Corinna Heiberg’s Random Pictures from Chisang Clinic
Yamuna taking a blood sample during community outreach
Woman getting her temp taken at community outreach event
Suture of Shishir’s forehead
Staff and Becky
Shishir post-suture!
Painting – always improvements being done to the clinic
Mother and newly born child during home visit:interview
Heading off to set up for community outreach on the clinic’s bicycles
Corinna standing in front of the rice field she planted with her parents, Anita, Laxmi, and Ashley
Corinna holding a baby during an interview regarding the pregnancy and birth
Corinna cleaning and bandaging a wound at community outreach
Corinna being blessed by the local priest in front of the temple
Community outreach
Community outreach at Narayan chowk
Clinic staff organizing the supply cabinets
Clinic
Becky seeing patients at community outreach
Baby getting weighed for the growth chart
Alaka examining a patient at community outreach
Dr Briana’s Pictures of Chisang Clinic (March – May 2012)
Chisang Clinic staff with Dr Briana
Dr Briana holds a baby at the clinic
Villagers with Dr Briana
Debendra Karki with the clinic staff
One of the Examination Rooms at the clinic
Dr Briana performs an Ultra Sound on a pregnant woman
Patients at the clinic
Dr Briana examines a patient
A patients gets his wound cleaned
Dr Briana with the clinic staff
Medic Becky Thomas – Experience in Chisang Clinic in Rural Eastern Nepal (Vol. I)
Compared to my home in the UK, night time in Nepal is somewhat different. The sun goes down, the lights go out and with no regular electricity the area is often plunged into a peaceful darkness.
It is at this time that villagers bring in their goats and cattle for the night, and everyone settles down after a hard days work. The air erupts with the evening chorus of bugs and frogs. It was always at this time we had the most serious of patients. And at this time just over a week since I arrived at the clinic, was when we had our first major trauma case.
Our Chisang Clinic team at this point was made of the three wonderfully supportive and diligent permanent staff; Alaka the Health Assistant, Gita the Nurse and Yamuna the Lab Assistant. Working with them were the three international volunteers; Corinna public health student, Ashley human rights student and me, Becky, medic. Working as part of such a supportive team completely made ease of working in such a new environment.
Kopila on the balcony
That evening we had been invited to the house of a lovely couple named Chinnie-Maya and Tej. We had spent the evening laughing and joking with Chinnie, comparing fashion tips and trying on Saris. We were just winding down standing on their balcony, drinking our Chia and watching the sun go down, when Chinnie-Maya left to take in her cows. After a few moments we heard a loud cry “GUHAHR!”. Not yet knowing much Nepali we looked over at Gita and Alaka to find fear cast over their faces.
We ran down stairs to find Chinnie-Maya drenched in blood and clutching her head. “KE BHA YO?” “WHAT HAPPENED?” Her bull had charged her as she was leading him home. Animal accidents are common in this area. We just had time to give her some cloth to compress the wound, when she lept up and started striding out ahead of us towards the clinic. We scuttled along after her. As we passed through the winding village paths, our neighbours, alarmed to see Chinnie-Maya in such a state, joined the procession in escorting her to the clinic. By the time we all arrived at the clinic night had fallen, and with no electricity available the clinic was dark. We settled Chinnie-Maya down, cleaned the wound and by torchlight prepared for sutures. With the windows blocked with spectators it was gaspingly hot. Yamuna crouched beside Chinnie-Maya with one hand fanned her face and with the other shined the torch for us to see. With no adequate light and a large audience of villagers we shakily began by cutting back her hairline to reveal a 8cm gash in her scalp. In a hasty team effort from Alaka, Gita and I, we had doused the bleeding and stitched up the wound. And after her TT shot and some skillful bandaging by Gita she was free to return home.
The team in action, stitching the wound. (Photo by Corinna Heiberg)
The wound quickly healed and after 5 days the stitches were ready to be removed. Chinnie-Maya was so happy with the results “Ramro” “beautiful” she said as she inspected our handiwork. It than dawned on me after all the excitement had passed how critical our service is to the community. If the Chisang Clinic was not open, Chinnie-Maya would have had to travel miles either on foot or by the excruciatingly expensive nighttime taxi to the overfilled, under staffed and over expensive hospitals nearby.
The day following this incident we all got to work organizing and labeling our stocks of emergency equipment so that we could now efficiently find the trauma supplies if needed. The clinic also invested in its own inverter generator so that now electricity and lighting is available 24/7. We also got to work writing the trauma and wound care protocols, and running group-training sessions for everyone at the clinic. Now when the emergencies come in after dark we can provide the best possible service to those with critical need.
Two days later, the wound is healing well! (Photo by Corinna Heiberg)
Interning at the clinic has given me so much invaluable experience. With no, senior colleagues to shy behind, you are really forced to develop quickly into a competent clinician. I will miss working with my Nepali team very much. I have never experienced working in such a close nit team and it is really a testament to the other girls at the clinic, how adaptable and supportive they are. And although I was far from home, I really felt like I had a new home in this little village in Nepal.
Chisang Clinic family
Dr. Briana Cranmer’s Chisang Clinic Experiences (Vol. III)
It is a hot April day in the village Chisang Clinic. As I am praying for rain or even just a soft breeze the curtain shifts and a mom enters with her child. Mom is young, maybe 18, she looks tired and slightly unsure of herself. Using my limited Nepali I tell her “bosnus, sit down.” I then turn to my wonderful translator Geeta and ask why mom is here. The baby has been sick, not eating, not drinking, and vomiting constantly for the entirety of her 17 days of life. Mom is at a loss. She says she is breastfeeding every hour, but only for five minutes at a time. She has tried supplementing with formula, but every time baby feeds, she “vomits.” This is mom’s first child, the pregnancy was normal, the delivery went smoothly, but baby only weighed two kilograms
(4.4 pounds) at birth.
The Bhawanee community
in the clinic
I peek over mom’s arm and glimpse a sleeping baby girl. I gather her in my arms, shocked by her lightness. Medical school lesson #1: when evaluating a patient always determine, sick or not sick. Tiny warning bells sound off in my head, this baby is sick. Removal of each layer reveals a malnourished, underweight, lethargic baby girl in dire need of medical attention. Medical school lesson #2: never use the term “lethargic” when describing a baby unless you truly mean it. The warning bells are deafening, this baby needs immediate medical intervention. Baby’s fontanel is sunken and her heart is racing implying dehydration, her breaths are quick and shallow, but thankfully no sounds of pneumonia. She is tiny, skin and bones, and barely holding on to her two-kilogram birth weight.
Dr. Briana Cranmer and nurse Geeta evaluating a sick child
I consider the options available in this rural clinic, 1.5 hours and many kilometers from the nearest hospital. I remind myself that the clinic has only been open for two weeks and we are currently in limbo with regard to our ability to manage sick patients. If their fundraising efforts are successful, the Chisang Clinic at its peak in a year or two, will have a 4-5 bed inpatient unit for severely/acutely sick patients requiring 24 hour care and a 10-15 bed obstetrics labor and delivery ward. The clinic will have IV fluids and nutrition, heart and oxygen monitors, an extensive pharmacy, and all of the medical resources necessary to nurse this baby to a proper weight and health. Although, construction is underway and funds are being raised, I am currently without the necessary resources. My options are either to attempt to manage baby with my limited supplies or refer her to the hospital in Biratnagar.
My medical supplies
In America, when you make a referral it is typically because you believe a different facility or doctor may have the knowledge or skills more fitting to the needs of the patient. I quickly learned that this was not true when it came to the hospitals and physicians nearest to the Chisang Clinic. Often, I discovered patients received lesser care or no care compared to what I was able to offer. So when I was faced with a medical challenge involving one of my babies, I did the only thing I could think of. I asked advice from the most reliable source I could think of – my sister, a pediatrician in Seattle, WA. In my anxiety over the severity of my baby’s condition, I forgot the twelve-hour time difference to the U.S. and she received a 4:00 a.m. consult call from Nepal. Ooops!
Government Hospital in Biratnagar
Ultimately I recognized that without IV fluids and proper nutrition this baby girl might not survive. Her needs were beyond my ability to provide care. I sent mom to the hospital with a detailed medical note and instructions to return if there were any problems. As they walked away, I sent a handful of prayers after them in hope that they would receive the medical attention they deserved.
It has been a week since my encounter with the 17-day-old baby girl. Suddenly, while on my weekly home visits, I find myself standing on her front stoop. An elderly lady sits next to a bundle of blankets. As I approach, a tiny hand shoots up out of the mass with a second tiny hand following close behind. My heart jumps as I peek into the bundle and see baby’s sweet smile. I gather her into my arms, forgetting to ask for permission in my excitement. Baby did in fact receive care at the hospital and she was finally eating better and gaining weight. I look forward to the continued development of the Chisang Clinic and their future ability to manage patients such as this baby girl. Soon enough as the clinic continues to grow, the people of Bhawanee village and the surrounding areas will be saved the 2000 rupees cost of transportation and the stress of being far from home. Instead, this community will be provided with caring healthcare providers who offer patience, a kind ear, and advanced medical care.
17-day-old baby and four generations of her family
Dr. Briana Cranmer’s Chisang Clinic Experience (Vol. II)
The clinic is filled with the giggles of the twenty women sitting in the waiting room as they joke and laugh. It is the unofficial opening day for the Chisang Clinic in Bhawanee village of eastern Nepal. In the promotion of maternal and child health our local friend Anita has ridden her bicycle 15 miles in each direction to spread word of the clinic and recruit pregnant women for their prenatal care. Today these women have arrived in masses bringing their joy and excitement of motherhood.
Performing Ultrasound on a Pregnant Belly
As the day wears on and I settle into the groove of the clinic I meet Laxmi, a first time mother at 36 weeks of pregnancy. Thankfully she has been receiving regular prenatal care at the government clinic, but sadly this costs her much time and money. As I examine her records, measure her belly, and use the ultrasound to see the baby, I realize how important the Chisang Clinic is to the health of the community. Not only is the clinic essential for the acute care of wounds and pneumonia, but in providing routine and preventative care the clinic is crucial in promoting the health of the entire community.
Today I am only able to offer a simple evaluation of this wonderfully pregnant woman, but hopefully soon the Chisang Clinic will offer much more as it continues to fundraise and collect donations. They plan to have a lab in order to conduct the necessary tests, to build a pharmacy to provide the appropriate antibiotics and vitamins, to obtain more medical supplies, and to build an obstetrics unit to allow for safe deliveries. As she slides off the table to go, I remind her to drink water, take her vitamins, and to return if she has any concerns. With Namaste and a smile she passes through the curtain.
Koshi Zonal Hospital, a Public Hospital, in Biratnagar
My time volunteering as a physician at the Chisang Clinic has come to an end and the clinic Director Debendra Karki and I are headed to Biratnagar. He has emphasized the importance of visiting the government hospital in order to better appreciate what a referral means for our patients. He also hopes to show how incredibly valuable the Chisang Clinic is to the Bhawanee community. At the hospital I am disturbed by the mass of people forced to wait in the heat of the sun, the women sprawled on the floor, the children hooked up to IV’s scattered along the windowsill, and the trash bins overflowing with needles. One man vomits into his hands on my left while a family weeps over their ailing child on my right. The extent of pain and suffering is almost suffocating, not to mention the smell of sickness. A woman grabs Debendra’s arm and pulls us to a bed. She is from our village, her son has had diarrhea and vomiting for the past week and they have been in Biratnagar for the last two days receiving treatment for severe dehydration.
Namaste
“Why didn’t you come to the clinic?” I ask. My heart breaks to hear it is because they didn’t believe we had the appropriate medical supplies and assumed they would be referred to the hospital anyway. Although I am sad to see them in the Biratnagar hospital, I am hopeful that as the Chisang Clinic continues to grow it will acquire the necessary resources to manage this child while saving the family money, emotional stress, and time.
A Bhawanee Family with their Sick Son at Koshi Zonal Hospital
We say our farewells and continue to the maternity ward. Looking down the dank and narrow hallway I see a woman standing in the light of a doorway. I recognize the black and red pattern of her traditional skirt. As I look to her face, my pace quickens, I know this woman. And she knows me.
A Proud Mom and
Grandmother with their New Newborn Girl
She ushers me into the room. My patient Laxmi sits on the fifth bed to the left holding her beautiful new baby girl. She had delivered just two hours prior, no complications with the delivery, and they are set to go home within the hour. Mom is glowing and I am giddy with excitement as she places baby into my arms. I am reminded yet again that this is a patient who could easily be managed by the Chisang Clinic and in just a year’s time and a lot of fundraising they will have that capability. Although I was not granted the privilege of delivering this child, I know soon enough the clinic will have that honor.
Dr. Briana Cranmer Holding
the New Baby Girl
Pictures from Chisang Clinic (Vol. I)
Chisang Clinic staff and International Volunteers on the way to make a home visit
Alka, Chisang Clinic’s Medical Assistant, makes a Home Visit
A child rests on the Examination Table at Chisang Clinic
Yamuna, Chisang Clinic’s Lab Technician, at work
Yamuna hard at work
Chisang Clinic’s Summer 2012 International Volunteers Corinna Heiberg and Ashley Phillips
Gita, Chisang Clinic Nurse Midwife applies Mehendi (Henna) on Shari Davis from GlobalGiving
GlobalGiving’s Shari Davis and Ellen Curin show off their Mehendi (Henna)
Chisang Clinic’s Founder and Director Debendra Karki
Future and Present Research Topics at Chisang Clinic
CHISANG CLINIC
Research Topics
Bhaunne, Dangihat VDC-4,
Morang District, Nepal
chisangclinic@gmail.com
1) Gastritis
What is the main cause of the numerous gastritis cases in Nepal? Is gastritis caused by patterns of food consumption and the diets of the villagers or by Helictobacteria pylori?
- About 10% of all patients come in to the clinic with epigastric pain as their main complaint and gastritis or gastroenteritis as their diagnosis. At this time, the main treatment given to patients with stomach pain is various antacids that help relieve the discomfort, such as Omeprazole or Ranitidine. But, if the underlying cause of their pain was discovered to be either the specific H pylori bacteria or their daily diets, then there could be much more successful interventions and treatment programs tailored for the people of this region.
- Look at and test the cause of gastritis of each patient with epigastric pain and determine the appropriate treatment and future advice.
2) Community Outreach
What are the costs and benefits of community outreach efforts? Is Chisang Clinic providing quality service to the people that they visit?
- During community outreach, clinic staff travels to nearby villages to examine sick patients, collect blood samples to perform blood tests, and provide prescriptions. In order to do this, extra supplies and resources are needed, as well as the additional transportation expenses. For the patients, it is a way to access healthcare in their own community, though it may be a reduced service since they are not being seen in the examination room.
- Look at the expenses and resources needed to put on a community outreach event and the services provided to the patients who may have not otherwise received care in order to improve future community outreach efforts.
3) Health Seeking Behavior
Who comes to the clinic and why?
- Men, women and children of all ages come to Chisang Clinic. Look at the socioeconomic profiles of each patient – age, sex, caste, income, autonomy, etc to determine if there are certain populations or under privileged people not being reached and specific ways to reach these people.
4) Health Seeking Behaviors of Tribal Populations
What are the health seeking behaviors of the different tribal populations that live in Nepal? Is Chisang Clinic reaching every caste and tribal group equally, or do the clinic and outreach efforts only reach certain groups of people?
- Look at the profiles of both the patients who come to the clinic for treatment and the people who seek treatment at outreach clinics in different villages. Investigate the underlying reasons that some tribes may seek healthcare more often or from certain facilities and some tribes may refuse to receive medical treatment.
5) Animal and Occupational Hazards
What are the health impacts for villagers working in the fields with animals?
- Many people in the villages sustain injuries, trauma, or wounds from farming and working with large animals such as ox, cows, and buffalo. Since there is often a need to continue farming, and little incentive to travel far to a health clinic, often times people will try to continue working or put off getting healthcare. Even if people do come to the clinic for wound care (sutures, dressing, cleaning, etc), they typically return to work that day, which may prevent them from being healed.
- Look at the most common occupational and animal injuries and develop interventions aimed at preventing future injuries. Develop strategies aimed at encouraging patients to keep their wounds clean and uninfected while continuing to work.
6) Maternal and Child Health
What is needed to start a birthing center in a rural area with few resources?
- Chisang Clinic is looking to open a birthing center later this year. In order to do so, the clinic must first follow international protocols and guidelines, gather all of the necessary supplies to provide safe births, and have a staff experienced in obstetric care.
- Complete a literature review to record and consolidate information from peer reviewed journals and articles. Summarize the necessary steps the clinic must take prior to opening a successful birthing center. Focus on other international examples of new rural birthing facilities.
7) Nutrition
What is the calorie and nutritional profile of the typical meals that villagers eat every day? Does it meet the WHO international nutritional guidelines? Is it in balance with the energy output of people doing heavy labor? What are villager’s ideas of what is nutritious and is it correct?
- Every day for lunch and breakfast the majority of Nepali people cook and eat some form of dahl baat tarkari or lentils, rice, and vegetables. Though there is variety in the types of lentils and vegetables consumed, these three foods make up almost the entirety of Nepali’s diet. When a member of the family is sick, pregnant, or has a certain condition, there are numerous beliefs and practices of either excluding certain foods or consuming additional foods such as sweets, meat, or fruits that may or may not be based in scientific research.
- Evaluate and measure the nutritional value and calories in a typical meal of dahl baat tarkari as well as the total nutrients and calories in a day’s worth of food intake. Compare this with the energy expenditure of men, women, and children doing housework, working in the fields, etc. Evaluate the impact this has on people’s day to day lives, energy levels, and overall health. Also evaluate the impact of excluding or adding certain foods to the diet of people who are ill and if it improves, worsens, or has no effect on their condition.
8) Water Content
What is the composition of the drinking and washing water in Bhaunne? What are the levels of arsenic? How does the drinking water affect health?
- Test the water in Bhaunne from several different common water pumps and examine the composition. Look at the ways that certain amounts of minerals, bacteria, etc may be affecting villagers health
9) Child Rearing Practices and Child Abuse
What are the child rearing practices of babies and infants in Bhaunne? Does it promote a healthy lifestyle? What are people’s attitudes and responses to cases of child abuse and how often do they occur? What are the policies and system to deal with child abuse?
- Interview villagers and ask questions about their attitudes and own practices related to raising children. Look at different religious and cultural customs that occur from the time the baby is born to when they are infants, children attending school, and finally adolescents. Specifically, look at cases in the community of child abuse and interview both the family members and community members to evaluate the level of response and ways that abuse is handled.
10) Breastfeeding Practices
What are the breastfeeding practices of women in Bhaunne and does it differ than international trends?
- Perform a literature review of international recommendations and breastfeeding practices in developing and developed countries and the changes over time. Then, interview and observe the practices of women in the village who have recently given birth.
11) Staff Behavior
How does the staff interact with patients of different castes and income levels? Do they treat unmarried or younger women differently?
12) Domestic Violence and its Public Health Implications
What are the forms of domestic violence and some example cases from Bhaunne? What are people’s attitudes and responses to domestic violence in their communities?
- Perform a literature review on international domestic violence policies and compare it with the practices and laws observed in Nepal.
13) Decreasing Agricultural Land and its Effect on Nutritional Status
Subdivisions of agricultural land occur both by families selling off portions of their land for a profit, and dividing the land between family members as people move to work abroad. What is the effect on the nutritional status and diet of family members that continue to live in Nepal?
14) Farming Practices
What are the effects of fertilizer and pesticides on the health of the people in the village?
15) Female Community Health Volunteers Impact on Healthcare Access
What are the roles of FCHV in Nepal? What is their training? What services do they provide? Do they have a positive impact on the health of the population? How do FCHV compare to community health workers in other countries?
ONGOING RESEARCH TOPICS
1) Antenatal Care and Birthing Plans
The focus of this research topic is to identify health seeking behaviors and services available for pregnant women in Nepal. Through interviews with pregnant women and women that have recently given birth, issues such as the quality of antenatal care, and choices made about birthing are addressed. The responses will then be used in the design of the birthing center to ensure a facility for safe deliveries.
2) Pharmacies
Many people in Nepal look to pharmacies to provide primary healthcare even though pharmacists have minimal training and qualifications. This case study requires visiting pharmacies, evaluating the services and medications they provide, and interviewing the pharmacists. The purpose of this research is to determine the effects of this trend on health and to encourage Nepali people to seek more reliable sources of healthcare.
3) Prevalence of Uterine Prolapse
Since Uterine Prolapse is an extremely prevalent reproductive health condition in Nepal, this research investigates the causes and primary symptoms that affect women in this area. Patients identified at the clinic with Uterine Prolapse are surveyed regarding their delivery experience, risk factors, and how their quality of life has been affected. The results of this research hope to increase awareness in Nepal and advocate for organizations to find ways to address this issue.
4) Human Rights and Access to Healthcare
This research topic aims to explore human rights as it pertains to the availability and financial impact of healthcare. Patients that were referred for further treatment and investigation have been interviewed to learn more about their likeliness to follow-up with the referral, obstacles in seeking healthcare, and overall experience. The topic is also an investigation of the roles that gender and socio-economic status play in the healthcare decision making process as well as the common behavior in financing healthcare.
Dr. Briana Cranmer’s Chisang Clinic Experience (Vol. I)
A jumble of Nepali voices dance through the darkness. There is nervous tension in the air. “Ke boyo? What happened?” At the center of a crowd stands a mother tightly grasping the hand of her frightened son. Despite her calm demeanor there is a sense of urgency in her eyes. Closer inspection reveals dried blood spattered across their hands. Mom slowly removes her thumb to reveal an open wound at the base of her son’s ring finger. Her son sliced his hand on a piece of sharp tin 30 minutes ago. We are the closest medical center for 80 kilometers and the only place available at seven at night. “Kripaya timi sahayog garna sakchau? Can you please help?” she pleads. My name is Briana Cranmer and I am a medical intern at the Chisang Clinic in the rural village of Bhawanne, Nepal.
Suturing by headlamp while mom covers her son’s eyes.
My medical career began five years ago while volunteering in village clinics across western Kenya with the organization Village Volunteers. It was these experiences that led me toward my life’s passion of providing care to underserved populations in remote areas lacking medical resources. After four months in Africa, I returned to the United States and began the pursuit of my medical degree in Family Medicine in conjunction with my Master’s in Public Health. In addition to my work in Kenya, I also worked alongside the Hopi, Navajo, and Apache American Indian tribes in the remote sections of northern Arizona and among Alaska Natives in central Alaska. My work in Nepal has simply been a natural extension of my zest for travel, medicine, and providing medical care to populations that lack access to adequate healthcare.
The recently constructed Chisang Clinic, established in eastern Nepal, supports more than 30,000 people in over 15 villages. The overall goal of the clinic is to promote women’s health through the provision of gynecologic and obstetric care including antenatal, natal, and postnatal management as well as monthly Healthy Women Clinics. Chisang Clinic also strives to improve the health of youth through Healthy Child Clinics and monthly Immunization Clinics. Additionally, the clinic will provide use of the facility to local and international Non-Government Organizations for special outreach programs such as surgical correction of congenital deformities, post-burn contracture repairs, and eye and dental clinics. Beyond acute medical care, the clinic intends to promote community wellness through public health and disease prevention services designed to address local problems such as sexually transmitted infections and HIV, helicobacter pylori, diarrhea, and maternal and child health. Furthermore, volunteering in the Chisang Clinic is an invaluable opportunity to practice medicine without reliance on technology, to test your clinical knowledge, to expand your skills, and develop confidence as a physician. It is also an extraordinary experience in learning a new language, eating authentic food, immersing yourself in a unique culture, and experiencing an amazing country.
Chisang Clinic
Soap and water, a little lidocaine, and four stitches later the boy whispers, “Malai sutna man lagyo;” he is ready for bed. With a payment of 130 rupees ($1.75 USD) the audience disperses and clinic life settles back into the rhythm of the village. This patient is only a small representation of the many acutely and chronically ill that the Chisang Clinic is able to care for. The ease and speed with which the clinic Director Debendra Karki and Children’s Medical Aid Foundation Director Carol Vernal have established theChisang Clinic reflects the strength of their determination and their commitment to the Bhawanee community.
Exam room
For a medical professional this is medicine at its essence. Where you use flashlights because the electricity does not turn on until 8:00 pm, where water is hand pumped from the ground because plumbing is questionable, and where tools are sterilized with boiled water because autoclaves are unrealistic. Where you are forced to rely on your stethoscope and ears because X-rays and ECG’s cost precious time and money, where you learn to trust your instincts because specialists are NOT a phone call away, where you hone your physical exam skills because lab tests are not readily available, and where appropriate patient management may mean the difference between a life-threatening ruptured appendicitis and a life-saving appendectomy. I am forever changed by this experience and thankful to be a part of such an impressive endeavor. If you are looking for an amazing experience or want to support the efforts of Chisang Clinic be reassured that this is truly a once in a lifetime opportunity; unless you do it twice.
Dr. Briana Cranmer with the village
Chisang Clinic 