February 2012 Archives

4 Residents Join MEDICO Team in Jalapa, Nicaragua

the following entry was submitted by Kimara Gustafson, 3rd year pediatrics resident


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The team reviewing chest x-rays and EKGs for pre-op patients

Bienvenidos a Nicaragua

We have all arrived safe and sound, and survived our first week. After spending one night in the capital city, Managua, we took a slightly nauseating 5-hour car ride north to Jalapa, a city just south of the Honduran border.

There are 4 pediatric residents (myself, Chris Jarosch, Christa Miller, and Megan Baxter) and a nurse, Jane, as part of the pre-team. The larger group arrives on Sunday.
 
This week we have been completing pre-op exams in preparation for the surgeon's arrival.  We have seen approximately 60 patients and have nearly 30 scheduled for surgery.
 
In our free time, we've explored the town's public pool, ice cream shop and Internet cafe.

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Bili bed constructed by previous residents on this rotation

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The OR at our hospital in Jalapa

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Our hotel

John Heimerl: 1 Month in Haiti

This entry was written by third-year Pediatrics resident, John Heimerl MD.

It has been awhile since I have last written on my experience in Haiti. Today marks exactly one month since I left Minnesota.

The Urgents remain busy. One day this week a girl was rushed in. A nurse pointed to her and asked if I could see her. My interpreter was a little late getting back from lunch, so I said yes in my limited French and Creole and was able to get the child's age and a little about her story.

I could tell she was febrile, breathing and responsive to pain. During my exam she began having brief seizures that lasted about one minute each.

Regan, one of my favorite nurses, was not available (he speaks fluent English), so after a few more minutes of intermittent seizures I asked another nurse to get me some rectal diazepam to give. The seizures immediately stopped.

I was then able to get more of the story and learned that the child is nearly two. She had been normal previously, until this morning when she was not acting like herself and was "getting worse".

My interpreter soon arrived and I was able to finish the history and get Regan to start with the orders. We got a bedside glucose (21mg/dL, which is extremely low), then gave rectal Tylenol, placed an IV, gave a dextrose bolus and obtained labs. When I left for the evening she was in a much better condition but still needing intermittent doses of diazepam for her seizures.

I learned the next morning that, shortly after I left, the family had taken her home to take her to a Voodoo priest, thinking her problem was that she is cursed.

I had a similar seizure presentation yesterday with a 11 year old who had been in an alerted state of consciousness or the past three days. She had been receiving some antiemetics and Benadryl at another facility and was sent to St. Damien's for further evaluation and management.

She was obtunded and, like the previous girl, was having intermittent seizure-like activity.

Her history was concerning--a severe headache prior to developing symptoms of slurred speech and difficulty walking, which then progressed to her current state. I ordered diazepam and asked them to draw up phenobarb. The nurse looked in the closet and reported they were out of both of the medications. After some searching she found some midazolam, which did the trick. (Well, it was that or the ceftriaxone.)

This morning the child was awake, had a completely normal exam and was asking for food. Amazingly, the same seizure intervention had two distinctly different outcomes.

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On Urgents ward with Nurse Geno and my interpreter, Hilaire.

On my most recent day off, I was able to tag along with a Chicago photographer and journalist as they made a couple of stops on their way to Cité Soleil, the largest slum in Haiti.

The first stop was Operation Blessing, a well-financed NGO that is in the process of building a fish farm, with plans to expand these low-impact ponds to other locations. Apparently Paul Farmer has worked on the planning process for the ponds.

I had seen tilapia farms in Zambia, but those were small scale. This was the other extreme; the operation was impressive. Each pond contains 25,000 fish fry, there is a filtration system and a separate water well that supplies fresh water to the tanks.

The most amazing aspect of this operation is how minimally invasive it is to the land here. Operation Blessing hopes this project will be the first of many tilapia farms that will help provide both fresh protein and jobs to Haitians.

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The fish pond at the fish farm.

Operation Blessing also operates an orphanage that houses several hundred children. They also recently have gotten into the exotic fish business.

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The halls of the orphanage operated by Operation Blessing, home to several hundred orphaned children.

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Aquarium at the fish farm operated by Operation Blessing.

Our next stop was a school financed by Artists for Peach and Justice, which teaches music to the impoverished youth of Cité Soleil. We were delivering a new batch of donated instruments. The children were appreciative of their guitars and xylophones. They are in the process of forming a marching band, so they are awaiting the delivery of some brass instruments this month.

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Young musicians at the music school operated by Artists for Peace and Justice in Port au Prince, Haiti.

On we went to Cité Soleil. We were to tour the new trauma hospital that Nos Petits Freires (which operates St. Damien's, where I'm rotating) is forming; a different NGO that had been providing medical care following the earthquake had left a gap in services when they recently closed their trauma facility. The building was mostly empty, but a small clinic had been set up.

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Cité Soleil Hospital

On the way to the hospital, one of our traveling companions warned us to be extra cautious because fuel had run out across Haiti. So, while there would be fewer vehicles on the road, others might be stranded and might make take "drastic actions" to get more fuel. I did notice fewer cars on the streets, but aside from the long lines at the gas stations and some hospital staff not being able to get to work on subsequent days, I didn't see any other sign of the fuel shortage.

Cité Soleil is a slum with inadequate housing and water. Wikipedia claims that, "the area is generally regarded as one of the poorest and most dangerous areas of the Western Hemisphere and it is one of the biggest slums in the Northern Hemisphere". NPH and other groups (including Sean Penn) are working to build new quality construction in the area. We saw a couple of these $7,000 cement structures. The NGOs are planning to eventually move all inhabitants to these houses which have running water and toilet facilities.

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New permanent houses built by NGOs in Cité Soleil.

The remainder of Cité Soleil consists of corrugated steel roofing fashioned into a house. These structures do little to prevent rain water from entering, and when we visited, the city was in the process of drying out from the previous night's rainfall. Children were playing in stagnant, foul-smelling water. Pigs were foraging through the piles of trash. (Cité Soleil happens to be situated at the end of all the gutter runoff for Port au Prince, so during the rains the trash in these ditches makes its way to Cité Soleil).

We walked a short loop. Our guide had chosen the loop so the rental truck could always be within site, to ensure we could keep an eye on the equipment that was left. This, however, was not necessary as everyone welcomes the new hospital in their community. Children flocked to the professional photographer. Teenagers engaged us in conversation, usually culminating in a request for financial assistance for school. One nice boy asked if I could help him with his English. When I told him I would be there only for a few minutes, he returned shortly with an English book, and we practiced his pronunciation.

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On Valentine's Day I was asked to work an overnight shift in the hospital. The hospital director would be available by phone should any crisis arise. So I worked till noon then had the afternoon off.

At 5PM I returned to a busy Urgents. Most of the children had minor complaints. Around 6:30 a nurse asked me to examine a child who they were giving manual bag mask ventilation to and who had no heart rate. We coded him for the next fifteen minutes, and it was only after I pronounced him dead that I recognized his malformed ear. I had admitted this child for pneumonia my second day in Haiti, and he had subsequently returned home appearing much better. And he returned within a month in respiratory failure.

Fortunately that was the only death of the night. It remained busy till midnight, and then I was able to return to my house and lay down for a few hours.

That gave me yesterday off, so I was able to catch up on some sleep. In the afternoon we delivered a portable oxygen system, provided by a group called Urban Zen, to a chronic patient named Peterson. He has been in the hospital for over a year and remains on an oxygen concentrator.

Urban Zen fundraised the $4,000 dollars for the device, which ultimately will allow him to go back home and to school. We had him practice putting it on and using the device. He enjoyed walking down the hospital and to the street, where he would yell at people so they noticed he was not confined to his room anymore. The internal and two external batteries will give him 7 hours of continuous use. He has a ways to go, as his legs were tired from the exercise after just going a few feet.

I will have to check on him today to see how he liked using the machine last night.

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Peterson and his new oxygen machine

Till next time....