Support

Today was another crazy day. 55 inpatients and a handful of admissions – a few of them sick – will do that. From a child with SVT and a possible ingestion to a week-old 970 gram premature baby who had been living at home (and doing surprisingly well!) the day was full of activity. I had to refer a baby to another hospital for surgical evaluation, and another child with kidney and brain issues proved to be more of a mystery than I’d initially thought.

The day was more bearable because I had E, my translator, L, my invaluable assistant, R, an ER physician with valuable global health experience to share both in person and via phone consult, and M, another ER physician (here teaching an ultrasound course) who actually stayed late today to help me by seeing about a dozen of my patients. I also had comments and emails from family and friends, friendly texts/calls from my housemates, and movie night tonight at the house.

So even though it was crazy and busy and a really long day, I feel thankful to have ended the day feeling so supported. I am still processing all the events of yesterday, and how best to approach things moving forward, but it’s nice to know that so many people, both here in Haiti and in the US (and Canada!), are supporting me.

Tomorrow is my day off, and I am excited to get to unwind and enjoy some down time. Happy weekend, all!

Not fast enough

Warning – this post talks about a child dying.

Yesterday was a really tough day for me. V, the other pediatrician, didn’t show up until 4pm. He had texted me in the morning to say he would be preparing for a presentation and should be in by 1 or 2. So, I was on my own seeing the roughly 50 inpatients in the hospital, as well as any outpatients.

We relied on our security guard, who controls who enters the unit, to triage any outpatients that arrived to be seen. Usually there are 30 or so who show up to be seen for colds, tummy trouble, etc. (There is another place at the hospital where outpatients are seen, but many prefer to be seen by V, who is one of the only pediatricians in Saint Marc, so they just show up on the wards and he sees them there.) He only let in those who he thought might be gravely ill. Not a perfect system, but we did still see some sick outpatients without the usual large crowd of not-urgent outpatients.

My first patient of the day was one who had been admitted with dehydration from vomiting and diarrhea early the previous morning. She had been severely dehydrated, so V very appropriately ordered IV fluids to rehydrate her. She then sat waiting for a nurse all morning without receiving fluids or any other hydration, until the mother carried the now-limp child back into the evaluation room in the afternoon. She had gotten much worse, and required CPR to resuscitate her. She finally got fluids, but it was too little too late. I found her near-dead yesterday morning and my best efforts at resuscitation (best under the circumstances) were not enough to save her. She died after about an hour of our efforts.

Any child’s death is tragic, but this one stung extra due to the factors contributing to her passing. In the 21st century there is no reason a child should die from gastroenteritis, particularly not one who has presented to the hospital in time. She didn’t receive fluid in a timely fashion because our two nurses were so busy seeing the 50+ patients already in their care that they simply couldn’t spare a moment to start IV fluids for this new child. That is partly due to understaffing and partly due to the extreme chaos of the workflow. We also lacked the equipment we needed to resuscitate her optimally. For instance, I don’t think having a suction catheter would have changed her outcome, but it would have been good to be able to do things the best, not just the best we could manage.

I am hoping today will be better, but there will have to be some real changes for things to actually improve. Some days piti piti just doesn’t feel fast enough.

One starfish at a time

Today I had a moment of victory in the hospital.  Malnutrition is a big problem for Haitian kids, and can be serious enough to require hospitalization.  We have a great nurse who runs the outpatient malnutrition program, giving moderately malnourished kids Nourimanba and special fortified milk so that they stay well enough to avoid hospitalization,  and she also treats the hospitalized patients who have severe acute malnutrition.

I have met a few malnourished kids already.  The toughest ones are the ones whose mothers have either died or are sick, so breast feeding – a cost-free and nutritionally sound feeding method – is not an option.  One of those babies is 5 months old and weighs 3.3kg (7 pounds 4 oz) – about as much as a newborn baby should weigh.  His mother has died, and his grandmother cannot afford to feed him.  On the day I met him I’d asked why we weren’t providing him treatment for his malnutrition (i.e. food!) and I was told that the malnutrition program only treats patients who are at least 6 months old.  From my reading of the protocol mentioned above, I knew there was a whole chapter devoted to patients under 6 months old – a minority of malnutrition patients, for sure, and one that requires some slightly different care.

We first discussed treating this patient’s malnutrition on Friday, when the grandmother told us she didn’t have anything to feed the child.  I felt powerless and really discouraged to hear the answer – we can’t do anything.  He’s too young.  We don’t give out formula.  So I went home and did my research, found that protocol, and brought a copy with me to the hospital.  Today I saw the malnutrition nurse and asked if she’d see my little patient.

She agreed, and came over to see him, but frowned when she heard he was only 5 months old – too young to fall under her care.  I mentioned to her, in Creole, that there is a protocol, and asked if she would look at it.  I ran off to get that protocol, and showed it to the skeptical-looking nurse.  She gave it a glance, jotted down the numbers that she’d need to calculate how much formula to give to my baby, and quickly agreed to treat him.  I was thrilled!

He’s only one patient in a sea of malnourished Haitian children, but he’s one patient.  One patient who I helped today.  I can feel good about that.

Where to begin?

So, my first few days her have been so full and interesting, I hardly know where to start. The hospital feels a bit like that, actually. So full and interesting.

On my first day in Saint Marc S, my boss from Boston, was visiting. We had a really productive discussion with the Haitian pediatrician with whom I work. We talked about seeing the sickest inpatients together, which has so far worked out well. We also made some moves to try to begin improving patient care, such as weighing all of the sickest babies every day and making an effort to use pulse oximetry (measuring a patient’s oxygen level) to help guide our decisions about keeping them on oxygen. Prior to that none of the patients were getting weighed, nor were oxygen levels being checked regularly. With only two nurses and one or two physicians providing care to around 40 patients, there are many aspects of patient care that have simply fallen by the wayside. My hope is that by improving how things are set up we can get things moving in the right direction. For instance, the scales for the babies were both tucked away in a side room. One needed to be calibrated, the other wasn’t working properly on an uneven surface. The scales are now calibrated and one is in a location closer to the “NICU” rooms.

I will admit I feel a bit overwhelmed by how chaotic the current system is at the hospital; there is a lot standing between my patients and good care. It is not the fault of any one person, but rather a system which has been set up for failure. I have to believe that the people I work with there are doing the best they can, given the circumstances, and as of Thursday I am doing the best I can as well. We don’t always have the medicines I want to use or the resources I wish were available, but I’m doing my best to begin sorting out which of the problems are ones I can tackle (not weighing babies, a lack of communication around plans of care, etc.) and which ones I cannot (issues with drugs not being available, not having enough nurses, etc.). My initial reaction is to want to try to fix everything at once, but I have to remind myself that Rome wasn’t built in a day. (Piti piti.) So I’m picking my battles, figuring out who my allies are, and beginning to try to make some changes.

Anpil

Today I finally made it to Saint Marc! It was a long and interesting day, and I’m sure I will have plenty to say about it once I’ve had a good night of sleep. For now I will just say I’m glad to be working with some good people, and that I am already learning lots. For instance, you can provide scales in the pediatric unit, but that doesn’t guarantee that anyone – not even the “roughly 1kg” preemie – will actually get weighed.

It was both an overwhelming and exciting day. Definitely discouraging at times as well, but I am looking at it as lots of room for improvement. Anpil, as they say in kreyòl. Anpil means, roughly translated – plenty, or a lot. Tons. So, nou gen anpil timoun – we have lots of children! Or li bwe anpil – he drinks plenty. Or less exciting, li tusse anpil anpil – he coughs so so much!

So, I’ve got anpil tasks ahead of me, and fortunately anpil support in doing them. It’s going to be an interesting 6 months, that’s for sure.

Ready?

I can tell that the Haitian pediatrician I’ve been working with this week is sizing me up.  She’s not too impressed yet with my limited knowledge of things like malaria treatment, but she’s been mostly encouraging so far.

So I had to laugh when we had the following conversation today after rounds.

Her: So, are you ready for Saint Marc?
Me: I hope so!
Her (looking skeptical): So do I!

I’d mistaken her inquiry as interest in my personal feeling of preparedness, but I think she was expressing concern for the children of Saint Marc who are going to be in the care of this blan* who doesn’t know how to write orders (in French), struggles to remember “basic” Creole words, and generally doesn’t seem to be quite on her game yet.

I know that it’ll be a rough start, but I’m learning more every day.  I’ll work with a Haitian pediatrician in Cange, and the two pediatricians here have assured me I can use them as resources as well.  Plus there’s C, my “other half” – the guy I split my jobs with.  He moved back to Boston when I moved to Haiti.  He’s just finished 6 months of doing what I am about to do, so I am sure he will be happy to offer a hand as well.  Maybe it’s just the effect of a productive but enjoyable weekend, but I’m feeling optimistic that I’ll get the hang of this.

*”Blan” is a Creole word which literally means “white.”  It’s used, though, more generally as a word to describe foreigners.  My colleagues and I are all blan.

Celebrity, and learning the everyday

Cange attracts some high-profile visitors, both from within the organization itself and celebrity-wise, and it has been interesting to see them around. Overall everyone has been very gracious and nice. We have had a few chances to interact. It feels a bit surreal to be sitting around drinking coffee with the founders of the organization, but it is also really nice to connect with people who far outrank me but share my views and passions when it comes to our work here. I think the most is-this-really-happening moment, though, was last night when the guy behind it all poured me a rum and coke at a nice gathering at his house. If you had told me a year ago, before I knew I would get this fellowship, that I’d be having drinks in Haiti with the group that was gathered there, I’d never have believed it.

It is exciting to rub elbows with such big names, but my focus has been more on learning how to function as a reasonable pediatrician in Haiti. I admitted my first patient from clinic yesterday, and got a lesson in medical French in the process. This morning’s admission went more smoothly, and I started to feel like maybe I’m getting a bit of a handle on how to do this. I’m really thankful to the patient docs here who have been training me in all the ins and outs of pediatric practice here. They’ve mentioned some of the challenges that arise here too. It’s good to hear their perspective and know that they will be offering their support if when I need it.

Not just yet

I had originally thought I’d be moving to Saint Marc tomorrow, but as it turns out I’ll be in Cange for an extra week. This is good because it gives me more time with the doctors who are orienting me to pediatrics in Haiti, and I get to spend more time with my friends here. I know two of the folks here from Boston; one was in my Haitian Creole course this summer, and the other was in my global health summer program at HSPH. They are both great people and I am excited to share time with them and hear about their experiences in Haiti so far. The other people here are great too, but there’s nothing like a familiar face when you’re in a foreign locale.

The down side is that I have to wait another week to get settled in and start work in Saint Marc. It will be nice to unpack and start getting into a daily routine. There is a family practice residency program starting here, and apparently I will be a part of the team responsible for teaching the residents. I am looking forward to meeting them and finding out what role I will play and what sort of work lies ahead!

In the meanwhile I’ll keep on taking notes, speaking kreyòl, and enjoying the great company.

Piti piti

The title of this blog is my favorite Haitian proverb.  It means “Little by little the bird builds its nest.”  It was one of the first proverbs we learned in my Haitian Creole class this summer; the professors seemed to understand just how overwhelming beginning to learn a new language can feel.  But that’s how we went through the three weeks – little by little, until we all left the class with a feeling that yeah, maybe we could begin to understand this new language we’d set out to master.

Unfortunately I didn’t get much of a chance to practice my Creole living in Boston, so now I’m dusting off those words and phrases that I learned in July and trying to apply them to life here.  The basic greetings came back pretty quickly, so I’m at least not actively rude to the friendly Haitians who greet me on my way to breakfast every morning, but my medical Creole is a bit more rusty.  I’ve been shadowing Dr. R, one of the pediatricians here in Cange.  He is very knowledgeable, and a good teacher.  There is a medical student, A, on our team who speaks very good English, so she has been very helpful to me as well.  I’ve been mostly just observing, but today in clinic they encouraged me to take the plunge and start interviewing patients in Creole.  I made it through a handful, with some help from A and some patience from the children’s parents.  I was pleasantly surprised that I was able to get the diagnoses correct each time – nothing exotic, just your typical URI, fever, etc.

One thing that complicates the language issue around the hospital/clinic is that all of the notes and orders are written in French!  People here seem surprised that I don’t know French (doesn’t everyone?) though they’re often amused when I offer the explanation that since I have a Spanish last name I always had chosen to study Español.  It seems less than fruitful to explain to them how much more utility I’d thought I would get out of Spanish, and indeed, I have had Spanish-speaking patients during residency and even during my time in Boston.  I don’t think I’ve had any Creole-speaking patients.

The bottom line is that I’m working on both my Creole and my medical French.  It will be an interesting 6 months!

Manje

One thing that I love about moving is trying out region-specific foods.  Just about anywhere I’ve lived has its own specialty, from Spiedies in Binghamton to such PA Dutch treats as chicken and waffles in Danville.  I will admit I’m not much of a chowder person, so Boston’s namesake soup held little appeal, but Boston creme donuts are always tasty!

The food here in Haiti has different flavors but also different timing; the cooks here at Cange prepare two meals a day.  Breakfast, served at 7-ish each morning, was eggs yesterday, cream of wheat today – each day with toast and fruit to accompany them.  There is hot coffee, and some sort of fruit juice.  All together it is a satisfying meal and a good way to start the day.  Meals here are something of a social affair, which is a very nice switch for me after dining alone in my apartment in Boston for the majority of my meals over the past 6 months.  It is nice to have a sit-down time to chat and discuss plans for the day.  Lunch/dinner happens around 2pm and is another nice time for socializing and catching up on the happenings of the day.  Rice and beans are a common theme for dinner, with some meat and vegetables usually making an appearance.  Yesterday there were meatballs, today it was a stew.  Sides have included squash, corn, mayi moulen (corn-based dish similar to polenta), and fried malanga (similar to taro.)

As many of you are, I’m used to having a third meal of the day, but for now two big meals seems to be working out okay.  I have brought along protein bars to act as a third “meal” (or a second on days when the food might not be something that agrees with me.)  I have promised my mom that I won’t waste away, and those bars will help.

I am thankful to have such good meals here, particularly when I see so many kids with malnutrition in my work every day, and while I may not always care for the selections (e.g. I’ve learned that goat can be great or not-so-tasty depending on how it’s prepared) I know that we eat like kings compared to many of the folks I will encounter here.