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 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. 

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

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

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 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. 

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). 

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

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

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

Bridge in Haiti