about chicharrones, but I still have no clue what they are and I also haven't tried the Costa Rican beer, Imperial.  Within 5 minutes we had plans to go to a bar/restaurant nearby that is famous for its chicharrones right after work.  We went to the restaurant which was called, "El Jardin Cevichero" to try both of these! I loved the decorations inside!

We ordered an amazing plate of mixed meats, including salchicha (sausage), bistec (steak), chorizo, and chicharrones, along with my first Imperial which came with a very large wine glass for me to drink it from. Odd, but I liked it. I learned that chicharrones are basically fried pork rinds, and they were DELICIOUS!

We chatted for a while, and I had so much fun.  It still amazes me how open and inviting the people are down here.  Here I am, a random student from the US, out to dinner with three people I met not even 2 weeks ago, and I feel right at home as if I'm out with my family.  Here is a picture of all of us.  From left to right, Dra. Ovares, Carolina, Mari, and me!

I noticed this USA Today newspaper was laminated and framed on the bar near our table, so I went over to check it out.

The owner, the male in this photo, saw me perusing the article, and came over and introduced himself.  I almost didn't make the connection because this photo above was about 20 years ago! He was very sweet and we chatted about the award he received and how he went to Chicago to receive it and got to see a big game in Chicago Bulls history while he was there. Like the true Mama Tica that she is, Mari insisted that I take a photo with him, so of course I did!

Needless to say it was a great afternoon/evening, and I had so much fun! Here are some more photos I took with Mari before we left to go home for the night. She is so fun!

The ups and downs of witnessing a natural birth 11/14

Thursday 11/14

I arrived at La Carit at 7 like normal, amped to see the cesarian and natural birth which I requested to view. I went down to the labor and delivery floor where I was then told they don't start until 8. I worked in the pharmacy until then, and then at 8 I went back to the floor. I met the chief ob/gyn doctor, and we walked together down to the pre-operative area. I've never worked on a labor and delivery ward in the states; I've been to them as a family member and as a technician, but this was a whole other experience. I arrived in the completely open pre-operative area to see three beds, all occupied, in front of me, with curtains separating them. The curtains blocking the vertical view into the "rooms" were almost never pulled for coverage, so from the second I arrived I watched as the nurses and doctors ran between the three beds determining who was the most dialated, and who would be brought next to the procedure room. The woman in bed one was wheeled off to have a cesarian as they explained to me it had been to long and her contractions weren't very close together. I changed into the necessary scrubs and returned to pre-op and a few moments after I returned, everyone sprung into action as the woman in the middle room was about to give birth. I ran behind the medical team with another intern as we entered the first available room for the woman. It was me, the intern, the delivering doctor, and 2 nurses in the room. I witnessed it all. Everything from the crowning of the baby, to the removal of the placenta, to the stitching up of the mom. It was incredible. I couldn't believe my eyes, and the doctor was great at explaining every step to me and the other intern. I couldn't believe how fast everything happened from the second we left pre-op to when the baby starting coming out. The whole process was believe it or not, beautiful.  

At the end of the procedure, I was nearing the door, and the last thing I remember is expressing my gratitude for allowing me to shadow and leaving the room feeling a bit short of breath...The next thing I remember I was being shaken awake, my neck was being dabbed with alcohol, and 10 doctors and nurses were standing around me, one of them holding my legs in the air. I managed to pass out, although I'm not quite sure why it happened when it happened. I have never had a problem seeing blood or needles or any of that, and the entire procedure I was completely lucid and glued to watching. The doctors explained it was probably due to not being accustomed to wearing the mask plus a combination of shock, excitement, and sheer awe. I immediately started apologizing and they were laughing saying it happens all the time and they're used to it. I moved to a chair and everyone went back about their normal business and then one of the PCTs came up to me and said she caught me right before I hit the ground. I figured she must be joking because this woman was literally half my height. Thanks to her, no concussion for me!  

Anyway, that was the big excitement for the day, and it was all anyone wanted to talk about when I returned to the pharmacy. Later that afternoon I met with the director to sign off on everything I have done with her at La Carit thus far. She will give me a copy of these paperwork for me to send to UConn. We had a staff meeting at the end of the day to review how the transition to the new pharmacy was going. There were some topics discussed in the meeting that brought up mixed emotions among the pharmacy employees. For example, Dra. Ovares, who is the only pharmacist who works everyday, besides the director, has an office in the new pharmacy. Early this week, she showed me how she keeps track of all the error data of the pharmacy, is in charge of all the patient education, and does much for more the hospital. There is push-back from one of the purchasing technicians who thinks he should get the office instead to work on the daily purchasing orders. The rest of the pharmacy staff agree that Dra. Ovares should get the office, but the director, still being relatively new, is easily influenced by the technician. This discussion was difficult to listen to and I could see both of their points of view. Another hotly discussed topic was a phone call the director received this week from a PCT while in a meeting with some of the OB/GYN doctors. The phone call was the PCT shouting at the director because the scripts she dropped off in the pharmacy for an inpatient weren't ready fast enough for her liking. The final "ugly" topic discussed was that many of the PCTs were under the impression that there would be a window in the pharmacy specifically for them to fill their personal prescriptions. Of course such a window does not exist, but many people have been asking the technicians about such a window and it had to be discussed. After this not so enjoyable meeting, we adjourned and went home for the afternoon. When I got home and relayed the story of me passing out to Mama Tica, she nearly passed out herself. She couldn't stop laughing for most of the night. She is the best!

Trip to the FDA of Costa Rica 11/13

Wednesday 11/13

Thanks to the connections of the pharmacy director at La Carit, today I was able to have yet another great experience involving pharmacy in Costa Rica. I went to Hospital México, which is the largest (or second largest depending what you measure by) hospital in Costa Rica. It has more than 600 beds! I started my day in "El Laboratorio de Productos Farmaceuticos del Seguro Social" or "The Laboratory of Pharmaceutical Products of the Social Security". This lab is where they make some of the nonsterile products for all the hospitals of "La Caja" in Costa Rica. This laboratory is one of the two that exists to make products solely for the 29 public hospitals that are part of La Caja. First we toured the warehouse where they store all the raw materials to make the medications in giant barrels. 

Next, I went for for a tour to see the entire manufacturing process and I met some of the assembly line workers who were nice enough to demonstrate how their machines worked.  Here are some photos and a video of what I saw while in the manufacturing area.

After this tour, I visited the area where they do quality control of the samples, to ensure the full batch is able to continue being manufactured. Here are a few photos of the lab technicians hard at work checking to make sure the "muestras" (samples) are up to La Caja's standards.

Later I went to one of the "floor pharmacies" in Hospital Mexico. There I learned that they have a decent sized pharmacy on each of the ~9 floors of the hospital, where all the patient-specific medications are prepared in a cart and brought to the nurses. These "mini" pharmacies receive stock from the central pharmacy which I visited later in the day. After the tour of the floor pharmacy, we got in one of the lab manager's cars and drove about 20 minutes to "Laboratoris de Normas y Calidad de Medicamentos" which they explained to me as being the equivalent of our FDA, but on a much smaller scale. I met with the assistent director and then with one of the pharmacaists there who gave me a tour of literally every single process they do there! It was fantastic! I met so many pharmacists and researchers and was able to swop business cards with a few of them. One of them was interested in having pharmacy students come to do a rotation solely at this quality control facility! After the tour we returned to Hospital Mexico where we went for a tour of the central pharmacy. I have never seen such a big pharmacy! This pharmacy was detached from the hospital, but located right in front of it. Just as there is at La Carit, there is an outpatient side as well as an inpatient side which mostly consists of stocking in the "mini" floor pharmacies in the hospital. 

The outpatient side had 10 individual windows to drop off/pick up prescriptions, and rows and rows of chairs in which to wait.

After this tour of the central pharmacy, we returned to the lab and Dra. Moya, who I was with all day, insisted on taking the bus back with me to make sure I got home alright. She was like another Mama Tica! She also invited me to go with her and a group of friends on a tour of the Golfo de Nicoya this weekend! Here is a picture of her and I at the end of our day together.

First day in the NEW pharmacy! 11/12

Tuesday 11/12

Today I was back at La Carit, the all women's hospital, but we are now officially operating from the newly renovated pharmacy! It's beautiful and looks even better now that it has everything from the old pharmacy moved it. In the old pharmacy, most of the shelving, boxes, and tables were made of painted/treated wood. In this pharmacy, everything is of metal which they explained to me is in accordance with new regulations stated by La Caja. Here are some photos of the new space!

I started the morning working on the outpatient side, helping fill and dispense to the patients who come from the clinic. Today I was able to fill by myself! After lunch I went to the inpatient side and attempted to relearn where everything is to help fill and dispense on that side. While there, I also learned with the assistance of Mari, shown in the picture below, how to type up the scripts that come down from the floors. They type them into a program that is used in all public hospitals (hospitals of La Caja) so it was the same program that I saw being used at the pain clinic yesterday. They input the information and a sticker prints out. We then fill the script and the pharmacist checks that the medication matches the sticker which matches the hard copy of the prescription. 

In the afternoon I met with the director to talk about what I learned yesterday at the pain/palliative care clinic, and she told me a bit about what I would learn, see, and do tomorrow when I go to the medication production laboratory in the Hospital México.

Day at the pain clinic 11/11

Monday 11/11

Today I went to the "Centro Nacional de Control de Dolor y Cuidado Paliativo" or "National Center of the Control of Pain and Palliative Care".  This clinic is one of the 29 hospitals that are part of La Caja, as is La Carit.  The pharmacy director, Doctora Claudina Aguilar Corrales, was very inviting and excited to have me there for the day. She is a friend of the pharmacy director at La Carit. We started off the day with a tour of all their facilities. Here are some pictures of the pharmacy.

Where they type up the prescriptions to make labels.

One of the pharmacists checking the prescriptions.

The window where the PCTs drop off prescriptions and pick them up when they're filled.

The outpatient window to serve the patients of the clinic.

One of the filling counters.

Because the hospital is in the city, they have many buidlings that are rented and located around the corner or up the street. While on the tour, I learned all about the types of patients who come to the clinic from all over Costa Rica, for pain management referrals, chronic pain referrals, terminal cancer, for first time visits if they live nearby, or for end-of-life care. First, we went to their storage room to learn about the purchasing process with their purchasing technician. They are trying to move this "bodega" or warehouse to a location closer to the pharmacy because it is currently in a building 1 block away from the pharmacy of the pain clinic. I learned about the purchasing process and how they must use the money given to them by the Caja before the end of the year or it is gone. The are really pushing to move the bodega to another location because the current building in which it is has a leaky roof that they're afraid will affect the storage of the medications. They had interesting moisture absorption buckets shown below.

Then I went for a tour around the clinic including where the patients wait, where they are seen by the doctors/nurses, administration, and the pharmacy. I stayed in the pharmacy for most of the day working with the pharmacists mostly. I learned how they must check the scripts for controls/narcotics in a certain way. They also fill non-control medications at this pharmacy as well. In the afternoon, I met with the director again when she gave me her presentation about the rules La Caja has for which pain meds can be used in which order (first line, second line, third line). The director also explained to me that they are working to become more interdisciplinary in terms of pharmacist involvement. I also learned there are interdisciplinary teams that do house calls for patients too sick to come to the clinic. Overall it was a great day, and I loved the pharmacists and technicians I worked with! Here is a nice picture of our group.