Simple, complex, unjust.

It’s been a while, but I’ve had a long day, so here it is.  Warning: this is not a happy post.  A child dies.  Skip it if you don’t want to read about that.  I’ll try to make a happier post soon.

 

Today I lost a toddler to malnutrition. He had been seen at three other health centers, including one where we are running a pilot to improve pediatric care, prior to showing up in our emergency room today.  He was correctly tagged as gravely ill and sent my way.  Too quiet to attract much attention, I could see how he might have slipped through the cracks.  Kwashiorkor is funny that way – the kids get swollen instead of skinny, so it’s harder to identify them as malnourished.  

A closer look, though, told me an all too familiar story.  Cold, low glucose, barely conscious, anemic with a hematocrit too low to be a healthy hemoglobin (Hematocrit 7.8), grunting and breathing as quickly as his starved body would allow him.  We did everything right, or as right as we could.   We got him on oxygen as quickly as I could pull it off a less-sick kid, (we were out of oxygen tanks, but had a concentrator that worked,) got a glucose bolus into him, fluids started.  Couldn’t warm him because we couldn’t find an extension cord for the bare lightbulb that serves as my warming lamp – a proper way of warming bigger kids is on my wish list.  His mother sat across the room, unwilling or unable to engage.  Labs sent, appropriate antibiotics started, and he was in our most visible bed.  

But all that wasn’t enough, and a few hours later my nurse called me over to begin resuscitation.  She was the one to initiate chest compressions, while I got a bag and we began a code that I tried to get as close to the PALS protocols that I once taught as possible.  15:2. Something firm (my other hand) under the patient. Compressions deep enough.  Breaths that moved the chest, not too deep.  NG placed to decompress the stomach.  Verified hypoglycemia was no longer a problem.  Discussed using drugs.  (I was told epinephrine wasn’t available.  Turns out it was, but it wasn’t immediately apparent in our catastrophe of a drug cabinet.)  Reviewed whether there was anything else we could do, given the circumstances.  Concluded that in absence of labs, monitor, diagnostics, warmer, or any sign of response to our resuscitation efforts, there was not.  

And so all of our efforts were not enough, and I lost a little boy, someone’s little boy, to a problem no more complex than this: he didn’t have enough to eat.  It makes me angry and sad that in the marvelous world that we live in, there are still so many kids who suffer this criminally simple problem – not enough food.  They get sick.  They die.  It happens all the time.  All.  The.  Time.  

And the rational part of my brain can process that it’s not simple at all, it’s complex – the factors that go into my kids in Boston shortening their lives from obesity while my kids here in Haiti are literally dying for lack of food.  That foreign food aid has created the obscene problem of locally grown food being more expensive than the cheap imports we fly in, robbing Haitian farmers of incentive (or means) to produce enough food to feed their people.  That custom or superstition or convenience or marketing has convinced a whole generation of Haitians that formula – way too expensive and prepared with unsafe water – is a better option than the breast milk that is superior in quality, availability, and safety.  That centuries – centuries – of injustice have rendered this country So Damn Poor.  These are hard problems and complex ones, but they boil down to the same thing again and again – too little food, and a child dies.  Just barely more and they’re sick.  Stunted.  They lose a few IQ points, a few inches of height.  Their parents lose work because they’re in and out of the hospital.  It’s a vicious cycle.

I’m angry and I’m sad that that little boy died today and that it was shocking to nobody – not to the mother, not the nurses, and not to me.  I hate that it was not shocking to me.  When I started here I swore I never wanted to be not shocked by malnutrition.  It is shocking.  But there are only so many times you can face it, so many times you can hear the same story, before it stops being such a shock.  It’s life here.  Not enough.  Never enough.  We can improve the care in our unit, and we have.  We provided good care today.  We could make it even better, but until we figure out how to address the galling inequality that got that child and so many others into that situation, it will never be enough.

Because I can run the best code in the world, in the best hospital, but if patients are really badly malnourished, it’s just not enough.  The body can only take so much.

I can only take so much.  My heart hurts tonight, and the solution is so much bigger it makes me wonder if it’s even possible.  There is just so much to do.  I remind myself of the ones that do well – the majority of our malnutrition patients – and vow to spend a little extra time in the malnutrition room tomorrow.  To work with our assistants to clean up the medication closet so we can find the epi next time.  To put together a proper code box.  To find that damn extension cord.  To look into other options for warming bigger kids.  To find a spare lightbulb for that stupid lamp.  To try to do some preventative maintenance on the oxygen concentrator that keeps quitting on us.  Oh yeah, and to provide care to about twenty of our sickest patients while juggling whatever other crises might arise.  

I love my job here, but I’m starting to really look forward to the quiet hospitalist position that awaits me in MA when I return to the US this summer.  As unjust as the US system might be, we have it so much better.  

Haiti Hiatus

I am on hiatus for the next few weeks. My dad will be having surgery tomorrow and I will be in NY with him and my family. It is hard to leave my little patients in Haiti, but family always comes first.

Until then,
Dr. Sara

Something’s bugging me

20130209-211803.jpg
Not actually inside my patient’s eye*. Whew.

*Just in my ophthalmoscope**.
**aka eye-looker.

First World Problems read by Third World People

A taste of the cognitive dissonance I experience when I try to reconcile the reality of my patients’ lives here in Haiti with my own life experiences.
This video was filmed in Haiti.

Diphtheria

We had a child yesterday morning with severe trouble breathing. He was one of the sickest kids I’ve seen in a while. He was on oxygen but still really struggling to breathe; even pausing the flow of oxygen for a second made him frantic.

The thought crossed my mind that he could have some sort of obstruction – I thought about tracheitis, epiglottitis, a mass, etc. However, the thought of diphtheria, something you read about in old books, had never crossed my mind. I had not gotten to look in the frantic boy’s throat until V, my Haitian colleague, happened to show up mid-morning. He immediately grabbed a tongue depressor so we could take a look. Sure enough, there was the scary grey membrane they talk about covering the throat – he had diphtheria!

I had to admit that I had never seen diphtheria before. It is a disease that is virtually never seen in the US, thanks to vaccination. We called the local health department to get antitoxin and had already started erythromycin – an appropriate antibiotic for diphtheria.

We wound up transferring the child to another hospital for more intensive management, knowing how close to respiratory failure he was. It wasn’t until mid-afternoon that I got a text from V reminding me of something else I had forgotten about that old-fashioned disease – exposed contacts need prophylaxis and a vaccine booster. So today V and I will roll up our sleeves at the vaccine clinic, and I’ve started my own course of erythromycin last evening.

Never a dull moment here in Saint Marc!

Throwing rocks, and dance therapy

Today was a day of highs and lows.  The biggest low was definitely this morning – we heard a commotion and learned that people were throwing rocks because a student had just been brought to the hospital – she was hit by a car as she was taking a moto (motorcycle taxi) to school.  This would have been very sad under any circumstance, but the reason for the rock throwing was that she had been hit by a MINUSTAH (UN) truck.  After bringing cholera to Haiti, raping a boy and leaking video of it (posted online by ABC news last year), and allegedly committing other various crimes against Haitians, one might say the UN has really worn out its welcome here.  So hitting and killing a child with one of their (usually well-armed) vehicles was a particularly inflammatory sort of accident for them to have.  

I ran into a fellow “blan” who works at a local orphanage later this morning.  We have about six of his kids at our hospital right now with what looks like a mild case of cholera that had spread through their orphanage.  He looked a bit unsettled – apparently he’d been on a taptap* – a Haitian taxi, really a pickup truck with space for people to sit in the back – this morning around the time of the accident, and people had stopped his taptap twice and tried to get him out of the vehicle so they could throw rocks (or worse) at him.  Both times he was able to explain that he had no ties to MINUSTAH, and was allowed to pass, but it was worrisome to hear nonetheless.  By this afternoon everything had settled down and he felt safe enough to travel home with one of our patients who has recovered.  I myself felt safe the whole time – our hospital has a cadre of guards at the main entrance, as well as a guard at the entrance to the pediatrics unit.  I know most of them by name, have treated some of their kids, and know that they keep a very close watch on things.  They can (and occasionally do) lock up the pediatric ward as necessary. By the time I finished work this evening there were a few rocks piled in the road leading to the local UN base (blocking the road seems to be a common form of Haitian protest) but otherwise no sign of any of the protests/rock-throwing from earlier in the day.  

So that was an unsettling way to start the day.  This afternoon’s levity helped balance things out.  We have a patient with abdominal tuberculosis; she has been bed-ridden for at least a month, and as she recovers I am trying to encourage her to get up and walk more. Her mother is afraid she is too weak to get up, so she hasn’t been pushing her to try.  This afternoon I went and found her in her bed, got her up and walked her outside – she has had some delirium over the past few weeks and I hoped that getting outside might help to orient her better.  She tolerated the walk very well, so when we got back to the room I jokingly asked her if she wanted to dance.  She just looked at me.  I pulled up some Haitian music on my phone and began to dance.  I took her hands and encouraged her to dance with me.  Her mom laughed and encouraged her, and soon the two of us were dancing together in the middle of a crowded room of pediatrics patients.  We must have been quite a spectacle – my sickly-thin somewhat delirious patient and I – dancing ungracefully.  I announced that we were having a party and invited others to join in; none of them did but many were pleased to watch.  My resident was shocked that I had a song from a popular Haitian band on my phone, though he watched my dancing with a look that I have seen before – it was not unlike the one that teenagers give their parents when they do something embarrassing in public.   I spun my spindly dance partner around once, and then she had me do it a second, third, fourth time before grabbing my phone and embarking on a parade around the room with it, enjoying the music all for herself.  

Like Charlie’s grandfather, my young patient’s energy for dancing only lasted a few minutes – not entirely surprising since it was her first time out of bed in quite some time – but when I asked her if we should dance again tomorrow she answered in a quiet voice “I would like to dance again.”  I don’t care if the rest of the ward thinks I’m crazy for doing so – I do believe I’ve got a date for another dance party tomorrow, even if it’s just the two of us.  

*Don’t worry Mom and Dad, we are not allowed to take taptaps.  Our drivers are very safety-conscious at all times.  

Religion and belief

Haiti is a nation of two primary religions – Christianity and Voodoo. It is not uncommon to see people praying over sick children here. Yesterday a grandmother came in and was loudly exhorting Jesus in a hypnotic almost chant in which she mostly offered praise to Jesus’ name, calling out that only He had the power to heal this child. She continued for several minutes, and the other women in the room would murmur Amens at the appropriate points. Sometimes on the weekends there are people who come in to sing hymns – somehow nearly everyone knows the words. Even in fairly poor families, it is not at all uncommon to see that people have brought their bible (or sometimes a smaller booklet with excerpts) with them to the hospital.

I have less contact with Voodoo. I have already had my first patient leave this month because their problem was “not a medical problem.” I have written about this before – the belief that some problems are best handled by a boko – a faith healer. Much tricker for me to navigate, and a topic which people are often unlikely to want to discuss with me.

Somewhere in the middle lies a set of beliefs that I think belongs not entirely to either realm. For instance, people have a very fatalistic attitude. If I am looking to explain the uncertainty of a child’s prognosis, the best way I’ve found is to say “It is God who knows.” Mothers almost universally agree, usually noting that God is good, and saying that it is for God to decide. Same when I tell a parent a child is dying – they will commonly attribute it to God’s will, and say if God wants the child to live, it will live. If God wants it to die, it will die. This does seem like a way of pushing off some of the worrying that I see parents (and virtually all people – myself included) elsewhere engage in – they realize that the outcome is out of their hands and give it over to something they know they cannot control.

There are also interesting superstitions, same as you will find in any culture. I read an article this morning about Korean beliefs about deadly electric fans. I would be interested to read the book mentioned in the article, looking at the truth behind such beliefs from around the world. My favorite one here is a string placed on the forehead of a baby – it ward off hiccups.

I would love to hear about your favorite myth or belief, whether one that you hold or one that you encountered elsewhere. Leave a comment below!

Transitions

I took a quick trip to Miami this weekend. It was a wonderful break, filled with good company, delicious food, and fun adventures. Coming back to Haiti after even that short little break feels incredibly hard. It was a quick reminder of the life I’ve put on hold to be here, and even though I value my work here incredibly, some days it feels really hard to know the struggles that face me each day and to keep up my energy and enthusiasm in the face of so much adversity.

I found this quote this morning, courtesy of Nyaya Health, a group doing great work in Nepal.

“Of all the forms of inequality, injustice in health care is the most shocking and inhumane.” – Martin Luther King Jr.

And there it is. I’m ready. It will be a tough day, but I can do this.

Good from tragedy

As I mentioned briefly in a comment on my previous post about the boy with the stroke, unfortunately he died later that night. However, I have been heartened by the cardiac surgery team’s response. They acknowledged that he had fallen through the cracks and sent out a urgent email renewing their commitment to prioritize tracking down those patients who have been “lost” along the way. In the days since his death they located 24 of 50 such patients, and are working to mobilize more resources to devote to finding those kids. As one person noted, we sometimes lose sight of the importance of clerical work (keeping track of patients) in the urgency of the day-to-day work here, but it is just as important.

That clerical, more longitudinal approach is one that I am working on cultivating. Organization can be a challenge for me even under the best circumstances, and it is so easy to lose sight of any one particular patient within the chaos of a busy day or week here. But I am trying to keep better notes for myself, set clear priorities, and keep track of the patients I’ve made varied commitments to.

It is an ongoing process, but I think I’m getting better at it – little by little. Piti piti.

Milk!

Something really great happened today.  I had a grandmother of a baby who suffered birth asphyxia ask if I could help her find some more milk for her baby.  I am not sure why the mother isn’t here at the hospital*, but the grandmother has been dutifully caring for her baby, giving the infant frequent feedings through a nasogastric tube as he emerges from a coma.  The baby is making great progress, but his family lives far away and the grandmother was totally out of money.  Could I help her keep her baby alive by providing a little formula?

In the past the answer to this question would virtually always be “No” – unless I wanted to walk down the block and purchase some formula myself.  Not exactly a sustainable solution.  The total lack of formula in our hospital was something I discussed with local and remote leadership until I was blue in the face, but it never seemed to go anywhere.  Everyone agreed that feeding babies who didn’t have milk was important, but nobody wanted – or seemed to be able – to be the one to do anything about it.  

So today I asked the nurses whether we had any milk to provide this baby.  (I already knew the answer – we didn’t. I had gone out twice over the weekend to buy formula already.)  The nurse replied that “Dokte Sara” would have to go ask the depot herself.  The depot is the warehouse on the hospital campus where all of our supplies are stocked.  So I marched downstairs, and found my way to the depot on what I was sure was a fool’s errand.  Last year I’d asked the depot for formula on countless occasions – only once, when we had a baby who was abandoned at the hospital, did they provide even a single can.  They had informed me how expensive formula was, and asked me not to make the request again.  

I got to the depot, asked whether we had formula, and they said “Yes, of course.” as though it was no big deal! They reminded me that I would need to provide the patient’s information and justification for why we were providing formula, and told me they would dispense two cans of formula per request – one for the patient to use and one to keep as backup in case the patient ran out while the depot was closed.  Each time a patient needs a new can I will need to make a new request, but they said even if it is a long hospitalization, they can provide milk for those patients in need.  

I nearly pinched myself in disbelief – I was sure they were joking, but moments later one of the guys emerged with my two cans of formula, and I was off to the ward!  Part of me thinks it is sad that I’m so excited about something that should be such a basic part of providing care for children, but this was such a huge battle to get the hospital to recognize that we were obliged to provide food for our littlest patients.  I’m not sure what finally changed to create this shift, but whatever it is I’m extremely glad for it.  What a great day!

 

*If I had to guess why the mom is not present, here are a few theories: she might be at home caring for her other children, she could be ill, she might still be recovering from her child’s delivery, or she could be working.  It does not seem to be a given that mothers will accompany their babies to the hospital here.  

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