Learning to Live It, Love it, and grow…

It is amazing how time flies. Standing here at the brink of Autumn, heading into my senior year at Macalester, I find my mind wandering backwards to contemplate this summer as much as it surges forwards,  pondering how these lessons, connections, and ideas will inform my work in the future. My experience with the Live It project has taught me lessons I definitely didn’t anticipate, and allowed me to forge connections that hopefully will remain for years to come.

Pilot Colonel Jose Antonio in front of plane with A Tu Lado members

I started this project in January while working as an intern for A Tu Lado, grappling with understanding the scope of the vision of the organization, while simultaneously struggling to keep my footing on a constantly shifting field of immediate priorities and concrete necessities for the organization. Lesson number one:  small NGO’s may have big visions, but the everyday realities of funding, logistics, and communication take up the majority of staff time. Big accomplishments are possible, but it’s necessary to buckle down and take care of the nitty-gritty work (while not getting completely subsumed in it).

This project also taught me that even if you have a big, beautiful vision that seems to make all the puzzle pieces fit and is guaranteed to improve a situation, as a global citizen, you have to recognize that your individual analysis of the situation is not the only important one. A week ago, after two months of increasingly spotty communication from our Bolivian partners, we received the news that the project was being put on hold, due to a miscommunication over a proposal for the electronic medical record system. This shocked and saddened me; although some of our point people had been not as engaged on this element of the project, I had no idea there was so much confusion within the organization as to cause a major hold-up in the process. Reflecting on the development of the proposal, and the project in general, I realized that the A Tu Lado team, and I personally, analyzed, discussed, and dreamed to put together a plan for how the service could improve, and it seemed, in general, to be a good plan, incorporating evidence-based self analysis, tracking of performance, and improved communication. But although we were constantly updating our partners in Mano a Mano and discussing these issues with them, somehow the vision ended up not being shared or understood fully by each side. Or if it was, the implications of such, and the responsibilities and commitment it entailed was not understood by members of our partner organizations. In short, although there was always enthusiasm expressed for ideas and plans we brought to the table, it often seemed that we were left enacting them on our own, unsure of how dedicated our partners were to the idea. Some of this was cultural difference at play: we moved fast, and didn’t take into account the bureaucracy and need for processing time that our partners had. We also didn’t count on the fact that perhaps there is a cultural tendency to avoid expressing difference of opinion, and in the future, I will be exploring ways to ensure that when I am working with people from different backgrounds, we create space for discussion that is more open and sensitive.

Fortunately, from recent conversations with our partners, it sounds like the project will be back online after Mano a Mano completes an internal review. The lessons learned from this incident were the hardest I have faced yet, but important ones to learn for a student interested in international work.

Maps with David, member of SAR Bolivia. Credit to Will Chilton for the photo

Despite these setbacks, reflecting on my summer I am so glad I had to opportunity to carry out this project. In teaching the course, I forged relationships with truly inspirational citizens of Bolivia, who are dedicated to developing themselves to better serve their neighbors and communities. I also had the opportunity to learn so much about the potential and drawback of technology in development, the benefits and difficulties of working with a small NGO, and the beauty and frustration of networking with organizations and individuals across cultural and geographical distance. The relationships made and the lessons learned will stay with me for many years to come, and have definitely influenced how I see my role as a citizen of the world.

The graduating EMT class and instructors.

Certificates, Village Visits & of course… more Maps!

The course is finally over and we are graduating a class of 18 with certificates from the Universidad Mayor de San Simon. Though the final flurry of grading and testing was stressful, the sight of the students proudly claiming their certificates and the enthusiasm of our partners in the emergency flight service was well worth the long hours. After several weeks of 12 to 14 hour days putting together the course, I am pleased to have a little more time to dedicate to the other elements of the project.

The other pieces of the puzzle are falling into place as well, as we make plans for another course in August, and finalize many parts of the documentation system and maps. Meeting with a local cartographer who works with SAR Bolivia opens new doors for collaborations in the future. After several weeks of work with the pilots, we have finished a flight planning system that incorporates all of their flight strip data into Google Earth and allow changes to sync between the various pilots and myself. They are really pleased with the system, and excited to learn more about ArcGIS, a demo version of which is installed in the computer in the hangar that was purchased with Live It funds. I have also finished mapping government data on health centers and population centers, which in combination with the Mano a Mano landing strips is allowing the pilots to find the most rapid and efficient way to reach their patients. As the data from the service is collected using the new flight record system, I will continue to help produce maps that allow for retrospective analysis of the service and epidemiology of the region, hopefully continuing my work with Mano a Mano and A Tu Lado into the future.

Before take off, flying to the San Lorenzo with a toddler, his mother, and the Catholic sister who runs the alternative health center in town.

Finally, I also had the opportunity to ride along on a flight to see one of the communities in the Amazon region. San Lorenzo is one of the largest towns the flight service visits regularly, since it actually has a government health center with a doctor, making it a primary referral point. Patients from surrounding communities often come in with critical health issues which are recognized by the medical staff, and a branch of a Cochabamba Catholic sisterhood works with Mano a Mano to fund flights and find free health care for the patients who are almost universally uninsured and impoverished. On the hour long flight I am sharing the back of the tiny plane with a woman whose toddler just had a tumor on his cervical spine removed, a missionary who is paying for the flight, and several large sacks of onions. The town is 5 hours by road from the nearest city during the dry season, but after the rainy season is takes approximately 4 days on horseback to reach the next nearest town. We touchdown on a muddy grass runway, skidding for a few seconds in the tropical heat.

I had hoped to talk with members of the community who might be interested in attending a first responder course in the future. However as things worked out I fell into conversation with one of the Catholic sisters who has worked with the community for 8 years. They have started an alternative healing center (including traditional Amazon healing practices from the region). After a brief conversation about her work, I shared A Tu Lado’s vision for the Emergency Medical System in the region. As well as having paramedics on the flight service, we hope to create a network of local responders, a type of community health worker trained in basic emergency medicine who would act as the first link in the chain of survival. As well as providing basic health care, these community members would be the designated link with Mano a Mano Aviation, checking on the state of the runway, reporting on weather, and identifying emergencies and developing health issues. Although we had originally planned to teach the first responder course at the same time as the paramedic course, the resources were not available to realize this vision this summer. A silver lining in the delaying of the course is that I was able to go and actually see some of the situation on the ground and speak with local health workers, deepening our knowledge of the reason and allowing us to plan a more pertinent first responder course in the future.

From speaking to the nurses at the clinic, it became apparent that some local efforts were already underway that A Tu Lado and Mano a Mano might be able to collaborate with. Nurses have been training community health workers, albeit in a sporadic fashion, for the past several years, although efforts have died off in the last year. The health workers were enthusiastic about the idea of equipping community members in the remote villages with health knowledge and resources in order to provide grassroots medical care where currently no organized system exists. They also proposed various innovative ideas of how to manage logistical elements of the course, and indicated their strong interest in receiving further training themselves, as well as collaborating in any classes for community members. Informal conversations with a few community members at the runway indicated that there is a high level of interest in emergency medicine, which is perceived as a real need in an area where trauma from animals and machinery, as well as medical and obstetric emergencies are common occurrences. With hordes of new ideas and potential collaborations swimming inside my head, I climb back into the plane headed for Cochabamba. Reflecting on our new knowledge with the pilots and my team members, it looks like there is a lot of work left to be done in the area, but a lot of potential as well. My time here in Bolivia is almost done however, so I will be dedicating my last few days primarily to wrapping up the loose ends of this project and making plans for the future.

Maps, Plans & Planes

Will Chilton

Demonstrating spinal stabilization with a KED device. Photos all credit of Will Chilton.

The first week of classes has been both exhilarating and exhausting. I have been writing lesson plans, running scenarios, and of course, working on endless documents that will be needed for the flight service. The students are enthusiastic, chiming in with their knowledge (which can be profound—there are practicing doctors and paramedics of 20 years who are taking this course), and arguing over the best way to perform procedures. I am deeply impressed by the students, and have found this to be much more of a learning experience than anticipated. Still, in teaching about pulse oximetry and altitude, or reviewing the procedure for back boarding a patient with a spinal injury, it is also clear that we have a lot to offer. Prehospital medical services are completely unstandardized here in Bolivia, and doctors who are well trained in hospital procedures are not prepared for emergencies in the field. Good to know we are proving useful in some way! If you want more details on the course, check out the A Tu Lado blog (news.atulado.net)

One of the essential parts of the project here is setting up a system of patient records and flight records. Hopefully this record system will serve several purposes, including improving patient care after hand off to hospital staff, providing a way for the organization to make informed decisions on how to improve the service, and helping to develop an epidemiological profile of the region. I have been working on setting up the run sheets that the emergency service is going to use. These will document each encounter with a patient, and will be one of the main sources of data for the retrospective analysis, as well as being part of a patient’s permanent medical record. There are plans to have the entire system digitalized by August. A lofty goal, but through our collaboration with a team of OpenMRS (open source medical record system) experts called eHealth Systems in Santiago, Chile, I think we have a good shot.

Will Chilton

Practicing loading patients onto the Mano a Mano Apoyo Aereo planes.

In the meantime, I’ve restarted conversations with the pilots in the flight service about what they want to see out of the mapping initiative. I have been working on a few maps since first coming to Bolivia in February. We had initially imagined these maps would show the normal and emergency runways with pertinent information for navigation. Turns out the pilots had begun to use Google Earth since our conversations in February, and had already figured out a rough system to plan flights using the open source software and their GPSs. Although I was initially dismayed at having been left out of the loops on this, I am feeling really positively about this unexpected development. I have already begun working with the pilots to make their system more streamlined and to use the information from ArcGIS to enhance their data on Google Earth. ArcGIS will still play an important role in helping with the retrospective analysis of flight patterns and resource usage, as well as displaying geographically any epidemiological trends that emerge from the emergency flight records. We have also begun conversations on how to improve the flight record system, so I am looking over how they currently do their documentation. Amazing how far a working knowledge of Excel will get you!

Will Chilton

An improvised patient transportation simulation, run by the Cochabamba police.

Getting Geared Up to Live It!

Hellos All!

My name is Margo Faulk. This coming Fall I will be a senior Geography major with a concentration in Community and Global Health. Since December I have been working with a small non-profit run by two recent Macalester graduates. The organization is called A Tu Lado, which means ‘by your side’ in Spanish. We work with partners in Venezuela and Bolivia to provide training and to improve emergency medicine systems, empowering local communities with the knowledge and tools needed to save lives and build safer neighborhoods. You can check out our work at www.atulado.net.

A Tu Lado is currently collaborating with Mano a Mano, a Bolivian NGO which builds healthcare infrastructure in the Andean region of the country. Mano a Mano also provides a medical air service for the northern rainforest of Bolivia, the Beni, where a small and disperse indigenous population has very limited access to clinical care. With a fleet of four small planes, they have transported over 1000 patients to Cochabamba since 2004. In addition to those emergency transports, they regularly fly medical teams to these villages to provide primary and preventative care.   A Tu Lado is setting up a course to train paramedics to attend these flights, building a patient information system, and helping to improve the logistics of the program. I will be working specifically on the patient information system and teaching a few elements of the course. I am also mapping resources and epidemiological trends to help the flight service better know their population and maximize their efficiency. Finally, I am hoping to talk to some community members in the areas that are being served to get a better idea of what community priorities are and how they would like to see the service take shape, as often in development projects indigenous voices are marginalized in the name of efficiency and improving patient outcomes.

This project expresses my vision of global citizenship in multiple ways. Instead of unilaterally carrying out the project, I am working collaboratively with local organizations developing curricula and train local providers– ensuring a sustainable, culturally appropriate service. Instead of pursuing development blindly, my research will encourage self-reflectivity and critical evaluation of results. Ultimately, the health and flight registry systems will give our partners the tools to make informed decisions about their development.

Mano a Mano hanger. Photo by Will Chilton @ A Tu Lado

The last couple weeks have been hectic. I have been finishing up my semester abroad in Arica, Chile, where I was studying public health, traditional indigenous medicine, and community empowerment. And of course, I have been trying to get some of the prep work done for this project. A few of the highlights in the process of getting ready to launch this project are listed below.

I took a trip to Santiago to talk with Joaquin Blaya of EHealth Systems about our vision for the patient record system and incorporating research and internal review elements. He is an expert in an open source medical records system, OpenMRS, and an innovator in applied mobile technology for medical care.

We are starting a dialogue with potential partners in South African who are also building community based emergency response systems. Already this new link has lead to exciting ideas!

The first computer purchased failed to load Windows, the second blew up. We are currently having it fixed by a wonderful Cochabamba tech wiz. Fingers crossed!

After a lot of reading reviews and comparing prices, I have purchased glucometers and oximeters to determine patients’ vital signs as part of the service. As well as improving patient care, these tools will help us to establish a system of internal monitoring over time to see what effect the service has on patient outcomes and determine areas we can improve.

Finally, I have been writing course material for the lessons I’m signed up to teach and generally reviewing EMT skills. I am honestly a little nervous about the teaching aspect… but the prevailing sentiment is definitely excitement!

Well, the bags are finally packed and I’m on the bus, headed to Cochabamba, Bolivia. I am ready to hit the ground running on this project. I’ll keep you updated as it gets rolling!