No safety net

Today a mother complimented me on how well I speak Creole. I have been working translator-free this week, which feels a bit nerve-wracking – like working without a safety net, but it has gone better than I expected. I have only needed to ask for help with two things – both of them fairly serious discussions. In the one case I think I probably did a better job anyway, and in that same case I was the one to get important details from the family about what was actually wrong with my patient. He came in this afternoon. It is a sad case but an interesting one. He is a boy who had heart surgery 3 years ago in Guatemala. After the surgery they put him on blood thinners, which the family has dutifully given him at 3pm each day – they proudly told me they never missed a dose. Today he fell, hit his head, and became unable to move one side of his body. The pupil opposite the paralyzed side is quite dilated. His presentation is classic for a stroke – something I’ve been lucky enough not to see in a child until now.

The tough part is that we are in Haiti, at a hospital that doesn’t have a CT scanner to see which type of stroke he has had. As a cardiac patient whose lesion we don’t know for sure, if he has a right-to-left shunt he could have thrown a clot to his brain, causing an ischemic stroke. But as a patient on warfarin (a blood thinner), he could have had a hemorrhagic stroke. I think the hemorrhagic stroke is more likely, making his massive stroke a side effect of his family’s diligence in giving him his medication. I am working on getting a hospital to accept him, and have word that we can likely transfer him by tomorrow morning, but that slogan “Time lost is brain lost” keeps running through my head. Until we know which type it is, we can’t even treat him medically – guessing the wrong one would have very bad side effects, since the causes are opposite – in one you bleed too much and in the other you have a clot that you want to go away.

Could his stroke have been prevented? Ideally patients on warfarin get frequent laboratory monitoring, especially in younger kids as they are growing. I am almost certain he didn’t get that, and for most kids once they have recovered from cardiac surgery they don’t need to stay on blood thinners. Something got missed – a consequence of having surgery in another country. You don’t get the same follow up, and the local doctors are left managing something they might not be at all familiar with. That safety net of continuity disappears, and even with good local doctors, things get missed.

I did get to have a rock-star moment with my resident – when we started discussing the patient and I mentioned the possibility of a stroke, he had this great “ah-ha” moment and high-fived me, saying “You really think as a pediatrician!” – he hadn’t considered that a child could have a stroke. He is a family medicine resident, so he’s seen plenty of adults with similar problems, and could name treatments, management, etc. but it hadn’t entered his mind until we started talking about it.

For tonight I will pray that the other hospital’s director is able to find space for my patient, hope that my own hospital’s director can find a functional ambulance, and wait until morning to see whether my patient has stayed stable enough to make the trip to Port-au-Prince. Kids tend to have better outcomes than adults, so he’s got that working in his favor, but just by virtue of his location this kid has a lot working against him. You might say that his particular net seems to have a few extra holes. We will see what tomorrow brings.

It Gets Better

So my first week back in Haiti is drawing to a close, and it has been an interesting week! It has been neat to see certain goals which have come to fruition, such as realizing that the nurses now wash their hands and encourage parents to keep the patient rooms sanitary. There are even signs hanging in the “NICU” instructing parents not to use their chamber pots in the NICU! (Can you imagine if people tried to do that in the US??)

Kidss are getting vital signs recorded three times a day, daily weights are such a routine thing that a nurse asked me today why I had weighed a baby (I’d missed where they’d written that day’s weight), and though we had run out of a lot of medications over the holiday, it seems we’ve restocked almost everything by today.

Most of the parents in the baby rooms are breast feeding their kids, and I find I’ve gotten a bit more relaxed about my approach to those who are formula feeding. (Haitians have a very casual relationship with time and the counting of things, which makes the American way of “Feed your (NICU) baby 17mL every 3 hours” an exercise in futility. Dr. Johnson would have a cow.) My new approach is less focused on quantifying exact amounts of feedings, and instead takes a more qualitative approach – you say you’re giving your baby 3 syringes of milk each time you’re feeding her? Great – let’s try four syringes each time! The next day we’ll aim for 5. My end point will be when the baby is gaining good weight, not when we’ve hit the magic number of milliliters per kilo per day that we’re trained to aim for.

I’m jotting down just a few of these positives now, during the first week, when I can appreciate how it used to be versus how it is now, so that on tough days – like today – I can reflect back and remind myself that yes – things really are getting better.

Departing

It’s been a long six months in Boston since I left Haiti in June. Hard to believe so much time has passed since then, though when I think about all that those months have held, it seems more than enough to fill any six month span. Ups and downs, 2012 was a year full of events which I will not soon forget. Now 2013 begins, and with it another chapter in my journey with Haiti.
Ann ale! Let’s go! Who knows what the new year will hold? I hope for nothing but the best.

More answers about my life in Haiti

More answers, and my apologies for not blogging in a while. This post is generally about the details of living in Saint Marc.

I live in a house which holds about 10 people in 5 bedrooms. We have a gate in the front yard, which is really more a giant wall than the picket fence you might be picturing. We have the luxury of a washer and dryer for clothes, but they only work when we have consistent electricity I do not do any grocery shopping unless I want a little treat like some candy or chips. Generally we have some women who work at the house and cook us two meals a day. Breakfast is sometimes quite similar to breakfast in the US (fruit, eggs, toast with peanut butter, coffee) and sometimes not so similar. My favorite – and probably the oddest breakfast – is the spaghetti and hotdogs. The spaghetti is cooked with a tomato-ish sauce (possibly ketchup-based) which generally has things like diced carrot and onion in it, and then hotdog is sliced up and mixed in. It is delicious. Lunch/dinner (our second and final meal for the day) virtually always includes either rice mixed with beans or rice and a bean sauce. There is generally either meat (chicken, beef, or goat) or fish, and perhaps fried plantains or some sort of vegetable.

There are two restaurants in Saint Marc. Okay, there are possibly more than that, but only two that we go to. They are located just about across the street from each other. They both serve good Haitian food as well as some American choices. If you have a craving for french fries, they are the place to go. The one also has a Salsa night on Thursdays. Very fun!

We can, in theory, walk to the hospital. It is about a 30 minute walk, but in the 90-degree heat that doesn’t always feel like the most appealing option. Fortunately we have a few drivers who will give us rides to and from the hospital – all we need to do is call. I do NOT drive here, nor do I have any desire to. The “rules of the road” have yet to be written here, as best I can tell.

I will try to post some photos soon to give a better idea, but I hope this helps to paint a little better picture of how my life is here. Since I live here as much as I live in Boston, it really has become like home. I will really miss it when I return to Boston in June and am already looking forward to my return next year.

Q&A: Dropped at ground zero, Big picture, Barriers, and How to help

More questions, from my cousin Karen. She astutely noted that although my organization has been in Haiti for many years, it seems as though I have been “dropped at ground zero” without a very coherent plan. The brief answer to that is that although the organization has been in Haiti a long time, they have only been working at my particular site in Saint Marc for the past few years. My co-fellow and I are the first pediatricians to be doing what we are doing in Saint Marc. There have been other pediatricians before us, but none staying at this particular site long-term. So in a way, yes, we are at ground zero.

Another factor which contributes to the chaos is that although my organization and my fellowship both have people coordinating from Boston, they depend heavily on Haitians locally for support and follow-through. One of the guiding ideas of the group is one of “accompaniment” – not just stepping in, taking over, and putting a band-aid on things, but partnering with local providers to strengthen the system and create sustainable change. Haitians love proverbs, so here’s one that fits this situation: “Give a man a fish, and you feed him for a day; teach a man to fish and you feed him for a lifetime.” While this is a beautiful idea, it often translates into a less orderly, less “American” system that we might like.

Karen also asked if I could talk about the “big picture” in terms of what my organization does to support me and what the barriers are that keep them from doing so. We have frequent phone calls and emails to try to discuss what the challenges are, what can be done to address those challenges, etc. but again, it’s all happening in the context of trying to strengthen the local system. This means that progress is often slower than we’d like, but as long as we keep moving forward I think we’re doing okay. The barriers, as described above, seem to stem largely from logistics and limited funding, but also come from a system which is just so broken on so many different levels that even the so-called experts don’t always have a good fix.

Right now we have run out of tuberculosis drugs at several sites. I’m told the reason for this has to do with everything from the US FDA to the way that we stock medication, to the budget for getting medication, to the system that we use for distributing those medications. I’m sure I am leaving out many parts of that particular equation, but you get the idea – even a simple problem is never as clear-cut as it seems. To quote another proverb, this one Haitian: “Beyond mountains there are mountains.”

Final question from Karen: is there anything we can do to help? Hmm. For me personally I would say everyone’s comments and emails really go a long way to lift my spirits when I am having a hard day here. For Haiti I would say supporting an organization* like mine is probably the best way to help. This country needs long-term thoughtful solutions, and supporting the groups trying to provide them allows their work to continue.

*Email or comment if you want the name and I’ll send it to you privately. I prefer not to mention it in order to keep this a neutral place for me to express my thoughts, and not a reflection on the group I’m working with. I try to keep the personal and professional separate, as much as that is possible.

Q&A – Reception, Organization, and Are You Really A Doctor Now?

Thanks, Aunt Barbara, for your questions.  

The first one was “How do you feel you are received by the Haitian people?”  That is a great question.  Occasionally smaller kids will be scared, but most kids seem excited to meet a “blan.”  Learning some kreyòl has helped with that reception – I think that being able to greet them in a familiar language takes away a little of the exotic-ness of meeting someone who looks totally different than the people they’ve grown up with.  In terms of my colleagues, I think they initially had their reservations about me, but the nurses especially have come to realize that I aim to be their ally.  They still sometimes think I’m pretty weird, getting all excited about things like “hand washing” (rarely done here!) but they have come to respect me.  

Parents of patients can have a few different reactions.  Some of them take my not-perfect kreyòl as an indicator that I must be not very bright.  Those folks usually come around after they see me providing good medical care around the unit.  Others are so surprised that I speak the language that they look to my translator to “translate” my kreyòl into kreyòl!  (This is not an issue of having an “American” accent; I’ve had many people comment on my near-lack of an accent.)  A few think that because I am an American (and therefore must be rich) I can provide them with things that they need.  This one is tricky, because by comparison even my meager fellowship salary makes me quite a bit richer than the people I encounter every day.  I usually answer (truthfully) that I am not paid to be here, and if they press further I tell them that I am not allowed to give people things.  (Mostly true – it is strongly discouraged.)  I would say the majority of the parents accept me as just another healthcare provider, and I like to think that they recognize my passion for providing good care.  

Second question: “What is the name of the organization that you work through? In other words, how did your being in Haiti come to be?”  I am in Haiti through a fellowship with a pediatric hospital in Boston and a Boston-based organization that has worked in Haiti for quite some time.  I’ve avoided mentioning the name of the organization on the blog, but it is an organization that gets mentioned in the news quite a bit in relation to its work in Haiti.  I am technically a volunteer with the organization, and I work as a pediatric hospitalist for the other half of the year when I am in Boston.  There is a second person in my fellowship who does the same thing but keeps the opposite schedule, so when I am in Boston he is in Haiti, and vice versa.  

Third question, easiest to answer.  “Are you a a full fledged pediatrician now or are you still in training?”  Yes, after finishing residency in June, I am a full-fledged pediatrician now.  When I am in Boston I sometimes supervise residents, and when I am here in Haiti I am one of two full-time pediatricians handling the patients who are admitted to the hospital.  I also teach residents here, which has been very rewarding.  

Reader requests – your turn!

A few weeks ago I had the privilege of being interviewed by my cousin’s daughter for a school project. She asked some really great questions about life here in Haiti, and I realized during the interview process that people might want to hear about things that I have not thought to write about.

So today I am opening it up to you – leave a comment with a question or request, and I will write a post about whatever you would like to hear about. Even if you have never commented before, feel free to chime in. I will try to write a post a day in response. I am at your service!

Late-night transfer

I had a really sick child come in to the hospital Thursday. He happens to be the son of the woman who works at a local orphanage, from which my friends are adopting a baby. We did all that we could for him, which wasn’t really enough, and I left the hospital yesterday evening with that doomed feeling I get when I know a child needs more support than we can provide. I was bracing myself for the worst.

Once I was home I started talking with my friend (the one who is adopting) and she suggested I look into transferring the patient to a private hospital. Usually my patients can’t even afford an ambulance transfer ($62 US) let alone a private hospitalization, so I hadn’t been thinking of it, but in this case I knew that wouldn’t be a problem*. So we started making phone calls, and in several hours I had an ambulance, a place for him at another hospital, and security clearance.

We left Saint Marc about 11pm, and got him there safely. I had never been the passenger in an ambulance before, let alone a Haitian ambulance. It was a fairly bumpy ride, but our driver was very skillful at navigating the bumpy, obstacle-filled roads as quickly as reasonable. He even used the siren. To make things more interesting, there was a heavy rain storm while we were on the road too. The ambulance only leaked a little.

On my return, I got a scolding for the way that everything came together – apparently there are official channels one must go through in order to make a transfer such as I did, and I failed to go through those channels. My boss here questioned the necessity of the transfer, and reminded me that there are important safety considerations when traveling in or near Port au Prince, especially at night time. In my judgment the patient’s breathing was so bad that he had a high risk of dying overnight without further intervention; the receiving hospital agreed – they intubated him as soon as we arrived so that they could put him on a ventilator.

Once I further explained the situation my boss agreed that I had made the right decision, even if I hadn’t executed it in quite the way that he would have hoped. The tone of our conversation at that point changed to a more congratulatory one, and he said I had done the right thing for the patient – whatever it takes. In this case whatever it takes meant a bumpy middle-of-the night ambulance ride and risking the ire of my superiors by doing things a bit outside the usual system, but it got the patient the care that he needed, and that is the most important thing.

We got back from the hospital around 3am, and I got into work Friday morning feeling like a post-call intern – tired but knowing I had a long day ahead of me. Sure enough, it was another busy day. I got home and happily got into bed to take a much-needed nap. Another exciting week in Haiti!

*The issue of transfer status being impacted by the patient’s ability to pay is a whole other kettle of fish which I will address in another post soon. In discussing the transfer after the fact I have heard that there may be money available to support transfers for patients who cannot afford it. Information I wish I’d had months ago. Layers on layers of inequality here.

Bodyguards

Okay, I wrote this post a little while back and haven’t posted it yet because I can’t figure out how to fix the picture.  If anyone can help me fix it, I’m all ears.  Otherwise, Happy Easter and turn your head sideways to see the cute picture below!

The Haitian pediatrician, V, has two bodyguards who accompany him to the hospital every day.  The rumor is that he has a feud with the director of the hospital, and feels that he requires the bodyguards to protect him from the hospital director.  General consensus around the hospital (V excluded) is that this is utterly excessive and unnecessary.  I’ve been to the hospital director’s office; he isn’t a violent or imposing man.  It’s interesting.

I’m mentioning this because yesterday I had my own bodyguards – two little 4-year-olds who walked around pediatrics with me, “helping” to push the metal stand that I put charts on, holding my hand, mimicking the beeping noise of the pulse oximeter, and just generally having a grand time.  The one also offered me his hand to re-bandage each time  his “band-aid” (tape with cotton under it) came loose.  I haven’t posted any photos yet, but I can’t resist sharing this one.

Meet my bodyguards.

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Great moments in nursing

Today was a great day.  I didn’t think it would be great, but sometimes it’s nice to be surprised.

I admitted a very sick 1 day old infant yesterday afternoon.  He had a bulging fontanelle, lethargy, poor tone, and very frequent episodes of apnea (not breathing) & bradycardia (low heart rate) – signs of a very serious infection, likely meningitis.  After another nurse initially said we didn’t have an IV small enough for the baby, L, one of our nurses, stepped up to the task and not only started an IV with the less-than-ideal IVs that we had, she also gave the baby everything I’d ordered to be given right away.
Then the nurses asked me what they should do that night when the baby’s heart stopped.  I said that if they corrected his apnea – pauses in breathing – his heart wouldn’t stop.  They repeated the question, reminding me that they have a lot of other patients to see; they were worried they wouldn’t notice if the baby stopped breathing.  I told them that if the baby’s heart stopped they could use the ambu-bag (used to breathe for the baby) and do chest compressions like M and N, our visiting neonatal nurses, had taught them.
I noticed that the baby was still bleeding from where I’d pricked his heel (to check his blood sugar) for quite some time after I’d stuck him.  Even applying pressure for 10 minutes wasn’t stopping it.  I asked for vitamin K to help stop the bleeding, but was told we didn’t have any.  Not good.
So I left the baby in a warmer with a monitor attached to check his heart rate.  The monitor was of dubious value since the baby’s grandmother (the one watching the baby) could not count.  She also had failed to recognize that the baby had stopped breathing several times while we interacted, even when I pointed out to her that the child’s chest wasn’t moving.  She was the only family member available, so I taught her how to stimulate the baby when he stopped breathing and told her to call for help if that wasn’t working.
I let the nurses know I left an ambu-bag at the bedside, but left feeling very doubtful about this baby’s chance of surviving the night.  So imagine my surprise when I arrived this morning to find the baby breathing consistently, with a neat bandage on his heel and another on his thigh – where he’d been given an injection of vitamin K!  I asked the parents in the room what had happened.  They told me how the baby was alive because of the great nursing care he had received.  Apparently during the night he had begun to bleed from his mouth.  Our nurse L came in, suctioned the baby’s mouth, used the ambu-bag, gave chest compressions, and successfully resuscitated him!  Everyone in the room was very impressed – none more so than me!  (She is also the one who gave and documented the dose of vitamin K she administered.  Not sure where it came from, but I’m thankful she gave it!)
I saw L this afternoon and congratulated her on saving the baby’s life.  She was beaming.  She told me how our visitors M and  N had told her that they recognized she had a lot of strength that she could use to help give good neonatal care – the very diplomatic end to a conversation with her about not yelling at parents, as I recall.   I told her what a great job she had done, and let her know I’d already sent M and N an email to share the good news.  It was fantastic.
The baby is still really sick, but he got the best chance at surviving this by getting such outstanding nursing care last night.  I’ve talked about nursing training as an effective intervention here before, but it is just so heartening to see how M and N’s training has had a direct and meaningful impact on patient care here.  I am extremely thankful for our visiting nurse educators and feel very lucky to have such great allies in my quest to improve care here.