Nicaragua Medical Mission – Photo Journal

Technology sometimes does not go your way and that is what has happened in the case of part 5 of my series on healthcare… my computer crashed and part of it was lost. I am working on recovering it so I can post part 5 to the series as one complete post instead of pieces. In lieu of part 5, I have put together a photo ‘journal’ of some memories outside of the clinic from my time in Nicaragua.

Enjoy!

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Volcanos galore from the plane

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Coming in for a landing soon

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The homes in the neighborhood were fumigated due to reported cases of Zika, Chikungunya, and Dengue fever. This is a common thing done by the government to try to prevent these mosquito borne diseases. 

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Controversial lighted trees in Managua. They are beautiful, but according to my hosts each one cost $20,000 to install.

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Transportation to and from the clinic… I don’t think I have ever felt this unsafe. I would compare it to the Indiana Jones ride at Disneyland without seat belts, while standing, and faster…

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Beautiful church that was partially destroyed during the last severe earthquake in Managua accompanied by a friend I made

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Host family’s living room. Their house was beautiful and was home to multiple family members, a common thing in Nicaragua.

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Arrived back at home after a long day of flying. Thankful to be back and for the experiences I had while there.

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Nicaragua Medical Mission – Healthcare Part 4b

This is the continuation of my blog regarding conditions and types of treatment seen in the clinic in Nicaragua.

Conditions and Types of Treatment

Now to the fun part…. what kind of conditions did I see and treat.

<Please note that I am going to be vague regarding the patient description to protect the medical information of those individuals.>

2. Allergies

When I was listening to patient’s lungs during my exam, the physician in the clinic would always ask me if I heard “wheeee” sound or a “whoosh whoosh”. That was their way of distinguishing between allergies (“wheee” or wheezes) and infection (“whoosh whoosh” or consolidation). In the Nica clinic if something was not an infection it was called allergies. Now in the USA we would have to specify more, because there can be many different types of allergic responses. The main reason why the physicians did not do any further diagnostic work up was due to the fact that for one it would not change the treatment and for two in the rural clinic they did not have access nor could these patient’s afford any further diagnostics such as x-rays or more extensive blood work.

The most common kind of allergy seen was Asthma and the patient was prescribed an Albuterol inhaler, which is similar to the treatment provided in the USA. There are a lot of factors that contribute to allergies in Nica. The time I was down there was their winter and the weather can change from sun, to humid, to rain, and to cloudy in the course of several hours. Also, the amount of dust and dirt around in living areas and public areas also contribute.

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Dust, dust, and more dust in the clinic during construction.

3. Chronic kidney disease

One of the most emergent issues taking the lives of men and women in Nica is chronic kidney disease. In the city of Leon and surrounding areas, there is a major health crisis involving chronic kidney disease. On my first day in the clinic, a patient was leaving with dark red circles below his eyes, sullen complexion, and looked very ill. Upon questioning he was one of many that is suffering from kidney disease. Part of the issue with kidney disease is that if it progresses too far, one of the few treatments available is dialysis, which is not available to many of the patients seen in the rural clinic I worked at due to lack of funds and lack of availability to get to a clinic or medical center three times a week.

Some factors that contribute to kidney disease are lack of purified drinking water and the humidity leading to dehydration, frequent urinary and kidney infections, poor diet (lack of fruit/veggie availability, high cholesterol/fatty diet, and lack of other options), and decreased access to healthcare on a continuing basis.

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Lab where patients receive blood draws, nurses interpret results, and where the new dialysis machines will be eventually incorporated into.

Treatment provided included medication to decrease cholesterol and fats (such as a Statin), sometimes a diuretic or Lasix to decrease water weight and edema, treatment for any infections, and counseling on diet/water intake. Unfortunately for many patients with this condition, there is not much treatment available. Fortunately the clinic has recently received a donation for 3-5 dialysis machines, which would provide patients with increased access to care and the ability to continue their life in a more comfortable way. That being said, it is a band-aid, not a solution to the problem.

4. Anemia

Many children that came into the clinic were malnourished, infected with parasites, and dehydrated. Almost all patient’s came in with ‘exams’ that included a Hematocrit and Hemoglobin and almost all the children that were seen had anemia, some that was pretty severe. The physicians acknowledged that these patients had anemia, but often there was nothing they could do outside of treating the infection or parasite the patient had and encouraging the mother to increase the nutrition of their child. It was not that the mother’s wanted their child to be malnourished or were poor parents. Often with young children who were being breast fed, the mother herself was malnourished. With children a bit older, it was due to a lack of availability of healthy food or enough food. The physicians would sometimes prescribe supplemental nutrition and electrolytes, but there was only a limited supply of these for the whole clinic, so it was often saved for the most severe cases. It was difficult to see these children that were full of life, but clearly struggling.

  • Of note, some of these children and adults had iron deficiency anemia, but the clinic had no access to iron supplements, so this treatment was recommended, but unavailable to these patients. This is an example of the difficulty of obtaining donations even when they are available in a foreign country.
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A sweet patient dealing with anemia, a parasite, and possible pneumonia. Unfortunately this was the rule, not the exception here in this rural clinic.

5. Other medical conditions

Lastly there were patients that came in with medical conditions that are common in the USA including chronic pain, high blood pressure, high cholesterol, and heart disease. These conditions were treated very similarly to our treatment protocols here… diuretics and other medications for high blood pressure, statins for cholesterol, beta blockers for heart disease, and pain medication for chronic pain. The main difference is that lifestyle factors, prevention, and alternative healthcare treatments were not available, discussed, and sometimes even known about.

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Many drugs and medications that are prescribed in the USA, but without the preventive and lifestyle factors in place lead to temporary solutions to chronic issues.

Overall the patients in the clinic were all fairly sick and needed treatment for multiple medical conditions. While the clinic does the best that it can, there is no way it can completely get these patients to their optimal health with the living conditions and lack of infrastructure in these rural areas of Nica. This is a stark contrast from patient’s who are living in the larger cities who have access to more healthcare. Working in this rural clinic, displayed the difficulty in helping these patients heal and obtain health, but it also showed me areas where Naturopathic medicine, preventive health, and other alternative treatments and therapies could possibly intervene and work together with the medicine in the area to help patients recover and possibly prevent further infection, disease, and early death. 

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Doctors, future doctors, and missionaries in front of the clinic

My name is Emma Petshow and I am a 4th year naturopathic medical student at the National University of Natural Medicine in Portland, OR. For more about myself, check out my bio. This blog is intended for information about preventive health and lifestyle improvement. The information contained on this blog is not to be used as medical advice. For specific medical advice you should consult your physician.

Nicaragua Medical Mission – Healthcare Part 4a

This is part 4 in my 5 part series on healthcare in Nicaragua. I did not realize how much I had to say about the different types of conditions in Nica. Since my post started looking more like an essay than a blog post, I have broken it up into a few pieces. Sorry it is such a lengthy one, but I wanted to be sure and discuss all the main healthcare issues seen in the country.

Conditions and Types of Treatment

Now to the fun part…. what kind of conditions did I see and treat.

<Please note that I am going to be vague regarding the patient description to protect the medical information of those individuals.>

1. Infection, infection, infection

The most common illnesses that were seen in the clinic were infections of all sorts. In Nicaragua, especially rural Nicaragua, most infections are bacterial in nature vs. in the USA they tend to be viral. Patients would come in complaining of difficulty breathing, cough, runny nose, or chest heaviness and upon listening to the lungs you would hear consolidation or according to the Nica doctors a “whoosh whoosh” sound. This to them meant infection, most likely pneumonia although they never did the follow-up labs/imaging to check for sure, and the proper treatment was antibiotics, NSAIDs for pain/fever, and vitamins once the infection was over. Most of these were seen in children, but some in adults as well.

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Getting ready to see patients in the clinic.

Along the theme of infection includes ones of the stomach or GI tract. Many patients come in with stomach pain, nausea/vomiting, or diarrhea (lots of diarrhea). After providing a stool sample and receiving a blood draw they would return with the results to be interpreted. More often than not patients would either have a high Eosinophil count (leaning towards allergies or parasites) and/or some type of bacterial culture in their stool (often E. Coli). While in the USA bacterial infections of the GI tract are not common, patients in Nica have the deck stacked against them.

The water supply is not purified, so many patients drink un-purified water. Also, the hygiene practices of washing hands and proper bathroom hygiene is not emphasized or even known leading to an increased chance of exposure. Lastly, the food in Nica is grown with un-purified water and washed in it as well contributing to potential exposures. Typically the treatment is an antibiotic, anti-acid (which does not necessarily protect from future infection, but it is a commonly practiced prescription to give for this diagnosis in Nicaragua), possibly a fever reducer or pain relief (Tylenol or Ibuprofen), and vitamins.

  • Probiotics are not prescribed although this would be protective from future infections. The clinic does not have access to probiotics to prescribe to patients. Also, there was a lack of understanding on the physician’s part regarding healthy/normal gut flora, which could be the result of a communication barrier or lack of this information being widely accepted in Nicaragua. 
  • I was taking a probiotic while in Nicaragua, to help prevent parasite/bacterial colonization in my GI tract by lack of space. The idea behind it is that if I fill up all the space for bacteria to adhere with ‘good’ bacteria that is commonly found in the gut, then the ‘bad’ bacteria that causes infection has no place to hang on to. When I tried to explain that, their response was, why would you take bacteria to avoid infection. 
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In such a beautiful country there is unfortunately a lack of infrastructure leading to increased incidence of infection and disease.

The last and probably most common infection that was seen in the clinic includes urinary tract, kidney, and vaginal infections. I combine these together, because often women who had one had the others and most of the men that came in with urinary infections they were advancing to kidney infections. These patients most often came in with the chief complaint of “chistata”, which is a local Nicaraguan word that means urinary symptoms or pain. Again the prevalence of urinary tract infections is partially associated with poor hygiene practices (either lack of using toilet paper completely, wiping from back to front, and/or decreased bathing), lack of water intake (with the heat in Nicaragua and the humidity it is easy to become dehydrated, which increases the incidence of vaginal/urinary infections), and lack of condom use or other forms of protection as well as high risk sexual behaviors. These patients would have a UA (urinalysis) done as well as a urine culture (and vaginal discharge culture for female patients). At the visit the doctors would interpret the results of the ‘exam’ and prescribe the appropriate antibiotic based on the type of infection (Bactrim for kidney/urinary or Clindamycin for vaginal). Often for female patients they would prescribe Monostat cream for fungal infections and overgrowth. Also, patients would receive pain medication and vitamins.

Infections are a commonly diagnosed thing in clinics in Nica due to the lack of hygiene, lack of infrastructure for pure water and good food, close living quarters, and lack of sexual protection and high risk sexual behaviors. The common treatment is an antibiotic based on the type of infection (not the bacteria involved but rather the location), pain reliever/fever reducer, and vitamins for after the infection resolves. Main differences between the USA and Nica in the diagnosis and treatment of infections include: 

  • Less emphasis on diagnosing the specific bacteria if it does not change the treatment vs. needing to be as specific as possible due to providing the most effective treatment and decreasing physician liability for incorrect treatment.
  • Decreased focus of lifestyle factors that contribute and lead to these infections partially due to lack of infrastructure to solve these issues vs. discussion of lifestyle factors with  the ability to change them. 
  • Treatment that is focused on resolving the infection, but antiquated information on adjunctive treatments vs. encouraging probiotics and other treatments and therapies that help support the system while it is fighting off the infection.
  • Antibiotic heavy prescribing vs. antibiotic light prescribing.

Overall the patients in the clinic were all very sick and needed treatment for multiple medical conditions. Other medical conditions that will be discussed in the rest of this blog post include: allergy, chronic kidney disease, anemia and other illnesses. 

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Doctors, future doctors, and missionaries in front of the clinic.

My name is Emma Petshow and I am a 4th year naturopathic medical student at the National University of Natural Medicine in Portland, OR. For more about myself, check out my bio. This blog is intended for information about preventive health and lifestyle improvement. The information contained on this blog is not to be used as medical advice. For specific medical advice you should consult your physician.

Nicaragua Medical Mission – Healthcare Part 3

This is part 3 of the series on the healthcare system in Nicaragua discussing the language and my role in the clinic.

The Language

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My interpreter and I walking inside to triage

All of the intake and the visit was completed in Spanish as most of the patients reside in rural areas where English is not spoken often. Even the physicians working in the clinic and the other staff understood very little English, which made it a challenge for me to communicate with them as my Spanish level is minimal. I did have an interpreter with me some of the days, which helped, but it is very limiting as a person let alone a doctor to not be able to communicate with my patients to the full extent that I wanted to. At the end of my time there I was able to complete an intake with the patients, completely in spanish, but I was not able to understand all of their responses. It made me more appreciative of patients who come into the clinic or hospital here in the USA who do not speak English fluently, because it is challenging and frustrating at times to not understand during a medial visit. Luckily all the medications in the clinic were from the USA, so I was able to catch onto the treatment fairly quickly.

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The pharmacy… drugs, drugs, and more drugs a Naturopathic doctor’s nightmare, but at least they were in English

Most Commonly heard Nicaraguan word in the clinic… “chistata” which is their way of saying urinary symptoms (UTIs and chronic kidney disease are very common in the country).

A note on Nicaraguan Spanish… Nica spanish is different from Mexican spanish or other dialects. There are certain words that mean certain things there that do not exist otherwise. Also, they do not pronounce the “s” at the end of words, so their sentences flow together much quicker and it makes it that much more difficult to understand for someone who is not a native speaker.

My Role in the Clinic

As a medical student I was unsure of what my role was going to be while in the clinic in Nica. When I arrived to the clinic on the first day, the physicians there told me that in Nicaragua I am Doctor Emma, so that is who I was, but it was not the only role I held.

Some days I was pharmacist Emma… working in the pharmacy counting out medications for patients, explaining dosages and side effects, and making sure that the medications fit the conditions they were being treated for.

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Pharmacist Emma… learning how to dose pills

Other days I was triage nurse Emma… working at the front desk in triage hearing the patient’s chief complaint(s), taking their vitals, and getting basic medical information from them.

Then I was phlebotomist and laboratory technician Emma… taking blood draws, looking at specimens under the microscope, and interpreting basic lab results.

Lastly, I was Doctor Emma… a role I was the most comfortable with. Hearing the patient’s medical concerns, doing basic physical exams, interpreting and discussing lab results, and providing basic treatments and follow up.

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Working as a doctor, Doctor Emma or Doctor E to be exact, treating one of the sweetest patients I have had the pleasure to meet

Some of these roles were easier to assume than others, but it was difficult to jump in between roles in a single day. The physicians in this clinic and others like it have to be prepared to assume multiple different roles at any time, which only increased my respect for them and all that they do.

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The doctors and I… they definitely took me in as family during my time here

Nicaragua Medical Mission – Healthcare Part 2

This is part 2 of my series on healthcare in Nicaragua covering a typical day in the clinic.

Typical Daily Clinic Schedule

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Several patients waiting to be seen

The clinic I worked in was open from 7:30 AM to 4:30 PM. We would arrive around 7:00 AM to anywhere from 20-30 patient’s waiting in the waiting area outside. Prior to the clinic being open one of the doctors or one of the medical missionaries (myself included) would give a short devotional to the patients outside.

Nicaragua is a primarily Christian country with 40% of the population Catholic and 40% protestant. While this would typically never happen at a clinic in the US, the devotional time allowed the patients to reflect on something during their wait period prior to being seen and also they saw that the physicians in the clinic cared enough to take the time to prepare something to say and pray with them. It was a sweet moment to see all the staff members and patients together as one in prayer.

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The doctor giving a devotional to patients waiting to be seen at the clinic

After that the clinic would open. Patients file in one by one, first going to the front desk and paying their 3 Cordoba (26 Cordoba = $1 dollar), which covered the whole medical visit including most treatment. Then they would go to the front desk where a nurse and/or medical missionary (like myself) would take their vitals and ask them basic intake questions about their current symptoms, allergies, medications, etc. Then they would either go get their blood drawn in the lab (an exam as they called it), meet with one of the doctors at their desk for a consult or lab result interpretation, or in some instances go into a treatment room and receive an ultrasound, EKG, or further examination.

Most of the patient visits involved very little examination outside of heart, lungs, vitals, and HEENT (head, eyes, ears, nose, throat). Sometimes an abdominal exam was performed. Sensitive exams (gyn exams, prostate exams, etc.) were only done on special days when outside doctors were visiting the clinic, generalists typically do not perform these exams in Nicaragua.

More on types of diseases seen and treatment administered in Part 4 of the series. After the patient discussed their symptoms with the doctor, they received a piece of paper with medications and doses on it. The patient would then head outside of the clinic over to the pharmacy window where the pharmacist or medical student or whoever was working the window that day would count out the correct number of pills and provide the patient with a bag of medications for no extra charge.

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Where I counted pills as a pharmacist

At around 12:00 PM, the clinic closed for 1 hour for lunch, kind of like doctor’s offices in the USA. All of the staff members would crowd around a tiny table in the middle of the clinic and eat and talk together. It was a nice moment in the middle of the day to slow down and check in with one another. After lunch was over, it was back to business, but typically slower in the afternoon. Around 4:00 PM we cleaned up the clinic, but did not mop or sanitize things, because they have a cleaning lady (janitor) who would pick up after everyone was gone.

The clinic saw between 70-100 patients per day of various ages, genders, and states of health.

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Entering into the clinic through triage

The overall clinic operations on a day-to-day basis was similar to a small rural clinic in the USA. Some differences were that all of the staff… doctors, cleaning staff, nurses, etc would sit together around the same table and eat during lunch. No one was working during this time, checking their emails, or reading. It was refreshing to disconnect. Also, there was less emphasis placed on exams and more on what the patient had to say. It was more personal. Similar to the US, the visits were rather short, 15 minutes tops (unlike a typical patient visit with a Naturopathic physician).

Nicaragua Medical Mission – Healthcare Part 1

Since my blog is about healthcare and preventive health, I figured making my first post about the heath care situation in Nicaragua would be fitting. This is a 5 part series that explores the healthcare system in Nicaragua including:

  • Clinical logistics and medical training
  • Daily operations of the clinic I served at
  • Spanish language barriers/benefits and my role in the clinic
  • Commonly seen conditions and treatment plans
  • Lastly places where I think Naturopathic medicine or preventive medication could play a role
Heading to work my first day

Heading to work my first day

Clinic Logistics

During my time there, I was working as a student doctor in a rural medical clinic about 20 miles outside the city of Leon. The clinic treats between 70-90 patients per day and has a staff of 2-3 Nicaraguan doctors (MDs). They also have 3 nurses which help run triage (vitals and patient intake), lab draws, and more. Other staff members include a pharmacy technician, front desk, laboratory technician, and nurse interpreting microscopic lab results. The clinic is set up as a non-profit and receives most of its medications and equipment via donation from the USA. This means that the staff and doctors make a living wage, but not much more. Most of them working here are working here, because they have the drive to serve others.

The 1 mile trek into the clinic from the main road

The 1 mile trek into the clinic from the main road

The patient population is mainly poor, rural, local Nicaraguan’s who cannot afford government healthcare or hospital care. A lot of the population cannot afford healthcare and therefore cannot see a doctor. With a population of about 6 million where 75% are making about $2 a day, you can see why there is a great need for affordable healthcare options.

All of the donations received by the clinic are carefully scrutinized by the Nicaraguan government, which often asks for part of the donation to allow it through to the clinic itself. The government and political aspects of the country are something in themselves, but I will hold off discussing that for now and leave it for a later date/post.

  • This year is an election year in Nicaragua, which played a role in my leaving prior to schedule and to protect the people who live in the country and others who are going to serve I am going to wait to comment on the political climate until after their election in November.
Some homes and storefronts outside of Leon near the clinic

Some homes and storefronts outside of Leon near the clinic

Medical Education

I spoke with a current medical student in Nicaragua about their medical training and it seems similar to the USA in some regards, but different in others. She states the medical training in total takes 6 years after high school. The students start their first 2 years of training in basic science coursework (biology, chemistry, etc.) and other basic clinical skills (vitals, patient intake, etc.). The student’s complete this training alongside nurses. At their third year, they split off and the nursing students continue on their curriculum for 2 more years, while the medical students begin to take more clinical course work such as pathology, diagnostics, and pharmacology. Their last 2-3 years are spent doing rotations in clinic and hospitals. At the end of this training they receive an MD. One notable difference, is that the students are not required to receive a bachelor’s degree prior to starting medical school, instead it is kind of included in the program. After their basic training, the students can decide if they want to be a generalist or specialized (Cardiology, Surgery, Etc.), which requires anywhere from 6 months to 3 years to complete.

Meeting one of the doctors

Meeting one of the doctors

Some interesting differences…

This might have been the clinic that I was working with, but there were some very apparent differences from the physicians ways of doing things in Nica compared to the USA.

Regarding diagnosis…

  • The exact condition is not as important if it does not change the treatment or outcome… if the patient has a lung infection and we have only one antibiotic to treat it, regardless of the infection type, there is no need to do further studies/imaging/etc.

Vs.

  • Diagnosis must be as precise as possible, because we would not want to give the patient an antibiotic or medicine if they truly did not need it.

Regarding clinical hygiene…

  • Certain conditions are only contagious to certain populations of individuals, so it is alright to touch the patient’s rash without a glove, because there is no way that it can be spread to you. Also, no need to sterilize your hands, stethoscope, desk, etc. after seeing each patient… only if you feel it is truly needed.

Vs.

  • Everything is infectious all the time, wear gloves always, disinfect everything every moment. Germs, germs, germs! 🙂

Regarding treatment…

  • Counseling patients on their diet, lifestyle, and physical activity is probably useless, because they will not listen, but we should do it anyways.

Vs.

  • Well honestly that is similar to the USA in some aspects… but we are trying to change that by meeting patients halfway!

Overall, while the education and some practices were different, their heart and purpose is in the right place and the clinic and the physicians working there are filling a huge gap in the healthcare system in Nicaragua and saving many lives… Check back for parts 2-5 to be posted throughout the weekend.

Some of the clinic staff during a women's only devotional/meeting

Some of the clinic staff during a women’s only devotional/meeting

Nicaragua Medical Mission – Update

Hey Everyone!

Sorry I have been silent the last few weeks… I have been serving and busy with my work down in Nica. I have since returned home a few weeks early due to several reasons including travel concerns, safety, and health. I am doing great, but will be self-quarantining over the next week or so. I have seen, experienced, and learned so much and I have a lot to say so I will be using my quarantine time to post about my experience, the people I served, and pictures (tons of pictures). If you have questions or things you definitely would like me to share about my time there feel free to comment below or send me a message and I will make sure to post about it.

Thanks again for your support and there will be more to come.

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