Mwen pale kreyòl

Last week E, my translator, had another job to do, so I spent the week working sometimes with another translator, sometimes on my own. I felt pretty intimidated heading into that first morning without someone to help me understand what was being said, but after the first few patients I started feeling a bit more comfortable.

The basic discussions I have with parents on rounds are pretty formulaic – how is your child today? Is she drinking? Did he have a fever? I’ve been able to ask those questions for a few weeks now. But I found myself pushing my limits – finding a way to explain to a mother that breast feeding is best for her baby, letting another mom know that we had gotten ahold of the medicine that her daughter needed and explaining how it would help her, etc. It was challenging, yes, but I got my point across. I also found that I could usually understand what a parent was trying to explain to me as well.

Going without my translator, who also happens to be my kreyòl tutor, also gave me a new appreciation for his skill as a translator and a teammate. E knows I can speak some kreyòl and gives me the space to do so. He anticipates what my next question will be and often asks it before I have to mention it. He knows my explanations of how to give oral rehydration (ti kras pou ti kras – little by little,) how to treat for scabies (lotion neck to soles of feet – including between fingers and under nails, socks on the baby’s hands so he doesn’t get any in his mouth, etc) and many others. He reminds me which stack of charts belongs to patients I’ve already seen and which ones I’ve yet to see, and helps me with pronouncing Haitian names of my patients. E knows how to talk to the nurses in a way that conveys my respect for them, and acts as my cultural translator as well, explaining things such as why so many babies have a thread stuck on their foreheads (protection against coughing.)

I worked this weekend, and E is back. Much as I enjoyed pushing myself to use my kreyòl, I am glad to have my translator/tutor/assistant/cultural broker back at my side.

Better than it seems

I saw my “country coordinator” – one of my superiors – at a meeting today.  She asked how things were going, and seemed very surprised when I smiled and answered “Good!” 

Reading my last few entries in this blog, I imagine some people might be surprised to hear that answer as well, but the truth is that despite the challenges and setbacks I’m facing here, I do feel that things are going well.  Pediatrics is still a joyous field.  Kids are still fun and cute and a pleasure to work with.  A parent’s delight at a now-healthy child still gives me a rush, whether they’re in the US or Haiti.  And regardless of all of the difficult things happening, I can see some positive changes since arriving. 

V, the other pediatrician here, has been far more present than he used to be.  Our working relationship is far from ideal, but we are sometimes working together, and that’s a start.  We got a third physician to share the workload; I think she will be a nice addition to the team once she is oriented.  A Family Practice residency program started here a few weeks ago, and that means I get to teach young doctors about pediatrics.  I really enjoy teaching.  The malnutrition training I mentioned a few posts back continues to have a positive impact – the malnourished patients are getting much better care now than they were before the training!  The nurses and I have been getting along better as well.  We are each learning to trust the clinical judgment of the other. 

To top it all off, we had some biomedical engineers stop by this week; they fixed five of my warmers (bringing the number of functioning warmers in the unit to… five) and helped troubleshoot a few other pieces of equipment around the place.  Having functioning equipment will only make it easier to provide closer-to-ideal care for my patients here.  And improving systems of care is what it’s all about. 

So yes, despite all the tèt chaje* challenges, things are going well. 

*Tèt chaje is a favorite phrase around the house.  It doesn’t have an exact translation, but it’s used to describe a crazy/messed-up situation. Can also be applied to people, but be careful! Calling someone tèt chaje may not win you any friends. 

Dignity

I try not to write about death too much, but it is tough to escape the topic when talking about healthcare here.

Some of the most important lessons I learned in residency didn’t come from books.  They came from the caring and professional staff I worked with.  The neonatal nurses and physicians in the NICU (neonatal intensive care unit) were especially instructive in the art of caring for patients and their parents at their most vulnerable moments.  We had a very ill baby come in this week, and despite several days of good treatment on Friday it became clear that he was not going to survive his illness.  I told the grandmother that we’d done all we could, and that her grandson did not have much longer to live.  She took a moment to digest what I’d just told her, then quietly asked if she could take him home.  I agreed, and prepared the baby for his final journey home.

As I disconnected lines and tubes, carefully cleaned him up, dressed him nicely and wrapped him in his soft blankets, I realized where I’d learned this ritual – this last act of kindness for my patient who would not survive.  I learned it in the NICU and the PICU where I trained, the places where our most critical patients sometimes spent their last ways.  It was there that I worked with incredible nurses who treated their patients with the care and dignity that they deserved, whether it was their first day of life or their last.  The practice helps me as much as it helps the patients and the ones who love them.  It is my way of saying “I have not abandoned your child.  I still care, even if I cannot help.”

I’m not sure what the Haitian providers think of the extra time I spend on these children in their final moments; death here isn’t treated with much ceremony.  It’s just too common.  But I think it’s important, when it’s possible, to take the time out to get that part right – to give them those final moments of dignity that they deserve.

Sleep, or lack thereof

Sleeping here is a bit of a tricky thing. It helps to have a mosquito net and some really good earplugs. I’ve got the net pretty much mastered by now, but the noise is proving a much more challenging issue.

In Boston I had lived on a somewhat busy road, and often heard sirens, car stereos, or people in the street. Here in Haiti the noises are different. This evening the dogs have been noisiest, howling for hours at a stretch. The roosters throw in their two cents now and again, without the slightest regard for time of day or night. There has been a really unhappy cat nearby the past few nights, and the goats have been quiet this week but can cause their own racket when they want to. The chirping of bugs only momentarily lulls when I turn off the lights in the evening. I think they notice a difference in the light shining from my windows.

The windows are screened but always open, so in addition to letting in sounds they let in the smells of cooking fires and the nightly trash disposal. If the neighbors’ house is set up like ours, their kitchen abuts the wall that my window faces, which explains how I know that the neighbors put out the trash every evening.

I have a roof over my head and a bed to sleep in, so I’m doing better than most Haitians already, but I think I’d be happier if I could just get one or two nights of uninterrupted sleep! For now it is way past my bedtime. I’m going to give sleeping another try. Goodnight all!

Okay now

The internet has been really spotty here lately, so I haven’t been able to update.  I tried to post last night, but it didn’t go through.

I wanted to give an update to my last post – I talked with the nurse who’d said those things, and we reviewed the protocol.  I pointed out the parts that supported my actions, and she seemed to understand why I’d done what I did.  She also said that she’d not meant to say that I was responsible for the child’s death – she would never say such a thing.  I wasn’t going to argue with her – she’s one of our better nurses, and I want to get along well with the staff at the hospital.

So things are okay with her and I now, and I’m feeling much better about my role at the hospital.  It’s still a lot of responsibility, but that’s what being a doctor is about.  The nurses have seemed a bit more inclined to work with me this week, and as my Creole improves I think that will only get better.  They even asked me to leave my phone number this afternoon, in case anything came up after I’d left.  It’s good to know that they feel that they can call me if they need something.

For now I’m going to be focusing on providing good care as well as teaching the Family Practice residents who have begun their rotations through the hospital.  I enjoy teaching, so I am looking forward to working with them.  If we can teach the residents to do things “the right way,” I think it will be a great opportunity to improve the care we provide.

The blame game

This is a tough post.  I’m sad this evening, but I think it’s good to write honestly about my experiences here, so here it is.

When we arrived this morning, M, one of our best nurses and one of the people involved in yesterday’s malnutrition admission, called over my translator and asked him to tell me “The girl with malnutrition died last night from hypoglycemia because Dr. Sara didn’t start IV fluids.”  I was floored.

First, I was surprised that that particular patient had died.  She’d responded well to our initial interventions.  Secondly, I hadn’t started IV fluids because it wasn’t indicated in that patient, and could have caused heart failure.  M either didn’t remember that part of the training or had disregarded it, since she’d wanted to start the fluids yesterday when the girl was admitted (I told her not to), but she clearly remembered my lecture in which I had said that patients can die from hypoglycemia during the night (if they are not fed.)

She continued – “You had said to check her glucose at 11, but she died at 10.”  I could fill in the blanks – my orders had been followed to the letter, but when the patient’s condition changed nobody thought to do anything but wait for the prescribed time to check the glucose or make any other interventions.

I asked if the patient had been getting her feeds as ordered – frequent enough to avoid hypoglycemia and to ideally allow the person giving them to detect it before it kills the patient.  I’m told she was, but somehow I doubt that she was being fed every two hours that evening, as I’d ordered.  The evening nurses often lack the follow-through of the daytime team, partly due to personality factors, but partly due to the fact that there is no pediatrician available during the night – that means for over 12 hours every day two or three nurses are on their own to deal with whatever problems arise with the 40-50 patients in our unit.  They have gotten used to bad things happening, and nobody responding.

So all I’m left with is that something changed with the patient, she didn’t receive an appropriate intervention, and the nurse saw this as my fault.  I guess if lack of availability is my fault, then yes – I’m guilty.  If lack of writing out a formal protocol for managing the patient was my fault, then yes – also guilty.  I’d written more comprehensive orders than I’ve given for any other patient since arriving, but I had not specifically indicated that they should adjust the feedings (as they’d learned earlier this week) in the case of hypoglycemia, nor had I specifically written that if the patient deteriorated they should check a blood glucose sooner than I’d asked.  We don’t have a protocol in place, and I did not specifically think of every possibility in terms of what could have gone wrong with the patient during the night. The patient’s initial good response to our interventions had lulled me into a false sense of security.  I need to learn from that.

There is a strong tendency to pin blame here – everyone is quick to point out “It’s not my fault!” if you mention a problem or something that needs improvement.  But though I know that there are systems of care which set many obstacles between my patient and good care, I can’t shake the feeling that if I’d done a better job maybe that patient wouldn’t have died last night.

I’ll write more thorough orders next time, and the nurses will become more accustomed to what to look for and how to respond to it, and we’ll implement a protocol soon, and we will get more supplies and maybe more staffing and maybe even eventually staff coverage in the evenings.  But my patient doesn’t get a next time, and that’s hard to sit with tonight.

What a difference 3 days makes!

This week there was a 3-day nursing training session on Severe Acute Malnutrition (SAM) – malnutrition so bad that the patient needs to be admitted to the hospital to receive life-saving treatment. Unfortunately we see patients meeting that criteria pretty regularly, but they hadn’t been getting very good care at our hospital. The regular nurses felt like they were “just” there to be fed, and didn’t really pay them much attention, while the malnutrition nurses would give them feeding supplies during the day but wouldn’t really work with the other nurses to address their medical problems. The three-day session was aimed at raising awareness of the seriousness of SAM and the steps we can take to treat it appropriately.

The training, which was taken from World Health Organization (WHO) guidelines, was comprehensive in scope and brought to light a lot of areas in which we can make improvements in the unit. But the real effect of the training came to light today.

This morning a severely malnourished girl showed up at the hospital. I began working on her admission, asked a nurse to start an IV and asked if we could get some ReSoMal – the special oral rehydration solution we use for malnourished kids. Several nurses promptly began working on gathering all the necessary supplies, doing all the appropriate assessments, and even reminding me to include all the relevant data in the note I was writing. They had a copy of the malnutrition protocol at the ready, and we quickly figured out how much liquid to give her. When I told them that she would need to be given fluids every 30 minutes for the first two hours (a major imposition on our super-busy nurses) a nursing assistant readily took up the task, and she did give all of those every-30-minute treatments. They got her into a bed and under a warming lamp quickly and appropriately. Every major part of her admission was addressed appropriately and with the promptness that it deserved. I actually felt like we gave her good care.

Yesterday’s post described the difficulty I’ve had getting people to respond to an urgent situation, and just one week ago I had had a nearly identical patient with SAM who arrived just as sick but who received next to no attention from the nurses. There was no ReSoMal, nobody knew how to make it, how much to give or when to give it, and nobody acted with any sense of urgency. L (not a nurse) eventually instructed the patient’s aunt on how to give her the fluids she needed. The contrast between that situation and today’s was like night and day. The training really did impact the care that we are giving, and it is exciting to see that change is possible in such a short time period. We will need to make some additional interventions if that change will be a lasting one, but it was so nice to have a difficult situation go well today. I am so proud of our nurses for embracing the training and really stepping up, and I intend to let them know I really appreciated their efforts today. Happy Friday, everyone!

Priorities

So, it’s been an incredibly busy and challenging week. One of the things I’ve struggled with this week is how people prioritize who will get their limited time and attention.

For instance, this evening a 1 month old baby came into the hospital very badly dehydrated and possibly septic (systemic infection – very serious.) Her mother has abandoned her, and the grandparents have been feeding her soup for the past 20 days. She looked very close to dying.

I began working on her admission right away, and asked a nurse to get an IV started immediately so we could give fluids and antibiotics. She rolled her eyes but started the IV – not an easy task in such a dehydrated baby. Even though the nurses here are great at starting IVs, it took her many tries, and several minutes. I thanked her and asked if we could get the antibiotics for this patient before she began administering the evening medications for the other (more stable) patients in the unit. She said yes, but then turned around and began stacking up some charts so she could begin giving out those medications. I began to give the baby a fluid bolus to help resuscitate her, but her IV stopped working very shortly after I began. When I let the nurse know, she just waved me off, saying “Tale, tale.” “Soon, soon.” That is the standard “I’ll get to it later” reply here.

I spent the next hour and a half working with E, my translator, and A, a physician/housemate who had stopped by the unit to see if I was ready to leave. A wound up being of great assistance, but she was really taken aback by the craziness of the situation. We did our best to get the IV working (unsuccessful), established an IO (interosseous) using an 18-gauge needle but it too stopped working after a few minutes (and the needle bent when I tried to re-establish it), then A inserted a femoral line (central line inserted in the groin) which worked great until we tried to tape it in place. The tape we had wasn’t very sticky, and the line fell out nearly as soon as we were done securing it.

All that is to say that after all of our many attempts to get fluids into this dehydrated baby who didn’t have a functioning IV or any medication, the nurse was still calmly administering medications to some of the least sick patients in the pediatrics unit. I finally sent A to ask for the antibiotics so I could give them IM (intra-muscularly – directly into the thigh muscle in this case) myself. The nurse who’d been waving us off finally brought the medications over, handed them to me, and watched me administer them. Unimpressed, she immediately turned and went back to her work, continuing to ignore my sick patient’s IV trouble. We reminded her one last time that the patient needed an IV, then had to leave for the day. (Transportation sometimes dictates when we stay/go a bit more than I’d like, but I’d been at the hospital for ~11 hours – an eternity in Haiti time.)

It’s not that the nurse didn’t care about my patient, she just had other priorities. Her goal was to get through administering all of the medications that she had to administer. She couldn’t take a step back and see that there was something more important to do in that moment – a sicker patient who needed her attention just then. I’ve run up against that way of thinking many times this week. We can be actively resuscitating a patient, but the nurses may just decide they’re too busy to help out.

I don’t want to sound like I’m picking on the nurses – it’s not just them. We have a new Family Practice residency program starting here, and the residents started working in the hospital this week. One of them was helping resuscitate a baby yesterday (a full code – chest compressions, bagging the baby, etc.) and his phone started ringing as he was gathering the materials to aid in the resuscitation. He stopped, answered it, and was having a nice chat until I waved my arms at him, reminding him that we were trying to save a baby’s life!

V, the other pediatrician here, is also similarly casual about urgent situations – he walked casually into one of the rooms on Monday and said to me “We have a baby with a temperature of zero in room G!” I asked what he meant, and he kind of laughed and shrugged, saying one of the babies was apneic. I took off for the next room, where E and L helped me resuscitate the baby. V did come to the bedside eventually, helped for a minute or two, then wandered off to see some outpatients. (That baby recovered fully after a brief but full resuscitation. Can’t have only depressing patient tales here.)

I just don’t understand how someone can see a baby stop breathing and not have the urgent “Call a code!” response that’s been drilled into us in my training in the US. One of my goals for my time here is to work on a system for “calling a code” to alert people to an emergent situation and to raise awareness re: what the appropriate response to an emergency might be. I imagine that folks here might see me as too fixated on babies who are “clearly” beyond the point of rescue, but then there are the kids like the one I mentioned in the previous paragraph – they do recover, and they do fine. I think every kid deserves a shot at that, no matter how “inconvenient” their crisis.