Going Home

The following was submitted by Ben Trappey, fourth-year medicine-pediatric resident.

I'm leaving today. It's hard to believe that I've been here for nearly a month. Part of me can't wait to get back. I'll be glad to see Emily again. And to be back to the comforts of home. And that the vast majority of my patients will survive.

However, Father Rick likes to point out that despite the difficulties and trials and struggles he's encountered in his many years in Haiti, he finds that life is much simpler here. After just a month here, I must say that I agree. People are easier to understand. Motivations are less complex. People come to you for help because they live in poverty and you do not. They are hungry. They are sick. They need a job. They need money. They ask. They do not use passive-aggressive manipulation to attempt to get you to do what they want without asking. You are either able to do something to help them or you aren't. Life moves on.

Father also likes to say that evil is not subtle here. It is ever present and comes in many forms--illness, infection, corruption, kidnapping, theft, armed robbery, and murder. It is easy to recognize, and it nearly all stems from the one great evil here.

Poverty.

You hear stories from people who have been here for a while. Times when they were robbed or forced to pay bribes or prevented from being kidnapped by a sum of money which would seem laughable to most Americans. But throughout all of the stories, there is always a common thread. There is rarely ever a question of motivation. There are very few senseless or random crimes. People rob and kidnap people for the same reasons they ask for help.

They need something, and you look like you can afford to provide it.

Cite Soleil is the poorest slum in Port Au Prince. It's a sprawling accumulation of homes built primarily of sticks and stone and tin and tarp which appear to be ever on the verge of tumbling down. It is quite possibly the most poverty-stricken and dangerous area in the Western Hemisphere and is effectively governed by the gangs who inhabit it. Father Rick has been going there for years--building more stable housing, providing clean water, and setting up impromptu street clinics. He has just finished building a permanent clinic and a bakery on top of a landfill there, and is in the process of building a hospital there as well. The clinic sits about a hundred yards from the ocean. Outside the windows of the clinic, you can see children playing atop mounds of garbage and goats and pigs foraging through the detritus as it makes its way to the sea.

For now the clinic is staffed on varying days of the week by Father Rick, Sister Judy, and Dr. Charles (a Haitian physician). Father Rick, who is known as "Mon Pere" among the Haitians, is so well-known and liked there that anyone who is known to be associated with him is given privileged status by the gangs. It is not unusual for groups of young men with gold chains to go out into the street to stop traffic to allow the passage of any vehicle labeled with the decals of one of Father Rick's many projects.

Unfortunately for Dr. Charles, his car did not have such a decal when he first started working there. He was coming home from the clinic one day and was approached by a young man with a gun. He demanded Dr. Charles's wallet and told him, "My children are starving. If you don't give me your money, you will die, and they will die. If you do, everyone lives."

There is no subtlety there.

Dr. Charles gave his wallet to the man, who took the money from it and casually handed back the wallet with his ID and other belongings undisturbed. Dr. Charles now catches a ride to the clinic in one of Father Rick's vehicles, but he still goes back to Cite Soleil every day. Because people still need help, and the evil is apparent and almost understandable--"You look like you can afford to give me something that I need."

Despite the fact that this sort of very real danger is always in the back of my mind whenever I leave the safety of the St. Damien compound, I still wonder how I will cope with going back to the safety and comfort of my life in Minnesota, where I will face very different and much less weighty problems. I won't have to worry much about being robbed or kidnapped, but I will be plagued by the complexities of a life that some Haitians would literally kill to obtain.

I'm not sure how I'll adjust to that.

I imagine that for a few days I will be very aware of how very fortunate I am as I return to my very comfortable life and leave the struggles of this place behind. But I fear that I will slide back into the life I have spent my whole life living.

I'm afraid that I'll find my "First World problems" to be incredibly weighty. That I'll hem and haw over what restaurant to give the equivalent of several days wages for many Haitians in exchange for food which will slowly kill me. That I'll worry over how to afford more things I don't need. That I'll have anxiety over maintaining relationships I'm blessed to have. That I'll feel frustrated about some minor unpleasantness or some perceived slight at work.

I'm afraid that I will once again come to think these anxieties are all very natural and important, because I will lose perspective of what real struggle looks like--that I'll lose sight of what poverty and long suffering can drive a person to do. I fear that I'll fail to remember the beauty that lives inside of so many of the Haitian people, despite that poverty and the suffering--the patience of the families and patients sitting in the hallway of Urgence, the joy of the children playing in the orphanage, and the comfortable calm of the Madame Lazarus family sitting on her front step.

I fear that I'll forget the spirit of this place. And I'll complain.

Until I return here and am reminded how blessed I truly am.

Kenscoff Orphanage



Another group of residents and an attending from the U.S. arrived this week, and I was given the last two days off from work in Urgence. I used the opportunity to get out of the compound and see some of the rest of Haiti.



I was able to catch a ride to Kenscoff, the site of an orphanage in the mountains that Nos Petits Freres et Soeurs (NPH) has been running for the past 25 years. It's only about 20 miles from St. Damien, but it truly seems like a different country. I suppose it's somewhat fitting that due to traffic and the condition of the winding mountain roads, it takes around 2 hours to travel those 20 miles.

The orphanage, which is home to some 450 children and provides school to hundreds more, is located 6,000 feet above sea level at the top of one of the taller mountains surrounding Port Au Prince.

The elevation allows for a much cooler and wetter climate where the locals grow onions, cabbage, turnips, and other vegetables in a patchwork of small fields precariously situated on the side of the mountain. One of the long-term volunteers at the orphanage told me that it's been said that "Haiti is the only place where you can kill yourself by accidentally falling out of your field."







The guest house in which I stayed is at the far end of the orphanage and is, itself, perched rather precariously on the side of the mountain. From its balcony, one can see the small footpaths that crisscross the hillsides and valley below and allow people access to their fields.





Since it is such a small community on top of the mountain and so many of the people in the area have benefited from the orphanage, I was assured by those who live there full time that it was very safe to wander around up there. I was able to find my way down to some of the footpaths and hike for awhile. The view was stunning. The absence of dust and noise was particularly striking after having spent so much time "down below" in the chaos that is Port Au Prince.

img_1176.jpg

The presence of pine trees seems particularly remarkable for Haiti, were most of the country is barren and deforested due to the demand for charcoal, which remains the country's primary source of fuel and claims millions of trees each year. The area around Kenscoff is one in which the felling of trees is illegal. However, when I woke up to leave the next morning, I could hear the sound of someone felling a tree under the cover of darkness in the valley below.



In the evening, we walked a few hundred yards down the road from the orphanage to the home of Madame Lazarus, an incredibly joyful Haitian woman of indeterminable age, who sells canned goods, soda, beer, candy, and toilet paper from her front porch.

The long-term volunteers at the orphanage know her well, and we bought sodas or beer and spent the evening sitting around her charcoal stove on the front step of her small stone house. We watched motorcycles drive or people walk past on their way to Holy Thursday church services as she and her family regaled us with the news from the surrounding area--marriages, births, tales of disputes over the ownership of chickens (the Creole-speaking volunteers would translate for me when something was particularly interesting), and her smiling grandchildren sang/rapped for us and gladly finished off the dregs of our sodas.

It was lovely to be able to get a glimpse of the real life of a healthy and seemingly well-adjusted Haitian family, who would be considered indescribably poor by American standards, but seemed quite content as they spent the evening in the company of each other crowded around a little charcoal stove as the sun disappeared behind the mountain and night fell around us all.

DeAnna Friedman Arrives at Chiang Mai University

The following was submitted by DeAnna Friedman, 3rd-year pediatric resident:

Hi everyone!

Made it to Chiang Mai safe and sound. I'm staying in a hostel right now, but I have more permanent accommodations starting on Saturday. Everything is new and different, and I've been finding my way around. I've never been in a place where so few people speak English before - wait, that's not true - I've never been ALONE in a place where so few people speak English before (I've traveled through Central America plenty, but I usually have a Spanish-speaking friend with me). I'm getting by with some pantomiming and brand names and such, though.

I've already had the chance to take lots of great pictures, which I'm posting on a public gallery. There are all kinds of old beautiful buildings here in Chiang Mai. I'm still trying to learn what everything is (again with the not-a-lot-of-English thing, I can't just ask people). I hope I haven't made any missteps as of yet with my picture taking - again, still learning.

I started work at the hospital today. Everyone here is very nice and very accommodating. They helped me find a place to stay from Saturday on, and showed me around the campus. I attended wards rounds, and they were nice enough to do them in English for me for today. I am to be paired with an ID fellow starting on Monday, but he's out of town right now, so they paired me with a neurology fellow doing general pediatrics wards rounds with one of the resident teams that speaks English well. The residents were a little nervous about doing rounds in English, I think, but it all worked well.

Photo of the outside of the Faculty of Medicine at Chiang Mai

Outside another of the Faculty of Medicine buildings at Chiang Mai University

I saw several children with issues similar to what we have back in the U.S.: a 15 month old with medulloblastoma with an infected extraventricular device, on meropenem and colistin and still spiking fevers; a 7 month old, ex-28 week premie who came in with hematemesis and was found to have esophageal varices and portal vein thrombosis, likely from his UVC at birth; a 15 y/o with a suspected brain abscess, although it seems to not be improving well on cefotaxime.

We ended with a girl with high-risk ALL who's relapsing while on her induction therapy. This child would have been on the BMT consult list back home.

Overall, things here are similar to the setup back home. CTs, CSF studies and cultures, phenotyping for the ALL, and meropenem are available. We have morning report or other conference first thing (8:30-9:30), then wards rounds until noonish, then an afternoon conference for teaching. It should be an interesting 2 weeks!

DeAnna

Greetings from Saint Damien's Hospital, Week #2

from John Heimerl, MD, 3rd year pediatrics resident at University of Minnesota:

Another week has passed here in Haiti. It has been a busy week.

Since my trip to Saint Damien's overlapped with the team from Brown University, I was put to work in one of the hospital wards for the week.

Initially, I was working with Dr. Vaz from Brown University.

We divided the patients up and tended to them one by one.

Seeing patients in the Orange Room on the wards at St. Damien's Hospital for Children

By the end of the week, I had developed quite a relationship with the parents and patients. A few of the children have been here for months.

The girls' room has a three year old with cardiomyopathy and TB who has been in the hospital for more than six months.

A few of the days she would sit on my lap as I worked my way through the charts.

Another girl had a right-sided empyema with a chest tube in place. After having the tube in for a week we got a CXR, and it showed no change. While the chest tube and collection system are the same we would use back home, there was no suction attached to the reservoir to assist with draining her plural fluid.

After she had had a few days of fever while on broad spectrum antibiotics and I had realized no more fluid was draining via gravity, I decided to see what I could pull out with gentle suction and a 60cc syringe.

Thirty-five mL of purulent fluid later, she was feeling much better and has actually continued to drain into the reservoir.

Following morning ward duty, I've spent afternoons assisting in the urgents (ER), where we are seeing all sorts of pathology--things I will never see in the U.S.

A few of the patients I have seen this week include a girl with CXR consistent with miliary TB as well as malnutrition of all sorts, from kwashiorkor to extreme marasmus.

One child I admitted over the weekend was 16 months old and was on breastmilk till 1 year of age, then apparently was fed cookies and juice. My interpreter made it clear to me that is was not "natural juice", which I thought was slightly humorous, as the nutrition value would still be minimal. Needless to say, this child should improve with proper nutrition, and along the way we will ensure the family receives some education.

A few patients have not made it.

On Saturday a six year old with pneumonia experienced complete respiratory failure.

I taught a Haitian medical student, who happened to have been walking by the boy's bed, to properly bag mask, then gathered the necessary intubation supplies and determined how to operate the ventilator. The intubation actually went remarkably well, however, I discovered that I had not paid enough attention to the respiratory therapists back home, and I didn't properly secure the tube.

The episode seems to have been a good learning experience, both for the med student and the nurses, though unfortunately, as expected, this child did not survive.

I did think it was a start at transitioning to the next level of care, and hopefully over the next couple of weeks, we can continue to teach the nurses.

I have had the opportunity to do a couple of day trips on my days off.

Last week I went with the Brown team to the beach.

Friday, I took a half day and was driven around the city. 

Public transportation in Haiti is called a "tap-tap".

We drove by the National Cathedral, which lays in ruins from the earthquake.

After the drive we had a wonderful, authentic Haitian lunch...

...topped off with fresh sugar cane.

Sunday I had the day off and went to the Kenscoff Orphanage for the 25th anniversary of NPFS (Nos Petit Freres et Soeurs, "Our Little Brothers and Sisters") the organization that supports St. Damien's and multiple orphanages.

Father Rick (pictured) and the archbishop attended the anniversary celebration.

Kenscoff is a breathtaking mountain retreat from the city. We made the trip with children from another orphanage that's located next to Saint Damien's.

This amazing view was taken from Kenscoff Orphanage, looking out over the adjacent hillside.

Following mass there was entertainment and dancing.

One more picture: this local artist makes these pieces out of 50-gallon steel fuel barrels.

Dr. Heimerl's First Week in Port au Prince, Haiti

Written by John Heimerl, M.D., 3rd year pediatrics resident

Chapel at sunset on grounds of St. Damien's Pediatric Hospital; Port au Prince, Haiti.

Well, I have embarked on my seven-week experience in Haiti. I arrived on Monday, January 16.

My flight was slightly delayed in getting to Port au Prince, due to the airport controller delaying our landing.

This circumstance allowed for us to circle the island prior to landing, and I recalled my first year of medical school when we read Tracy Kidder's Mountains Beyond Mountains.

It is no mystery where he got the name for his book: there are mountains beyond each ridge of mountains. It sure is beautiful topography.

Most of the population lives in the coastal town of Port au Prince, but houses and huts are scattered among the deforested slopes of the mountain.

I can only imagine how far residents must travel for water and supplies, especially since there are very few visible roads.

We ended up landing after dark and headed to St. Damien's Pediatric Hospital, where I'll be rotating. I imagine the distance was not very far, but the stop-and-go traffic made it seem further. We eventually arrived.

I was greeted by Sister Judy at the entrance of the hospital and met the two attendings and residents from Brown University that I'll be staying with, who have agreed to take me under their wing for a couple of weeks.

Recently the hospital upgraded from canvas tents to prefabricated houses. The prefabs each have three rooms with a small communal space and bathroom. Oh--did I mention they are air-conditioned? (The only such place in the hospital.)

As with any working communal living situation, I was told of the short list of house rules and also told that this side of the house was against the labor ward, so to expect screaming at all hours of the night.

Nevertheless, I had a great first night's sleep.

On the following morning I got to work and began with observing the triage process. Patients begin assembling at 0645a.

From triage, patients are sent to various places depending on how they look, their chief complaints, and their temperature.

Some are sent home with Tylenol, others sent to the adjacent clinic to be evaluated, others are sent for further triage, to the malnutrition unit, or to the cholera tent, if they have severe diarrhea.

The sickest are sent directly to the emergency department. I am told this triage process continues throughout the day. 

The services are free.

The hospital, which serves kids 3 months to 12 years old, is a complete pediatric hospital with OR, Lab, XR, blood bank, NICU, an ICU (Critique), wards, oncology (the only such unit in Haiti) and ED (Urgents).

I will be spending most of my time in the Urgents, which also functions as a extended-stay unit; after evaluation, they may stay for several hours or for days.

The mornings are spent rounding, first on the patients who are boarding in the Urgents, then with the new patients.

Mostly we are seeing meningitis, pneumonia, sickle cell crisis, malaria and other tropical diseases. Mixed among these are the more routine pediatric admissions.

I've been spending the mornings this week working in the general wards. Each room has a name that corresponds to the painting outside it, so today I was in Balloons and Watermelon.

Each room houses around ten patients. Each day there are a couple of new patients who made it up from the Urgents. My rooms had kids with chronic heart disease, sickle cell, meningitis, and pneumonia.

January 10th marked the second anniversary of the Haiti earthquake.

You can see evidence of the destruction in the adjacent buildings and on the patients who have scars or are missing limbs.

I am told a large ceremony was held that day at the hospital. Saint Damien's was built in the early 2000s prior to the quake and, due to its Italian engineering, sustained minimal damage.

I am told there were some cracks in the cement walls. Most have been repaired, but in one hallway, they have left the damage exposed as a mural of remembrance.

Dr. Tundun Williams - Week 1 In Lagos, Nigeria

Lagos is home to over 7 million people who call themselves "Lagosians". They are kind of like the New Yorkers of Nigeria. They dress to impress, drive... how shall I put this...purposefully, and are all vying for a bit of the wealth that is for the making in this city which remains the business capital of Nigeria.

Lagos is inhabited by the uberrich, who live in sprawling mansions on gated estates, as well as the destitute, who make do in shacks that house up to four families and have one communal bathroom.

To say that the wealth in this city is unequally distributed is stating the obvious.

I spent the majority of my time this week at the Massey Street Children's Hospital, a government-run pediatric hospital in inner-city Lagos.

I soon learned that the action at Massey was in the ED, a two-room facility on the second floor of the outpatient building, which was located across the street from the inpatient department.

After nearly losing my life trying to cross the street while dodging public minivans (danfos), three wheeled cabs (maruwas) and motorcycles (okadas) on my first day at Massey, I mastered the art of road-crossing in Lagos, which consists of venturing forth at a time when the road is relatively clear and then holding your ground in the face of any oncoming traffic until you are given the right of passage. You must show no fear.

The in-patient building at Massey

The busy street between the two buildings at Massey

The doctors in the ED were glad to have me on board. Part of the art of practicing medicine in the developing world is learning to improvise, and improvise I did. I performed an LP on a 6yo with a 20-gauge needle (stylet, schmylet), used the elastic band on the bottom of a pair of gloves for a tourniquet and did many other things that would never have crossed my mind in the US. 

I saw several cases of very classic kernicterus, a case of cholera and malaria galore.

Since Massey is a government-run facility, basic supplies like gloves, IV cannulas, syringes and needles can be obtained for free from the hospital pharmacy with a doctor's written prescription.

If the pharmacy happens to be out of stock, however, patients are responsible for purchasing their own supplies and bringing them to the hospital. The cost of medical care can be mammoth and is one of the factors that prevents the average Nigerian from seeking timely treatment.

Inside Massey's ED

A toddler at Massey with left lower lobe pneumonia. The cuts had been made in his village when he started coughing and then complained of abdominal pain.

When I was not at Massey, I pitched in to help Tina (Slusher) with her sunlight phototherapy study. At the end of this week, I will head to the small town of Ogbomoso, where I will be spending the majority of my time.

Dr. (Henk) Vreman and his helpers setting up the sunlight phototherapy tent frame

Down time at an ice cream parlor

Andy Keenan: A Day At Selian

Fourth-year Medicine-Pediatrics resident Andy Keenan is currently abroad in Arusha, Tanzania, completing a month of peds and a month of internal medicine at Selian Lutheran Hospital. Here's his most recent blog entry:

Things are going great here in Arusha, albeit with unpredictable internet.

Selian is a small hospital just outside the village of Ngaramtoni, near the town of Arusha.

It is a semi-private entity that receives support from the Lutheran Church and the Tanzanian government. Among the hospitals in Arusha, it does not offer as much subspecialty care as Arusha Lutheran Medical Center (ALMC), but often acts as a referral center from small local and regional hospitals.

The hospital is made up of a number smaller buildings, with an administrative offices, outpatient/casualty, pediatric/adult medical ward, OB/GYN ward, surgical ward, radiology, and a number of other smaller buildings for support services and living areas.

Each day starts with chapel at 0815. Some people skip this, but it's a good way act as a part of the hospital staff, and you'll get some good Swahili practice. It's also a great place to find people in the morning.

After chapel, there is morning report in the same building. They usually briefly review the hospital stats (admits, discharges, transfers, deaths), and admissions from the night before.

More complicated admissions are discussed in some detail. This can get sometimes get pretty animated, and is usually conducted in English. It can be a good time to learn about management styles, and the staff here are generally interested in resident input, as well.

Occasionally MR is followed by a presentation by one of the attendings, interns, or other staff.

Usually after MR we'll go over to the radiology building to review x-rays. It's a pretty open format, and they will often ask us to read the films. I hear the term "micro nodular" a lot.

Rounding can vary widely depending on who is present, what you view your role as, and several other variables that I have not been able to define for myself yet.

Usually the team is made up of an intern, a doc who has finished internship and is working in that department (senior medical officer), and an assistant medical officer (somewhat similar to a PA here).

Like in the U.S., the level of knowledge for interns can depend on the time in their training cycle and interest in the given specialty. They are my main resource for how things get done in the hospital.

The senior medical officers are also an excellent resource. Many of them have an interest in eventually pursuing specialty training in their field, so they are great to work with.

The assistant medical officers (AMOs) have a wider range of clinical skills. I've been told that many were initially trained to primarily manage common infectious diseases, but that their scope of care has increased significantly.

Some AMOs are among the longer-standing medical staff of the hospital.

When a patient is admitted, they come through Casualty, where they are evaluated by an AMO (usually) or intern (occasionally), who starts the initial workup and management, with the ward or on-call intern to review after admission.

This is where you can find the age and weight. The weight is especially important, as there is not a functional scale in the Peds ward. Often under DOB it just says the year, which can be a challenge when coming from the Peds side and it just says 2011. With the prevalence of malnutrition it can be more difficult to eyeball the age based on the size and development stage.

After evaluating the patient, the orders and documentation are done on the fly. Usually the nurse is updated on any changes or discharges, and you move on.

After rounds, the schedule gets a little more variable.

Most of my regular duties are on the wards, which are usually done by 12:00 or 1:00. My team (intern) is on the hook for reviewing admissions until 1530 when I'm not on call. Some post-rounding options are clinics, ultrasound, heading over to ALMC, or working on research.

The bus driving back in to town usually leaves between 3 and 4 in the afternoon. Given the challenge with getting back in another manner, I have been arranging my schedule to allow for this.

That's a day at Selian!

A memorable week in Bolivia

Dear all,

I've now been in Bolivia for six weeks, and the last one was certainly memorable.

I'll get the negatives wrapped up fairly quickly:

1. 
   My driver's license was confiscated by Bolivian police because I wasn't carrying the hard copy of my passport when I traveled between Cochabamba and Oruro, but fortunately I reclaimed it after a tense encounter at the station.
2. 
   My wallet was confiscated by parties unknown in Oruro during the Carnaval festivities after I had foam sprayed in my eyes and was shoved from two directions. Unfortunately, the money was not reclaimed, but fortunately I was able to cancel my credit and ATM cards before anyone tried to use them. And fortunately Rachel was able to help me out via Western Union.
3. 
   I decided to drink juice of "canela" at Carnaval. When I got to the bottom of the glass, I realized that it just didn't taste right. Evidently my intestines agreed, and they protested vigorously for the next 6 days.

So my moral of the story is--"When you go to Oruro, bring your passport but not your credit card, wear a money belt, and consume only saltine crackers and Coca Cola."

Or just don't go.

Despite the above challenges, I am still enjoying my time here.

Before the Oruro fiasco, I accompanied one of the MAP teams to the village of Morochata, where I had previously failed to get to during heavy rains.

I observed and participated in a workshop where the staff of Morochata Hospital (functionally, a community clinic) learned about how to help parents take care of children with developmental disabilities.

The MAP team, "Aprendiendo de las Diferencias" (Learning about Differences), focuses on eliminating the stigma that often makes children with physical and intellectual disabilities second class citizens in their families and in society.

The team also wants to empower families to be the best caregivers and therapists they can be in order to maximize their child's potential.

During the workshop, I also demonstrated the maneuvers to evaluate for congenital hip dysplasia in neonates, though my model was a grown man.

On the other weekdays, I have continued to see patients at the clinic in Chilimarca. Thus far, I have seen over 260 patients, including many well child checks, respiratory and diarrheal illnesses, musculoskeletal injuries, and even a case of Bell's palsy.

Miguel, my last preceptor in the clinic, is no longer working there as of last week.

Instead, a new doctor named Gustavo started on Wednesday. However, on Friday he, too, was unable to come to clinic because of a renewed transit strike (giving me the opportunity to see 26 patients on my own, including 17 well toddler checks in a 2-3 hour span).

At this point, I have no idea whether the strike will still be on tomorrow. The issue is that the drivers want to raise the fare, but the people don't want the fare raised.

The drivers have a valid point--the price of gas is going up, the price of everything else is going up, they aren't able to make money at the current rate.

The people also have a valid point--they don't want to pay more.

Thus, the literal impasse--complete with road blockades on the weekdays.

Personally, this hasn't affected me as much because I live right next to the clinic. But it is wreaking havoc on schools, offices, clinics, etc.

The plan for Monday is to attend the weekly MAP team meeting and then get oriented at the Center for Children Who Have Been Victims of Sexual Abuse (CUBE). We will be doing health maintenance there later in the week.

With luck, transit will cooperate; otherwise, I may stay behind in the clinic. For the next couple of weeks, I'll be doing more rotating around the various MAP programs, pitching in where I can.

This past weekend, I went to the village of Tuini Grande, which, despite its name, is very small.

It is a very rural area past Morochata in a rugged and hilly landscape that is beautifully green (thanks to the last two months of rains).

I participated in a workshop about sorting trash into organics, combustibles, and toxics, and the MAP capacity-building team is going to go back in 2 weeks to help the community organize a clean-up and waste assortment effort.

We stayed at the home of Asunta, a health promoter I've written about previously.

She is a pretty amazing woman who does just about everything--gardens and farms, raises chickens, runs a knitting workshop, oversees efforts for water filtration and latrine use in her village, and provides health care to the children and adults in her community.

I can now also attest that she is an excellent cook, which was extremely necessary since we hiked 3 hours uphill to her village yesterday from the nearest accessible road.

(Incidentally, within the first 10 minutes of that hike, my left leg went knee deep into the mud, suggesting that I should spend more time looking at the ground than the gorgeous scenery.)

I continue to be impressed and humbled by many of the Bolivians around me who are working so tirelessly for their communities.

In some small way, I hope to approximate their energy and approach in the future. I am doing well, and owe that mainly to the help of my neighbors Emilio and Ada, who ensured my safe return from Oruro, loaned me money until Western Union came through, helped me get my driver's license back, and have been nothing short of guardian angels.

Big thanks also to my supportive family back home. Unfortunately, today's friendly internet cafe computer lacks a USB drive, so I am unable to share with you my most recent batch of photos. I will try to send them soon.

Much to my delight, Rachel gets here in one week and she'll spend several days seeing each of the programs here (clinic, school, CUBE, Capacitation, Learning about Disabilities) before we embark on a week of vacation around La Paz and Lake Titicaca.

Thank you for reading along.

I wish I could better capture my day to day life here. The last couple of weeks were good for me in that I am not romanticizing my experience as much as I was initially, but I still very much appreciate the opportunity to be here and to see an integrated model of health promotion in a resource-poor setting in action with all its incumbent challenges.

Being here has definitely been a transformative experience for me, and I hope to be a better doctor and friend when I return.

Best to all,

Brian

John Heimerl Completes His Elective In Zambia

Wow, I am now down to my last few days in Zambia. It is amazing how fast time goes!

This past weekend the farm hosted a Tiny Tim and Friends social and graduation. Each month, children newly enrolled in the program gather to celebrate those who have been in the group already for six months.

The day is filled with education and activity and culminates with a graduation ceremony.

Over 80 children attended. I had the opportunity to take some good pictures during the event, and as soon as a camera was noticed I was surrounded by children asking to have their picture taken.

The farm also started building for the animal enclosures that are being planned for the farm.

This is the future site of the chicken house. The farm also plans to keep goats and ducks in the future.

Also on Saturday we visited Our Lady's Hospice.

Dr. Tim rounds there each week and sees the more complicated patients they are having difficulties with.

We saw three adult patients. One had suffered an acute intracranial hemorrhage following an eclamptic seizure, another was suffering from dementia, and the last was also suffering the devastating effects of a stroke. There were 28 patients at the hospice.

Our Lady's Hospice will be the site of the first pediatric palliative care center in Zambia.

TTF will start with 4 rooms at the hospice and then expand in time.

The project will allow for proper palliation and access to opioids when needed. Currently, terminally ill children in Zambia are either sent the University Teaching Hospital or are sent home with minimal pain relief.

The new palliative care center will be staffed with a specifically pediatric- trained nurse on site to care for the terminal children.

The training is intense and will take two months in Uganda.

There are big things on the horizon for TTF and the children of Zambia.

I will be traveling back to Minnesota on April 5, so this will conclude my blog updates from Zambia. Thanks to all of you for viewing my photos and posts while I've been here.

Cheers,
John

John Heimerl's 3rd Week In Zambia

This blog posting was authored by John Heimerl, M.D., 2nd year Pediatrics resident at the University of Minnesota.

We had another busy week at TTF.

Clinic days are full of patients to see. Here are two pictures from clinic.

Here is the TTF clinical team, along with a patient and his mother in the center.







Here I am with the pharmacist, Thomas.

I also had the chance to visit the large University Teaching Hospital
(UTH), which is the referral center for Zambia.

A nurse named Clements (the only male nurse I saw during my visit) give me a tour, which I limited to three hours. He showed me each section of the pediatric wards.

The pediatric department is spread out over a number of buildings, each housing a different ward.

I saw the emergency ward, then Admitting. From Admitting, patients are sent to one of the five remaining wards--Malnutrition, Heme/Onc, PICU, General Pediatrics (x2) and Endocrine.

I wasn't able to take any pictures of the inside of the hospital, but here is what the grounds and building look like.

Also last week I was able to do something I failed to do on my last trip to
Zambia--I took a bus 400km south to Victoria Falls, which borders
Zimbabwe (I hear we made good time; it only took us 6 hours, and I've heard it can take up to 10).

As you can see, the waterfalls were spectacular. In a couple of sections, you are drenched by the spray from the water falling, and it was entertaining to watch visitors get drenched.

Well, I have to get back to clinic to see the rest of the patients. Hope to send more pictures soon.

Cheers,
John