Joenard's Duke-EWH Summer Institute

Sorry for not posting for a long time. Here is what I was busy doing my last weeks in Central America…

Fixing Medical Equipment

For me, the learning curve was pretty steep in the first weeks working in the hospital. I got so used to the lifestyle in Costa Rica that I didn’t anticipate having to adjust in Nicaragua. But, after a week, I was able to get into the swing of things and get down to what I came there for: fixing medical equipment.

The first piece of medical equipment really threw us into the deep end of the pool: it was an infant incubator that had a low battery alarm. We spent the entire first week taking the incubator a part (not an easy task as there were many screws and small bits that we had to take track of) trying to look for the source of these problems. What made it harder was that they didn’t have the manual for it (which was the case with many of the machines we tried to fix). We first tried to replace the 9 Volt battery in the front panel, which didn’t stop the low battery alarm from going off. We then tried charging the main system lead-battery with a makeshift AC/DC converter (shown below). That took away the low battery alarm, but brought up a system error alarm. So, we looked at all the circuitry starting from the plug on. We looked at the fuses and the plug socket to see if they were in tact, which they were. So, the next thing downstream from this was a metal box enclosing a fan with its control circuitry and connectors from the power supply. We took it out and we found that the thermistor that shut off the entire system when it started to overheat was broken. We took it out and spent the next week talking to technicians trying to figure out what type of part it was and who we could call to order a replacement part. When all was said and done, we found out it was from GE and Alex was able to contact the president to mail us the part for free. Unfortunately, it reached Managua the last day of work and we weren’t able to install it and see if we could put it back into service.

Out of the 24 pieces of equipment that we looked at, we were able to put back 83% of them (20 out of 24) back into service. The average for the program is 70%. Although this is really a rough estimate of value, servicing these 20 pieces of equipment saved the hospital $23,089 that they could spend on complete replacements of these same machines. Most of these machines were fixed by cleaning out various components or soldering connections that were loose after wear and tear.

Breakdown of equipment we looked at:

Equipment Number
Aspirators* 6
Blood Pressure Machines 1
Centrifuges 2
Electrosurgery Units 1
Dopplers 1
Glucometers 1
Incubators 1
Lights 2
Other 2
Otoscopes 2
Pulse Oximeters 1
Wheelchairs 2
X-Ray Developers 1

*includes nebulizers

First fix – infant incubator


Apparatus to charge batteries.


Broken thermistor from the incubator.


Otoscope that wouldn’t light because there was too much earwax in the earpiece.


Centrifuge with re-soldered connections (in red).


Doppler probe with frayed connections.


Alex testing the doppler probe. (It doesn’t work on him, but it does work on everyone else!)


Antique cauterization machine. It didn’t go back to service. Our host dad wants it put in a museum in the hospital.


The bovie gun of the cauterization machine. It is the part that the doctor uses to cauterize wounds. We opened it up and we sanded out the corroded bits and now it works!


Alex on a makeshift wheelchair that was made/used before we came. We fixed the misaligned wheel.


Me opening up a pulse oximeter to test the electronics inside.


The only portable otoscope in the hospital.


Me testing the blood pressure machine we fixed.


Suction machine that we fixed for the pediatric ward.


Secondary Project – Alcohol Gel Stations

Right after he picked us up from the airport, our host dad, Osvaldo, started talking to my partner, Alex, and me about a “crazy idea” of his for our secondary project. The hospital that we were going to work in (and the one that Osvaldo works in as head of Epidemology among other titles) had soap that was too corrosive for standard soap dispenser valves. This made hand sanitation less accessible in hospitals. So, he asked us to design a valve that was made of a material that can withstand these soaps.

We were working on this for a couple of weeks until Osvaldo came back from a conference in Managua. He was informed that the government was recently interested in promoting the use of alcohol gel for hand sanitation. This changed our design criteria a bit. We needed to devise a way to mount an alcohol gel bottle (which was government supplied bottle) to the wall. We also needed a way to secure the bottle from thieves, but still allow people to get enough alcohol gel to sanitize their hands. This was all directed towards the same goal as the first project of increasing the accessibility of hand sanitation in the hospital.

In our brainstorming sessions, Alex thought of using a water bottle holder that is usually mounted on bikes to support the upside-down alcohol gel bottles and I thought of supporting the bottles using a mesh. However, the design truly came to fruition when Alex went out to the market and shops to see what materials we could use. The bike holders were too awkward to use and the mesh was nowhere to be found. But, he did find a PVC tube holder that fit perfect on the bottle and could be mounted. To support the top, we used some thick wire from the workshop to create a ring, which would support the inverted top of the bottle. The holder and the ring were connected by string. We then used more wire to tighten the holder and another wire to add more of a sense of security. We also replaced the sports cap that was originally distributed with the bottle with a soda bottle cap with a hole small enough to impede flow when not under pressure but large enough to dispense an adequate amount of alcohol gel.

After we assembled this and made sure it held up during use, we drafted a poster (in Spanish) to remind the staff how sanitizing hands can prevent cross-infection and how to properly sanitize hands. We printed out colored copies of these posters, laminated them, and then stapled them to 40 by 35 cm pieces of plywood. After we mounted the bottle holder onto the board, the station is complete! On our last day of work, we placed the stations in the cafeteria, next to the clock where people check out at the end of every shift, and in the emergency room. Right after we nailed them to the walls, we got a few curious people who tried the station out. A lot of the assembly of the station couldn’t have been accomplished without the help of our friends in the carpentry workshop!

The poster was just one part of the awareness campaign. The second part was to create a message that would play periodically through the PA system of the hospital. The only problem was that the PA system only had a microphone. So, we soldered a stereo plug and a mini-jack plug to two ends of a wire and used a CD player to play a message reminding people of the alcohol-gel stations. In order to get the CD player to run continuously, I had to look for 3 hours all over the markets of Masaya —a town 30 minutes north from our home-stay— for a power adaptor for it.


Alcohol gel bottle that the government supplies Nicaraguan hospitals.


The Alco-Gel station.


Closeup of the soda cap with the hole that attaches to the bottom of the alcohol gel bottle; the modified “valve.”

Here’s a Prezi presentation showing the various aspects of the awareness poster we made.



We put the first Alco-Gel Station next to the machine that all the employees use to sign in and out.


We also put a station in the emergency room.


We put the third Alco-Gel Station in the cafeteria.


The stereo to mini-jack cord we had to make for the sound system to periodically play a recorded announcement from a CD player.


The hospital sound system with the CD player/cords.


Front page of the assembly manual we wrote up.


Happy with sanitized hands!


Getting to Know Nicaraguan Culture

Right from when he picked us up from the airport, I knew that my host dad, Dr. Mercado, was well known within where we were going to stay and work in Nicaragua. Whenever we would travel with him, it was inevitable that he would meet one of the many people that he has made friends with over his life. I perceived him as a legend of sorts. This is a result of not only his interesting life (that I don’t feel comfortable sharing on a public forum such as this) but his knack of going out of his way to make everyone around him feel as comfortable as possible by being as genuine and friendly as possible.

More or less, I felt that there was definitely a higher threshold of genuineness and friendliness among Nicaraguans as opposed to people in New York City. These two qualities complemented each other: they were interested in your life and, in turn, they would divulge in you everything, vulnerabilities and all. This isn’t just a phenomenon that I’ve seen based off the encounters that I’ve had in the situations where the native residents were just being nice to the “tourist.” But, I’ve seen this between other native Nicaraguans as well. I’ve engaged in this first-hand when I was mistaken for a native Nicaraguan for the first time (when I have sunglasses on, I can even convince myself that I am) when a group of us went on a weekend excursion to Ometepe. We were trying to find a guide to lead us one of the volcanoes and we asked this convenience shop worker where we could find one. All the time he thought I knew the most Spanish and just talked to me. He treated me with the same friendliness that other Nicaraguans treated “tourists.” Consistently, I experienced this happen when other Nicaraguans took the impression that I was a native Nicaraguan.

I discussed this aspect of Nicaraguan people with a Canadian expatriate I met in a restaurant in Jinotepe who lived in Nicaragua for the past 17 months trying to start his own programming business. He felt that the friendliness was all a ploy to get something from tourists. He also felt that they were backwards as a people. He had a bad experience with a doctor at the Hospital Jinotepe who treated a friend of a friend who fell off a ladder. He then went on about his other observations of Nicaraguan people that helped form his cynical viewpoint. I thought it was refreshing to hear his cynical viewpoint because, up to that point, I felt like I was wearing rose-colored glasses and I was missing certain aspects of Nicaraguan culture. For example, there is a lower threshold of what is considered inappropriate. There were a handful of times I have walked down the street where Nicaraguans have seen me and called out to me “Chinito.” which means little Chinese man. In addition to that, the media was quite keen to show all the gory details of car accidents and crime scenes. My lack of understanding of this aspect spurs my desire to come back to Nicaragua. I would like to get even more immersed in the culture so that I can get close as I can to truly knowing the culture of Nicaragua.


The Nicaraguan bus as bold and beautiful as the people that occupy it. We used these types of buses to go to work every day and travel on the weekends.


The central park in Jinotepe. Every building was painted like the walls of this park; in bold, bright colors.


Spanish style buildings in Granada (the second biggest city in Nicaragua, which was an hour away from Jinotepe). Again, they are painted in bold, bright colors.


One of the national dishes of Nicaragua – Nacatamal.


Meringue band playing on the streets of Jinotepe.


Festival of the Saint Santiago, the patron saint of Jinotepe.


Me and my host family in Nicaragua.



On July 28th, Alex and I said our farewells to the host family and left on the back of a pickup truck with our luggage to a very intimate but upscale hotel in Managua. We checked into our rooms and caught up with the other 24 members in our program. The conference was kind of set-up for that in many respects. First, the C.E.O. of Engineering World Health, Melissa Beard, said some opening remarks and then student presentations began. Most of these presentations were about the different fixes that each group did over the past month at their hospitals. The remainder focused on the culture exchange and language of the program. I enjoyed the presentations from the Diriamba and Masaya groups the most. The Diriamba group presented a survival guide for future groups, which had all beginning Spanish speakers. The Masaya group came up with a version of an iPhone game where we had to guess the logo of companies that were ubiquitous in Costa Rica and Nicaragua and they distributed candy to the group that had the most correct answers. Overall, there were a lot of laughs and a lot of insight into the experiences of the other groups. The next day, we all left for our respective flights home.

Here’s the presentation Alex and I presented on our secondary project:

EWH Secondary Project – DIY Alcohol Gel Station (Joenard & Alex) from Joenard Diaz


Fun Stuff

1st Weekend – Ometepe (Largest Island in Lake Nicaragua with two volcanos!)

2nd Weekend – Granada

3rd Weekend – La Isla de Braisilles

4th Weekend – San Juan Del Sur, Lagoon de Apoyo, and Leon for Volcano Boarding down Cerro Negro