Still here

I haven’t written in quite a while. I actually had a post ready to go about two weeks ago, then lost Internet access and never got to post it. I will try to resurrect it this weekend. Since then I’ve been busy and a bit caught up inside my own head. Anyone who has emailed me recently can vouch for this too. I’ve just been hibernating when it comes to life outside of Saint Marc.

We had some wonderful visiting neonatal nurses here, which gave me some hope re: what might be done in our neonatal rooms here, but talking with them about all the shortcomings — all the seemingly insurmountable challenges standing between my patients and good care — was a bit like tearing the metaphorical band-aid off a second time. The initial shock and discouragement that I felt when I’d first arrived had dulled a bit after I’d gotten used to being here a while. But having two new caring professionals come in and experience it for the first time made it all new to me again. Newly shocking, newly frustrating – I found myself feeling pretty low despite my enjoyment of their excellent teaching and camaraderie.

So I’m digging my way out of the hole I’ve fallen into, which means I’m going to get back to writing, back to doing all those little things I do for me. So. I’m back. Back to writing, back to life.

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What time is it?

Today proved a very confusing but overall relaxing day.  I didn’t have work this weekend, so I got to go to the beach – a very welcome diversion!  However, there was a great deal of confusion over Daylight Savings time.  Haiti has not observed Daylight savings time since 2005/2006.  However, with a new president in power, there was some debate over whether this pattern would continue.  

Yesterday, the day before the day the clocks change, President Martelly apparently decided that he did want Haiti to change the clocks this year after all.  However, there is no local television station that I know of, and nobody watches TV (most families don’t own one), there is no daily newspaper readily available (probably partly due to lack of infrastructure to support distribution of a paper and partly due to the high illiteracy rate in Haiti), and our house does not possess a radio.  So, you can see where the confusion might come in.

I heard a rumor that one of the Haitian doctors who lives in my house got a text from Martelly himself confirming the Daylight Savings decision, and today we got an email from our in-country coordinator confirming that yes – Haiti is saving daylight once again.  Don’t forget to change your clocks everyone!

Always learning

This week I had a patient with tetanus – one of many diseases here that I’ve (thankfully) never seen in the US. Everyone knows that a tetanus shot is a good idea if you step on a rusty nail, but I think most people don’t really know what is involved beyond that.

I knew about it in theory, but when I was faced with this 10 year old boy who had painful whole-body spasms with even the slightest stimulation I found myself challenged. Was it really tetanus? What should I do? Fortunately I have a nice Tropical Medicine book – sort of the traveling doctor’s answer to Harriet Lane – that outlined the treatments I should administer. We didn’t have half of them, but I was able to at least improve my patient’s condition for a while.

This week has also brought several interesting patients who likely have tuberculosis, though I still think that one of them could have had lymphatic filariasis. TB was more likely, but we’ll never know now. His family decided today that they were taking him home to see a Voodoo practitioner, since they were dissatisfied with our diagnosis of HIV with likely TB confection. I can’t say that I would be happy to receive that news either, but I was still surprised to see the family pack up the (fairly ill) boy and leave.

It’s not the first time I’ve seen parents take very sick kids to be treated by “traditional healers” but it does frustrate me to see patients leave to see these non-medical providers. I don’t blame them for wanting another opinion, but I wish the system were different. As a blan I don’t get to weigh in on these decisions too often, since I “wouldn’t understand.” They already know that I will recommend that they stay at the hospital.

I guess you could sat the intersection of traditional beliefs and trust in modern medicine is just one more of those things I’m learning, piti piti.

Back to work

Today was my first day back at the hospital after a relaxing week at home in the US.  It was a busy day, with several sick patients and a few “situations” that came up throughout the course of the day, but I was glad to be back.  It’s amazing how quickly things change at the hospital – when you’re there every day it’s easy to keep up with which patients are where, to know who’s progressing, etc.  But after just one week since I’d last been there there was hardly a child in the place who had been there when I left.  I guess that’s good, that kids are getting better and going home, but it’s still a disconcerting feeling to realize everything is so different.

Tomorrow I’ll have a meeting with some other pediatrics people here about some new protocols we’re going to work on implementing.  They are all related to neonatal care, an area in which we could use some improvement for certain.  I am looking forward to being a part of the implementation process.  It can’t come too soon.

One of the bittersweet things about leaving last week was knowing that there are gaps I’m filling that wouldn’t get filled in my absence.  So, without a protocol to guide his care, the 830 gram* (1 lb 13 oz) baby I’d admitted two days prior to leaving – who would’ve likely done fine with appropriate neonatal care – died while I was gone.  But that’s an important reality check for me too.  My job here isn’t to keep on trying harder in order to personally save every patient who walks through the door – it’s to help set up systems of care which will give every kid a chance at getting the care that they need.  That’s a principle that I learned back in my QI training, but I’m really living it here now.

 

*Skip this if you’re not interested in medical details.  I Ballarded him out to around 29-31 weeks GA.  Certainly not a risk-free age, but he was stable on room air when I last saw him.  His biggest issue was nutrition.  Too young to have a suck reflex, he needed NG feeds with careful titration of IV fluids.  (Ideally with TPN, but we don’t have TPN here; most days I’m lucky to have my choice of IV fluids.)  We had NG tubes in stock (small miracle) but the mother wasn’t having any luck hand-expressing breast milk, so I’d asked the family to buy formula and begin some preliminary NG feeds.  But without appropriate tape to secure the NG, the tube wasn’t staying in place.  There was also a lack of knowledge of how to work the warmers, so a nursing assistant had unplugged and completely opened the incubator in response to the baby’s temperature being too high.  We don’t have IV pumps either, so giving 80ml/kg of IV fluid – a whopping 66ml/day – is nearly impossible to do accurately.  (That works out to 2.75 micro-gtts/min, or just under one gtt/min – that’s right, a single drop per minute.  Good luck titrating that one.)  So many things we take for granted in the US.  So many extra challenges for the patients (and healthcare providers) here.

Break

I’ve been on R&R this week – a week at home to recharge my batteries. It’s been great – very relaxing. I’ll be back to blogging soon.