December 2013 Archives

I suppose it is a common experience to struggle a bit with how to explain and portray an experience such as this. Ok, ok, maybe I struggle with the right words frequently in life.  For my last post, I described a typical day here in Tanzania.  As I near the end of my time here, I have been reflecting on what I will remember the most, and much of it comes down to this -- the people.  That has been a recurring theme in life and most frequently what I walk away remembering. I have been humbled and learned much from the people I have encountered here.  In describing them, I hope you will see the Tanzania I have grown to love.

Joseph, Emily, Dr. Mantz, Danielle and Maneno.JPG
From left to right Joseph, Emily Hall (PL3), Dr. Mantz, Danielle Brueck (PL3) and Maneno

Joseph:  Serving as the pediatric registrar, Joseph is at Selian Hospital 6 days per week with rare exception. He trained in China and is fluent in 4 languages (wow, I'm behind in life). When on call, he also covers medicine, surgery, and OB/GYN.  He is smart and dedicated, challenging the interns to think through a differential diagnosis themselves and not simply repeat what others have said.  He enjoys teaching and has been ever so gracious to accommodate and answer my frequent questions (which, no doubt, make rounds last much longer).  If he is told the hospital does not have a medication, he walks over to the pharmacy himself to check on the availability.  When he finishes his own work, he can often be found in the outpatient department helping others with the clinic patients that need to be seen.  During our rounds, he will pick up a child and set him or her on his lap. He truly enjoys caring for kids and reminds me of the simple joys found in pediatrics.  Joseph excels and pushes learning forward in a system where it would be easier to settle quietly into the background.  I admire the responsibility he has taken.

Joseph teaching some local students about malnutrition.JPG

Joseph teaching some local students about malnutrition

Maneno:  The intern on the pediatrics team, much of the "scut" work falls to this guy. You would never know it, however, as he is persistently eager to learn.  He wants more patients to come, saying that is how he will learn about what to do.  Being from further away in Tanzania, he stays in a room on the hospital grounds. But this doesn't bother Maneno; it means he is available to see more patients. He asks the other interns to call him if an interesting case arises. He is selfless, willing to pick up an extra shift if others must go out of town or have another obligation.  Maneno has reminded me how fun learning can be.

Cifa:  I met Cifa at church.  He is a generous Tanzanian who is full of life.  He has fostered/adopted many Tanzanian children over the years and truly has a desire to watch them succeed.  He cares for them and teaches them to care for one another, the older ones assisting the smaller children.  What struck me about Cifa is how passionate he is about caring for the less fortunate of Tanzania and what little regard he seemed to have for his own interests in this.  During my time in Tanzania, I read a book called Toxic Charity (thank you, Dr. Kate Venable, for this excellent suggestion).  It addresses the sustainability of charitable efforts and discusses how to avoid creating dependency.  The book challenged my own motives and forced me to ask myself some hard questions.  In the context of reading this, I had such a moment of clarity when meeting Cifa.  He genuinely embodied a sustained, grass-roots effort to impact those in need.

J:  J was just one of many patients I will remember from my time here.  He taught me a lesson in communication.  J is 4 years old and has been in and out of the hospital over the past several months and was admitted for approximately 3 weeks during my time at Selian.  He has developmental delays and is non-verbal.  Not knowing much Swahili, I have felt the language barrier more than I would have anticipated.  For me, so much of the joy of medicine lies in talking with people.  I have been able to have fantastic and academically stimulating conversations with my colleagues here but have truly missed just sitting to talk with patients.  With J, the non-verbal parts of communication became even more evident to me.  I loved walking in each morning to see his smile.  He would peer up from the bed through the window at me as we gathered our things for morning rounds.  I would duck down, then pop my head back up to find him laughing.  This game never got old.  J was scared of us at first, but it turns out that coin magic tricks and juggling are universally loved despite the language.

E:  We saw E in clinic one Tuesday afternoon, and he quickly captured our attention.  At 4 years of age, he is extremely small (7 kg or about 15 lbs) with a disproportionately large head.  His mother brought him to clinic for a completely unrelated complaint, and we wrestled a bit with how to broach the subject of his odd appearance.  E taught me about the ethics of practicing medicine.  I found his case particularly interesting from an academic standpoint and had to ask myself if meddling in his previously happy and fairly uncomplicated life was for his best interest or merely an indulgence on my part.  He came back to our clinic 3 other times during my 2 months here as we arranged to have some testing completed.  He was always a joyful and cooperative child, bright and slowly taking in the unfamiliar world of the hospital.  His family seemed genuinely appreciative though I continued to wonder if any actual good or benefit would come from having a diagnosis.  Sometimes, both abroad and at home, I feel better having an answer for myself.  E makes me more aware of how my actions can affect others.

Team rounds in the ICU discussing causes of heart failure.JPG

Team rounds in the ICU discussing causes of heart failure

David:  David is a taxi driver and was the first person Emily and I met in Tanzania and will be the last we say goodbye to as he drops us off at the airport this evening.  He was immediately friendly and welcoming.  He gave us just 2 pieces of advice to consider during our time in Tanzania -- pika pikas (motorcycle taxis) are dangerous, particularly at night.  And be careful of the local alcohol; it is strong and causes many a problem.  We decided to heed his advice on both these matters.  David is an extremely hard worker with a day job in an office and then driving as a taxi many evenings.  He never complains but is eager to meet opportunities.  He chooses good company and sets high goals.  His father once told him "If you do not clean the dirty dishes at night, you will have no plates for food in the morning."  His parents provided a constructive environment where he learned responsibility and discipline, and he looks forward to doing the same for his children someday.

The stories of others have long intrigued me, and these are just a few that I will carry forward.  These stories inform and shape my own.  There are many others (Tanzanians and ex-pats alike) who have made my time here a wonderful experience.  I am grateful to have been so included and welcomed here and will certainly miss the beauty of this place.

Posted on behalf of Calla Brown (MP3)

While Abby has been teaching ultrasound at St. Damien's, Hope, Adam, and I have been working on an evaluation project of a protocol for the admission of pediatric patients with severe acute malnutrition.  Ben Trappey, who is currently a Med Peds faculty member, our faculty advisor for the rotation, and also in the department of global pediatrics, did a four-week rotation at St. Damien's during his Med Peds residency.  While here, he worked with the staff to design an order set for malnutrition.  The order set was based on both the World Health Organization standards for the treatment of acute malnutrition and also on the Haitian Ministry  of Health protocol, and includes best practice guidelines like appropriate rehydration, feeding, and vitamin supplementation.  The staff at St. Damien's, including nurses and physicians, underwent an intensive training on its use in April of this year.  

One of the attendings asked us to evaluate the use of the order set.  We are evaluating two outcomes:  whether the order set was initiated upon admission to observation and whether the child survived to hospital discharge.  This evaluation is made easier by the department of Archives at St. Damien's.  All children who present with severe acute malnutrition, as defined by a weight-for-age Z-score of less than negative three or a weight-for-age Z-score of less than negative two with edema are entered into a book  and this data is eventually shared with the Ministry of Health.  

The Department of Archives

The Department of Archives has shared the book with us so that we can pull all of the charts from children admitted between January 1st and October 31st of this year.  From the chart we gather admission weight, gender, co-morbidities, and the above two objectives.  If the child did not survive to hospital discharge, we attempt to create a narrative history of the admission in addition to collecting objective data like vital signs, lab results, and blood sugar measurements, in order to understand as best as we can why the death occurred.  We will be collating and analyzing this data to share with the staff of St. Damien's.  Ideally together we will discover clinical correlates that could be intervened upon and then perhaps improve outcomes.  

Calla at the Archives.JPG
Calla Brown (MP3) at The Department of Archives

Hope at the Archives.JPG
Hope Pogemiller (MP4) at The Department of Archives

This quality improvement project has been interesting on many levels.  Firstly, we have seen many children who have been admitted for severe acute malnutrition, and in taking care of these children in partnership with the staff of St. Damien's, we have realized how critically ill a child with malnutrition can be.  Secondly, doing the project has inspired us to learn more about how treatment protocols for malnutrition were developed and what creative methods for its treatment have been implemented in different settings.  Thirdly, we have learned what a behemoth of a task it is to keep track of hundreds of thousands of paper charts in a navigable way.  We are still analyzing the data but we are excited to see what comes of this project.  Whatever the outcome, however, I think I can speak for all three of us when I say that we have learned a great deal.  

Abby Montague (PL3) creates a handbook on beside use of ultrasound

Posted on behalf of Abby Montague (PL3)

I am fascinated by ultrasound. In medical school I had the privilege of rotating at HCMC for an ultrasound rotation through the emergency medicine department. I spent a month learning everything from bedside FAST (Focused Assessment with Sonography for Trauma) exams and the basic bedside applications to looking for retropharyngeal (behind the throat) abscesses with intra-oral probe and confirming fracture reduction in the arm. Unfortunately, keeping these skills up during residency hasn't really been a priority due to the ready availability of excellent ultrasound technicians and pediatric radiologists. But I like looking at the images my patients get and guessing the diagnoses before the official read comes back. I occasionally would page through my Pocket Atlas of Emergency Ultrasound (by one of the HCMC faculty among others) to remember how I would do the studies myself.

Then I started preparing for Haiti.

Aside from X-rays, we knew an ultrasound machine was the only available imaging within the St. Damien's. I was excited about renewing my skills and asked Ben Trappey, our MedPeds hospitalist attending coordinating our trip, if the staff at the hospital would be interested in a little handbook on bedside use of ultrasound that I could do for my academic project.

They were.

After cramping my wrist at 5 am trying to get good RUQ views with the portable ultrasound in my call room, I had enough images for my project. I put together pictures of the buttons from our machines in the ED and on the floor for a mix of the way symbols appear and reviewed some radiology literature for images of clinical pathology. I printed up the guide on Saturday before we left and Ben presented it to our Haitian contacts when we arrived.

Ultrasound machine with Abby's booklet on the side.JPG

Ultrasound machine with Abby Montague's newly created bedside use of ultrasound booklet easily accessible on the side

One of the first ultrasounds we did here was evaluating a child with TB for pleural effusion (fluid around the lung). It was so grossly abnormal at first we couldn't find our landmarks. As we kept looking, we realized we were probably seeing TB cavitations within consolidated lung tissue (holes in the lung). It was impressive. The next was a child with abdominal distention who ended up having a complex cystic mass that was so large we couldn't tell if it was coming from the liver or the left kidney (on opposite sides of the body). Kids don't come to the hospital until they are really sick and their imaging findings, whether chest xray or ultrasound, tend to be dramatically pathologic. At first, the staff just asked us to go do the ultrasounds which couldn't happen until most people were gone for the day. Gradually, they started crowding around to look at the images in real time.

One of the new residents was the first to accept the transducer. Each ultrasound, I would pass it around to see if anyone wanted to practice, receiving a lot of smiling and head shaking with French explanations I couldn't understand. The resident, Renee, was admitting a child she suspected had intussusception (intestine stuck within intestine). After explaining my lack of training with intestinal imaging again (having attempted an appendix ultrasound the first week), I asked her to just start looking since we had equal lack of experience in this case. I shamelessly endorsed my ultrasound guide and showed her the pages about the difference between the probes and the standard probe positioning. She started scanning the abdomen and found a tubular structure with a target appearance in cross section. Never having ultrasounded a child before, she recognized the characteristic finding without prompting. The staff all came around to look and we had a long discussion about the next steps. With no fluoroscopy available, the child would need to have a reduction through an open abdominal surgery. A stunningly textbook history and suggestive abdominal film would have sent the child for reduction regardless. But I can't describe how satisfying it was to watch the resident add to her own clinical suspicion using ultrasound with minimal help.

One day I was asked to ECHO a cyanotic newborn. I am comfortable with the subxyphoid view but I couldn't remember the orientation of the alternative views of looking at the heart. The very same Pocket Atlas I used in MN had made its way to Haiti prior to our arrival and and I grabbed it from the stack of English textbooks on the registration desk to re-orient myself. Renee and I talked through the chapter on cardiac imaging, each tried a couple views and came to the conclusion the right ventricle was small and we could not determine much else. But the physician I had handed the book to was now flipping through other chapters to see what was possible with this machine they've acquired and now wanders in our direction to look over our shoulders whenever we bring the ultrasound out from radiology.

I have not stopped being completely anxious about people relying on our novicely obtained images. We are asked on a daily basis to ultrasound outside of our scope of familiarity - like the ECHO's for congenital heart disease, the intestinal ultrasonography, and examinations for biliary atresia. I've only turned down one request to look for peripheral pulmonary stenosis since I don't even know how to find the pulmonary arteries. But the giant septated pleural effusions are becoming more familiar and a new staff tried her hand at visualizing one today.

I've revived an old love and maxed out the space on my flash drive bringing home images to share with Ben. But I wish I had an image of the look on Renee's face when she found the right angle to visualize the heart. I felt like I really had brought something to give. Our Haitian colleagues have been most generous in sharing knowledge, skills, and gracious acceptance. My hope is that in this small way, we've shared something worthwhile in return.

Rainbows and reflections from Hope Pogemiller (MP4)

Posted on behalf of Hope Pogemiller (MP4)

On our walk to the villa one day after a brief rain, we were startled by the beauty of 2 rainbows stretching across the sky. We all stood back by the walls of the compound next to the road and excitedly pointed at the rainbows. We shouted excitedly to a man passing by, and he smiled and taught us the name for rainbow in kreyol as he walked. Everyone from security guards to cooks to patients are pleased with attempts to learn kreyol, and it is amazing how patiently they repeat words and help us to construct phrases each day. 

Double Rainbow.JPG
A double rainbow

Hope & Adam at the Compound.JPG
Hope Pogemiller (MP4) and Adam Foss (MP4) at the compound

As we bid farewell to so many favorite colleagues and community contacts, we often receive a wish that our final few days be multiplied 100 fold. We are surrounded by an intense love of Haiti that is shared by so many Haitians and aid workers alike.  The spirit of Haiti has crept into our souls, and even in our final days of this month we are practicing kreyol at dinner and planning our return.

Hope Pogemiller (MP4) and the arrival of the incentive spirometer

Posted on behalf of Hope Pogemiller (MP4) as she tells the legend of the day Adam Foss (MP4) brought the incentive spirometer to St Luc

St. Luc hospital cares for patients 13 years and older. Since the doctors are trained primarily in adult medicine, the style of care delivery leans toward the adult end of the spectrum. As is often topic of discussion in the med/peds realm, delivery of care to children and adults is fundamentally different. This has remained constant in our observations at St. Luc.  

In the past few weeks, we have been able to help patiently tease out history and current complaints from young patients at St. Luc. Noting a dire need for incentive spirometry,  Adam introduced bubbles today to a 15 year old male with a severe respiratory infection that leaves him sweating in rigors each evening and unable to sit up in bed due to generalized weakness.  

Adam making incentive spirometry.JPG

Adam Foss (MP4) making incentive spirometry

His chest xray, unstable respiratory status, and continued fevers have raised concern for tuberculosis. 

He was therefore ordered to produce an early morning sputum during rounds one morning. 

He cried out and mumbled something that was translated by staff as him refusing to cough. 

Pain Scale.JPG

Hospital pain scale

We contemplated a change of perspective. 

We helped him sit and encouraged him to try to cough, but he finally explained that he was afraid because it was so painful in his chest to cough. 

We mentioned that we could possibly obtain a gastric sample instead of a sputum sample, and the physicians agreed. They threatened him with insertion of a tube down his throat to convince him to cough. 

This had not been our idea, and we were beginning to feel uneasy when Adam enthusiastically announced that this child absolutely must blow bubbles. 

We left his bedside as he crumpled in a heap on his bed in relief that the team was moving on to discuss the next patient. 

After rounds, the local physicians helped Adam find a piece of circular plastic (formerly used to hang IV fluids) and an old medicine bottled filled with soap. 

Our incentive spirometer was born. 

Despite my reservations that an adolescent, severely ill Haitian boy would muster up the courage to try the bubble-blower, our patient became suddenly enthusiastic as his face lit up with joy when he was able to blow bubbles. Despite his fatigue and chest pain, he was able to produce bubbles for 5 minutes and promised to try once each hour while awake. 

The local physicians and patients in the adjoining beds shared our patient's enthusiasm, and Adam has effectively added creative incentive spirometry to the treatments available at St. Luc.

Christmas comes to St. Damien and St. Luc

Posted on behalf of Hope Pogemiller (MP4)

As Noel approaches, high-pitched electronic strains of Christmas cheer echo in the courtyards of St. Damien. Strings of tiny multicolored lights are draped across the Virgin Mary and priest statues, posters of jolly Santa visages adorn the halls and the emergency room. A festive Christmas tree has been placed in the glass security/hospitality booth in the foyer of the hospital. Patients are now greeted with inflated purple and white gloves hanging on the boughs among colorful mini-lights and red and gold tinsel garlands. The lab and medical records archive also have trees, and they are focal points for unending staff pictures. While searching for lab results each morning, our interpreters and the lab staff now ask us to pose with them. The mooing of the hemogram machine (the ever-present "cow" in the corner of the lab) is now accompanied by the tree singing high-pitched carols.

Christmas Tree at St Damien.JPG
Christmas Tree at St. Damien

Hope with 2 interpreters from the lab.JPG
Hope Pogemiller (MP4) posing with two interpreters from the lab

Hope, Lab Director, and Abby.JPG
Hope Pogemiller (MP4) and Abby Montague (PL3) pose with the Director of the Lab

St. Luc also has evidence of the upcoming holidays. There is a team of 5 young men whose job description includes rolling oxygen tanks to bedsides of acutely desaturating patients and wheeling patients to and from the CT scanner and X-ray. One morning, our rounds were followed by evacuation of all the patients out of the emergency department area and into the adjoining ward. The team of young men enthusiastically donned a combination of shower caps, hospital gowns over shorts, and bunny suits (jumpsuits) and filed into the emergency room. They energetically pressure-washed the entire ceiling of forest green plastic tarp lining the tin roof in anticipation of Christmas decorations to come next week. The wall trim has been repainted a matching forest green, and the tiled floors have been scrubbed along with the shelves in each ward.  

Pressure Washing.JPG
Pressure washing at St. Luc in preparation for holiday decorations

The temperature has dropped with a persistent wind that stirs the dust and prompts addition of a jacket and socks for breakfast. This chill along with the lights and tunes of the approaching holiday raise everyone's spirits as they plan holiday gift exchanges and fetes. As I walk back to our villa each day, I expect to see piles of bright white snow and am surprised to find piles of light brown rocks, rubble, and light trash dancing in the wind. 

Adam Foss (MP4) Shares at Visit to Kenscoff Through Pictures

Posted on behalf of Adam Foss, MD (MP4)

Greetings from the Haitian tropics!

We have been enjoying 90+ degree weather and are dreading returning home to the snow and cold. I wanted to share about a recent trip to an orphanage site in Kenscoff.  

A little history on Kenscoff:  In 1987, Father William Wasson founded Nos Petits Frères et Sœurs (NPFS), French for "Our Little Brothers and Sisters," a home for orphaned and abandoned children in Kenscoff, Haiti.. At its peak, there were over 400 children staying at the orphanage. Currently, there are 318 children at Kenscoff and there are several orphanages run by NPH (Neustros Pequenos Hermanos) in the surrounding communities. 

Kenscoff is a favorite of the NPH workers and visitors alike. Set in the scenic mountains, it offers a cool escape from the warm weather of the sea-side. 


Our trip commenced with a 2 hour drive up the mountain side (aided with the use of anti-nausea medications).

Road to Kenscoff.JPG
Road to Kenscoff

Adam, Calla, Hope, Abby - Riding in a Van.JPG
Adam Foss (MP4), Calla Brown (MP3), Hope Pogemiller (MP4), Abby Montague (PL3)

Fruit Stand on the way to Kenscoff.JPG
Fruit stand along the road driving to Kenscoff

Words cannot describe the utter beauty and peacefulness that is Kenscoff. We arrived to find the children engaged in boisterous singing during mass. We made our way to join the festivities, and the children quickly surrounded us. One child was quickly enamored with Hope's sunglasses and also her hair. Calla found herself quickly making friends and conversing with the children in Kreyol. Abby was greeted with a great big hug, which was greatly reciprocated. One child was quite delighted to examine my hands and compare mine to hers. 

Chapel in Kenscoff.JPG
Chapel at Kenscoff

We were taken on a tour of the facility including the different houses for the children, the kitchen, the volunteer quarters, the clinic, and also the impressive art department. 

Clinici in Kenscoff.JPG
Clinic at Kenscoff

School in Kenscoff.JPG
School at Kenscoff

Mural at Kenscoff.JPG
Mural at Kenscoff

It was great to have the opportunity to engage with the children and experience what others had been saying about Kenscoff.

Hope & Calla at Kenscoff.JPG
Hope Pogemiller (MP4) & Calla Brown (MP3) at Kenscoff

Emily Hall (PL3) shares 3 memorable cases

 Posted on behalf of Emily Hall, DO (PL3)

To be truthful, I have no sense of who reads these blog posts. Perhaps you're
  • a fellow resident or medical student thinking "Should I do my International Rotation in Tanzania?" 
  • or a faculty member thinking "Emily, you should be spending more time talking about your experience at the hospital" 
  • or my distant relative motivated by guilt, worrying about my well-being and thinking "how am I related to you, I would never associate with such impulsive travel plans and decision making." 
Regardless, I hope you've found my ramblings both interesting and of some value. 

I have packed my bag with the anticipated return to (the frigid) Minnesota and find myself with a few moments for reflection prior to catching a taxi to the airport. I have had incredible opportunities to see the country, develop relationships, and further my knowledge of medicine. I'll highlight some of the memorable patients that have taught me most about the art of medicine and the unique challenges of medicine in low-resource settings. I should note: the following pictures were obtained with parent permission and an understanding the photos would be shared with others who were interested in tropical medicine.  

CASE ONE: 9 year old with unilateral eye swelling. 

Case 1.jpg

Clinical Course. Febrile, sick appearing child (39.7) presents with 4-day history of fever and unilateral eye swelling. Temporal relationship to fever and initiation of eye swelling was unknown. Eye swelling progressed with bilateral involvement the day of admission with associated active serious drainage from the superior eyelid. No obvious skin lesion. Child reports eating cooked meat from a deceased calf approximately 1 week ago, the calf was notably sick prior to dying. No one else in the family or village has been ill; other individuals ate the same meat and did not develop illness or facial swelling.

On admission, the intern overnight believed this was a case of cutaneous anthrax (despite there being no classic eschar lesion). Child was started on high dose Penicillin.  Two days later, child's fever and facial swelling was persistent. Differential diagnosis was considered including H. flu or staph pre-septal vs orbital cellulitis. Antibiotics were empirically broadened. Within 1 week she developed a classic eschar involving the superior eyelid and her fever curve normalized. She was discharged home on mono therapy with high dose Penicillin. She was instructed to follow up within 2 weeks; she was lost to follow-up, presumed continued resolution of her bilateral eye swelling. 
Lesson Learned: Trust your colleagues, regardless of their 'rank' in medicine. The intern overnight reported seeing a similar presentation of cutaneous anthrax. Despite this, many (including myself) thought broadly about the differential and given the sick-appearance of the child promptly advocated for empiric antibiotic coverage. In the end, the intern made the astute and correct diagnosis. In retrospect, he had much more to say regarding how he came to this conclusion and demonstrated a sound thought process that was initially overlooked. 

CASE TWO: 4 year old with chronic constipation

Clinical Course: Child with developmental delay presents for repeat admission for withholding stool and abdominal mass. On presentation he last passed stool 14 days ago. No history of vomiting, anorexia, or weight loss. Review of systems notable for gross hematuria. Abdominal ultrasound obtained to rule out mass was normal. Abdominal x-ray with dilated bowel loops filled with stool, no bezoars noted. 

Despite aggressive attempts at a bowel clean out (NG placement, repeated enemas, etc). A bowel regimen was established, but would be required for many months duration. A referral to pediatric surgery was obtained to rule out low-lying Hirshprungs disease. Decision was made for colectomy--which came as quite a surprise to me. 

Lesson Learned: Accept clinical management differences. Though a colectomy seems like an incredibly invasive treatment approach for a child with chronic constipation, it prompted investigation into management options and approaches in Tanzania. Turns out, a colectomy is not an uncommon treatment modality in this area. Instead of trying to be understood--I found in this instance and many others the value of seeking first to understand...and then if prompted invite further discussion. There are many ways of 'solving' problems in medicine. It's refreshing and interesting to see new approaches even if at times they are counter to previous ideas.

CASE THREE: 26 month old with bilateral lower extremity pitting edema

Case 3.jpg

Clinical Course: Well appearing child was brought to the hospital from a rural by family after a medical worker had seen and strictly advised the family to seek medical evaluation for the child. Mother reports personal history of bilateral lower extremity pitting edema as well as siblings (child's aunts & uncles) with similar presentation since birth. No facial swelling. No change since birth. Does not bother the infant. On exam the child has 3+ bilateral pitting edema from the toes extending past the patella. 

Within 20 seconds of seeing the patient, the Australian pediatrician looked at all the trainees and said "there is only one diagnosis possible, I know what it is--and so should you." I looked at her blankly as if to say, "Please don't call on me." None of us came to the correct diagnosis--but after she stated the obvious, my love for physiology resurfaced. Congenital lymphedema. 

Lesson Learned: Hold dear in your heart the knowledge of physiology--and take time to think through problems for yourself. Even if it is a diagnosis you have never seen or can still come to the most logical answer, even when no or limited lab/imaging studies are available.

These cases illustrate both the challenge and the privilege of augmenting traditional pediatric training to include a global health focus. Building relationships and working with physicians who have diverse training and experience is eye opening and valuable. It isn't always easy to find time to make an International Elective experience come to fruition, but experiences such as this I find to be professionally enriching. If you ever find yourself contemplating spending time in East Africa, I certainly would encourage you! 

Hope Pogemiller (MP4) reflects on the first half of her rotation

Posted on behalf of Hope Pogemiller (MP4)

Sak pase! 

As the least formal member of our group, this is my favorite greeting. It's equivalent to "what's up, yo" and is best accompanied by some type of hip high five or fist pump.  For almost 2 weeks now, we have been enjoying the hospitality of the organization NPH (Nos Petit Freres et Soeurs- Our Little Brothers and Sisters) and learning about the medical system at 2 hospitals in Port au Prince, Haiti. NPH is a non-governmental organization that began in Latin America and has grown to include programs in both countries of Hispaniola (Haiti and Dominican Republic). With a multi-pronged approach, in addition to its pediatric hospital (St. Damien), NPH's programs include orphanages, a free primary school, a rehabilitation center for children and adults, a special needs school, and a pre-school.  They provide housing for volunteers and guests, which is adjacent to a cluster of their programs in Port au Prince. 

Our chalets have electricity almost continuously, with gloriously cold running water and beds with mosquito nets hanging from the ceiling (sea foam green princess mosquito nets with sequins and beads for the lucky ones).  We have fresh rolls baked in an NPH program for breakfast with a steady supply of nutella and peanut butter.  We usually have mangos, pineapple, watermelon, and hard-boiled eggs along with our deliciously rich coffee each morning.  Some of us converse with the friendly cat who answers to either Obama or Scabio (named for her high fungal and parasite load) prior to the short 10 min walk to St. Luc (hospital for people > 13 years old). 

Our homes.JPG
Chalets where we are staying

As Calla mentioned in her latest piece, a few of us have had the opportunity to enjoy daily 7 am rounds at St. Luc, when we walk from bed to bed and the night general doctor (not yet completed residency) rounds with the internal medicine doctor (completed IM residency specialization) and hands off the patients to the day team. We have been impressed with the incidence of chronic disease in proportion to infectious disease. In the inpatient ward, they usually have a section of CVA's next to a section of fever with diarrhea, cough, or nuchal rigidity.  Unfortunately high blood pressures in the 240s/140s are not uncommon and are accompanied by hemiplegia along with CT scans with hypo or hyperdensities indicative of ischemic or hemorrhagic strokes.  After days of particularly brisk wind and associated dust, we enter the emergency room to see clusters of young patients tripoding with albuterol nebs flowing. We have seen many 16 year old patients with sickle cell or fever with cough as well as the sequelae of home births with absence of prenatal care and hemorrhage or post-partum cardiomyopathy. There is reluctance to seek pre- natal care in part because pre-natal vitamins have been known to encourage larger infants. This raises mortality risk at delivery.  St. Luc's collaborates with an infectious disease center across the street, GHESKIO, and patients with a positive HIV or TB test who are stable on room air are transferred to GHESKIO for further evaluation, treatment, education, psychosocial support, and continuity care for these conditions. 

After rounds, we walk back to our chalets at Villa Francesca to refill water bottles and enjoy a meal cooked at the NPH-associated restaurant. This bean sauce with hot green peppers over rice with cooked vegetables (ranging from startlingly fuchsia beet potato salad to cabbage and carrots) is undeniably the tastiest lunch imaginable. I can't even begin to describe the mouth- watering, taste-bud tingling, thirst-quenching juice offered each lunch. 

The afternoon is filled with discussing patients triaged to the emergency room at St. Luc's with the Haitian doctors and monitoring the evolution of particularly interesting cases from the days prior. We have been broadening differential diagnoses while offering thoughts about patient care. Thorough clinical exams are essential, as patients must pay for IV injections after 24 hrs and pills after 3 days. If a test can be done at St. Luc it is free of charge (headCT, hemogram, bmp) but if the family must bring the sample to an outside lab the family must pay (thoracentesis sample, lipase, thyroid studies).  Most of the pleural effusions are not tested, and lumbar punctures are not generally performed as the samples must be analyzed in outside labs.  

Today we visited an endoscopy suite, where one Haitian doctor has been trained to do endoscopies to band varices, perform embolizations, and biopsy for h pylori and gastric cancer. These procedures are offered at a greatly reduced price for clinic patients in comparison to private clinics (10 times more).

Endoscopy Suite.JPG
Endoscopy suite

By 5pm we leave for the day to walk home in pairs and unwind-- each of us in his or her own manner. Calla's callisthenic "movements" are a highlight of many evenings, especially when Adam dons his matching workout uniform. We discuss concerning cases while listening to music, attempting to trick the Wi-Fi into allowing us to send a few emails and connect with home. Dinner is serenaded by Obama/Scabio who demands gifts of food deposits behind the kitchen. She curls up in the bookshelf for the night as we finish dinner and gladly remember we took our malarone in the am.  

As Adam so aptly declares, "These bugs, they be immune."  During our daily mosquito bite monitoring sessions, Adam has remained firmly in the lead. Our official mosquito magnet, he endorses 98.11% deet spray TID along with his daily malarone. 

Each night I am thankful for the particular mix of personalities of my travel companions. Abby's immense heart is available at all moments for discussion of intense emotional moments. Her ultrasound skills are quite valuable. She is also making great progress on development of a sarcastic side. Adam's vast medical knowledge allows him to offer suggestions and broaden differentials. His quick wit provokes laughter frequently--among Haitians and in our travel group. Calla's indefatigable spirit and boundless energy (which she refers to as "being squirrely") lights up the wards. Her word-for-word translations from the inspiring doctor trained in Cuba are invaluable. As Abby proclaimed tonight, "Calla, I just need more of you in my life for some more sunniness." 

I'm not really sure how I was so lucky, but these are my travel companions... who I harass freely and frequently (given my innate instigating tendencies). In such a welcoming Haitian community and with the strong emotional support of my companions, I look forward to learning more creole and medicine in the following 2 weeks.  One doctor at St.Luc today was laying the groundwork for future collaboration as he announced that after our month we could return to finish our studies, however we would soon return to work in Haiti for 2 yrs or so. 

Time to turn the lights out and tuck in the mosquito net. 
Bon Nwit (good night)
-- Hope

Abby Montague (PL3) learns Creole and tours Port-au-Prince

Posted on behalf of Abby Montague (PL3)

Bonswa from Haiti!

Since Adam told you all good morning, I thought I'd start with "good evening" in Creole!  

Haiti Rotation Group Photo.JPG
Abby Montague (PL3), Hope Pogemiller (MP4), Ben Trappey (MedPeds Hospitalist), Calla Brown (MP3), Adam Foss (MP4), and Mahsa Abassi (Global Health Chief, Medicine)

We've settled in pretty well here after our first week.  Our Creole is coming along okay - piecing together some of Calla's Spanish and Hope's French with our Haitian friends' phrases.  I have been spending my days at St. Damien's Children's hospital with 2 residents from Virginia while Hope and Calla are at St. Luc's for adults (Adam has gone back and forth).  

St Luc.JPG
St Luc

Every morning at St. Damien's, we start the day with mass, including small funeral rituals for the dead from both hospitals from the previous day.  There's so much more death than I'm used to.  As one of our Haitian doctors wrote in the NEJM, "Death's ubiquity, however, does not mean it deserves any less attention or thought" (2012;367:8-9).  I have many thoughts, and feel different almost every day.  I'm anxious; listening for names of children I know in the Creole list of the dead - not sure if it's the "Jean Pierre" I saw or one of the others.  Relieved, when the church banners and cloth are removed and I see the bodies on each stretcher are adult sized.  Or grieved when I see the name of the child I was worried about scrawled in blue sharpie across the label on their make-shift burial shroud.  On Monday, it was overwhelming with more deceased from over the weekend.  Numb on days it's too much to process and still go on working.  It's sad when there's few mourners and heartbreaking when you hear the cries of many.  Thankfully, I end up feeling peaceful and like we're providing a gentle send-off as we kneel together and hold out our hands with a benediction to the dead.  On Sunday, we had a candlelight Vespers service that traditionally has no funerals and renewed our spirits to start the week.  

We had our first days off this weekend and took a tour of Port-au-Prince with our driver and one of the day managers where we're staying.  They showed us a ruined cathedral, a newly built market, the site of the president's palace, and pointed out their own houses.  Signs of the earthquake were everywhere and they pointed out the changes we couldn't appreciate.  

Place of worship

Ruins of a cathedral

On Ben and Mahsa's last night, we had a beautiful dinner up on the mountainside overlooking the rest of the city.  It took over an hour and a half to get there with traffic but the view was worth it.  We were joined by Sister Judy (a nun who has worked in Haiti for years), Dr. Goutier (one of the Haitian staff), and Dr. Goutier's daughter and niece.  We spent 3 cool hours eating and chatting about life, medicine, and Haitian history.  

Evening View.JPG
View during dinner

Well, dinner's finished.  We have to go wash our pans from cooking eggs, tuna and spinach, and heating up ramen (not all at the same time, ew).  The local cat, Scabio, has eaten most of the leftovers.  The rest of the night we'll shower off the day's sweat and deet, type up our cases, submit our blog posts, and keep in touch with our families.  

Scabio the Cat.JPG
Scabio, the resident cat, hoping for more leftovers

A plutard (see you later), 

Calla Brown (MP3) finds inpsiration in the universal language

Posted on behalf of Calla Brown (MP3)

Hope, Adam, and I have variably spent time at both St. Damien's, the pediatric hospital, and St. Luc's, the adult hospital, and Abby has been at St. Damien's.  My favorite part of the day is the morning, when we participate on morning rounds in the observation unit.  Pre-rounding is performed by the overnight generalists, who are physicians that have completed their medical school plus their year of social service (a one year requirement in all countries in Latin America, including the Caribbean, as far as I know, prior to either practicing medicine as a generalist, or completing a specialty residency, of which internal medicine and pediatrics are included).  Rounds are run by the overseeing internist and include the unit nurse and physical therapist.

Rounds are a linguistic panoply.  The charts are in French and rounds waver between French and Haitian Kreyol.  With our presence English is added, with interpretation shared between Hope and all of the internists, who speak impeccable English, and Spanish.  One of the internists won a scholarship to study medicine in Cuba and who actually feels more comfortable with medical Spanish as opposed to medical French, or so his co-generalists say in jest.  I am, as per usual, incredibly inspired by the physicians here.  They have chosen this work and receive very little relative compensation and external esteem, but continue to work so hard for the benefit of patients and their families.   Rounds shift from discussions of physical exam findings, to pathophysiology, to social realities in which patients live, to how to talk with families when their loved one is dying or has passed away.  The physicians frequently talk of competing priorities including the focus on acute care, for example the treatment of infections, and the growing burden of chronic diseases including hypertension, congestive heart failure, type 2 diabetes, and disabilities.  In addition, the topic of palliative care comes up frequently, as there are deaths on rounds, deaths in the emergency room, and deaths in the intensive care unit.

In spite of, or perhaps because of, the mishmash of proverbs, dictums, and the like, the universal language of medicine plays strongly.  Respiratory distress with a resting oxygen saturation of 75% is sadly not uncommon at all, but spurs specific actions from all involved that readily translate.  The same occurs with Kussmaul breathing, and hemiparesis of acute onset.  The underlying causes are different, but the human body continues to fail in predictable ways when it is not supported, either by malnutrition or pneumonia or cancer.  This universal language is like a not-so-secret code, and being here makes me proud that I am learning to speak the language of medicine more fluently and also awestruck by how much more there is to learn.  It has been such a privilege to learn from such wonderful teachers.

Here are two pictures to leave you with from our time here.

Beach in Haiti.JPG
Beach in Haiti

Bridge in Haiti.JPG
Bridge in Haiti

Posted on behalf of Adam Foss (MP4)

615 AM- wake up for the day and get ready, always double checking that I took my malarone. I also double check that my pseudo-fanny pack has the essentials for the day- gloves, hand sanitizer, check that the pulse oximeter has working batteries.

630 AM- meet up with the other residents, Hope, Calla, and Abby, for breakfast, which consists of delicious coffee (Rebo) and a roll with peanut butter.

645 AM- leave for the hospital, a short trek down the road. The compound where we are stay is surrounded by a school. We are typically joined by numerous school children on our walk. Several children arrive by "moto" (motorcycle) and are not wearing helmets. The children are all in uniform and will greet us with "bonjour". 

7 AM- arrive at the chapel at St Damien for morning mass lead by Father Rick. Most mornings double as funeral services for patients that have passed away during the last night. Each morning I scan the draped bodies to see if patients I cared for are present.

Chapel Window.JPG
Chapel window during Mass

8 AM- start rounding on patients in the Urgence area. Patients will stay in the Urgence area until there is room in the hospital or if they are well enough to go home. Typically there are many children with severe malnutrition. I am continually reminded that children who are severely malnourished can also be quite sick from infections including tuberculosis, urinary tract infections, parasitic infections and/or HIV.

Lab tests can take time to track down, with a bit of time going to and from the lab looking for a specific result. I also spend time going to radiology to look at X-rays.  We have no radiologist and read all of our films ourselves. There is a CT scanner at the adult hospital that can do either head CTs or whole body CT scans for infants. The CT scanner is broken this week and will be fixed next week by a technician coming from the US.

1030-11 AM- work with a Haitian physician, discussing patients and the possible causes of fever. I pay particular attention to diseases I don't see in the US including typhoid, malaria, and tuberculosis. 

1 PM- regroup at the hospital and walk back to our compound for lunch with Hope, Calla, and Abby. Our food is made by the St Luc Foundation at a location across the street called "Francesvillle". At Francesville, they train people for a vocation. There is a pasta factory, welding shop, cement block factory, sewing factory and a restaurant. A typical lunch will consist of rice and beans with a chicken or beef for protein as well as a vegetable or fruit. 

Cows walking back after lunch.JPG
Cows on our walk back for lunch

Franceville, a vocational training facility

2 PM-5 PM- return to the hospital and check on patients from the morning. St Damien's recently started a Pediatric Residency and we get to work side by side with the residents in Urgence. It has been great to see them in action. We occasionally process new admissions to Urgence but leave most to the Haitian residents because they want to practice as part of their training program.   We assist with pediatric codes and resuscitations as needed. 

St Damien.JPG
St Damien

Evening: return home and make dinner. I have ramen most nights, which is quick and easy to make. I spend the rest of the evening looking up different diseases observed during the day and have been reviewing the disease course and complications.