John Heimerl's Last Week In Haiti

The following post was written by John Heimerl, M.D., 3rd year pediatrics resident at University of Minnesota

Most days at Saint Damien's begin with 7 AM church service, and most days there are several bodies nicely laid out on the church floor to receive a final blessing. On this day there is a small group of family members in attendance. One woman wails, and Father Rick takes time to explain to the foreign visitors that she is the mother of a 12-year-old boy whose body is in one of the caskets. This day also happened to be Ash Wednesday, which marks the beginning of Lent on the Catholic calendar and where ashes from last year's Palm Sunday palms are applied to attendees' foreheads to remind us of our eventual mortality.

I have been attending Ash Wednesday services my whole life, but never before had it coincided with a funeral mass; therefore the homily hit home all the more. Father Rick warned those in attendance that the caskets would be opened and the family would have the opportunity to see their loves ones for the last time. Visitors in the past have found it difficult to watch, so we were all free to leave following the final blessing.

Chapel at St. Damien's.

Also in attendance at mass is a group of fundraisers from California who I think, judging by their clothing selections, appear more prepared for a day of shopping in San Francisco than a day in Haiti. It is yet another example of a form of tourism that occurs daily in Haiti: people traveling to see how bad the conditions "really are", but never taking time to fully immerse themselves in the lives of the local people.

I, too, have been part of this.

A couple weeks ago I toured Cité Soleil with the sole purpose to see one of the poorest parts of the city. We were not there to provide help, but there to satisfy our own curiosity and photograph the conditions for others to see. The photographer and journalist I accompanied recently published their experiences in a Chicago newspaper. You can read the series of articles and view pictures here.

Having been present for part of these photographers' trip to Haiti, it was interesting to read their experiences and compare it to my experience of the same event. Much like a witness to a crime, we each view events from different perspectives.

A couple of days ago I was given the opportunity to visit the dedication of a new district clinic. The drive was about 3 hours from Port au Prince. We left before dawn and made good time. I spent a majority of the trip riding in the back of a pickup with Dr. Phil, a dentist from Vermont, who has been coming to Haiti since 2004.

We drove by the coast and could not help but think that in other places the sand and beaches would be lined with massive hotels and tourist attractions. Instead, the sand was littered. The last hour of the journey took us down a dirt road, and before reaching our destination we had to ford a river with the truck. I hear the crossing is much different in the rainy season when the river is much higher.

On the drive to Fonds des Blancs 

Crossing the river on our way to the new district clinic opening ceremony

The new clinic is freshly painted and is largely empty, but beautiful. There is space for a pharmacy, dental office and multiple exam rooms.

A local man named Farell who had grown up in the area financed and organized the building of the clinic. He has been finding ways to give back to his community now that he is financially set. His thought was that if he built the clinic, patients and doctors would come. The clinic is built, but no one is there yet to work or run the clinic. He asked me to work in the clinic on my next trip to Haiti, which would be a nice change of pace from the city.

Clinique Sainte Joan Margaret, the new clinic at Fond des Blancs

The dedication service included a mass and a plea to the community for nurses and a physician to work in the clinic.

Then there was music, dancing and food for the 100 people in attendance. When the music and dancing started we took the opportunity to head further up the road to Fonds des Blancs, where Farrel is from. We saw his parent's house, his construction business, a bakery he was instrumental in establishing, a potable water filling station, and at the end of the road, the Fonds des Blancs Catholic hospital. We arrived unannounced and toured the facility. The Haitian physician in the Urgents spoke amazing English, and as it turned out, had attend Dartmouth for a time (as had Dr. Phil).

A Fonds des Blancs physician

A washing station at Fonds des Blancs

Me and Dr. Phil at the bakery in Fonds des Blancs

We made it back to the clinic dedication in time for the recognition of the 50 people who had helped ensure the completion of the clinic. Sister Judy (of St. Damien's, where I have been working these past six weeks) was given a plaque for her part of the project. I had taken a couple of pictures and asked Sister if she wanted any. She only wanted the picture of her with the plaque to remember the day. I believe that it was not so much the plaque she wanted to remember, but the positive impact that day will have on the community.

Sister Judy received a plaque in recognition of her efforts toward establishing the new clinic

Children attend the opening ceremony at the new district clinic

I had initially planned to get two posts out this week before I headed back home, but it is now 14 hours before I start my journey back to Minnesota. As I type this, I hear the screams and moans of another woman giving birth to what is hopefully a healthy baby.

This has been a rough week for me.

When you come to do a rotation, you have a return flight and ending date. This week it became clear that I was nearing the conclusion of my trip. I had been looking forward to this week for many reasons. A big part of it was getting Kesley back as my interpreter. He is not only an amazing interpreter but exceptionally smart. Today I asked him if he makes good money and he replied that he does this work for the opportunity to learn better English (he also has been accepted to start a master's program at Washington University this year, if he can fund his living expenses). To the others, their work may be just a job, but to Kesley it is a chance to learn better English.

There have been some interesting patents this week. Unfortunately the interesting patients, due to their pathology, are also extremely difficult for me to deal with on a human level.

Yesterday, a boy presented in the morning who Doctor Augustin wanted me to see. He told me that since the age of 6 months this boy has had lesions on his face. He is now 6 years old, and the lesions now are everywhere. This child has been to other doctors, but nobody has been able to fix the lesions. I had no clue what this was. It was clearly a chronic process and looked both infected and inflammatory at the same time.

When in doubt, phone a friend.

I took a couple pictures and sent them to global health faculty in the states. I got some good responses, but it was not until I returned to work yesterday that Dr. Augustin told me one of the brilliant HIV attendings thought it was xeroderma pigmentosis. I was not completely convinced, so I Googled it.

Sure enough, it was as if I was seeing this patient in the pictures. Thankfully the initial email had been forwarded to a couple of dermatologists who felt it was consistent with XP.

A biopsy still needs to be done, but then again we are in Haiti, which means a trip to the general hospital. I have heard numerous stories about this place, and some are not so
positive. Jamie, my roommate for a couple of weeks, told me about a shootout he had witnessed on a trip there, but the general hospital is the teaching hospital and likely has one of the only dermatologists.

I got an email from Dr. Mike at Brown who forwarded the email to the dermatologists there, and apparently there are some philanthropists who are interested in possibly paying for the patient's treatment in the States. This remains a long shot, as the diagnosis is not confirmed, and if this is XP, it means he has skin cancer on his entire face. (I will not enclose his picture, but if you google XP and look for the worst image you find you will see something similar).

Yesterday I was working an afternoon Urgents shift when a nurse asked me to see a patient because his heart had stopped. There was no code blue alarm or code team, only me and two nurses, and twenty parents looking on. No pulse, so CPR was started after one cycle, there was no pulse, I examined his eyes and there was no pupil response. Pneumonia and severe anemia had claimed another 6-month-old.

No sooner had I finished his death certificate when I was asked to see another child, a newborn with pallor and clearly severe anemia. His labs were not back and until the labs are back one cannot go to the blood bank to get blood. He had some respiratory distress and poor perfusion, but otherwise looked well. I sent my interpreter to the lab to ask about the sample. They had received it, but could not be run it until the morning, as the machine was not functioning.

I again ordered blood STAT O-blood hoping that if it were ordered multiple times that it would happen. In the meantime I made him NPO and gave him a small bolus. He looked decent, and I thought he would make it till he was able to get blood in a day or two.

Today Dr. Augustin informed me that this infant had died due to severe anemia. Unlike back home, there are no continuous monitors and infants are not checked routinely. A third child also died, which Dr. Augustin was upset about, as that child had been doing well the previous day. What a way to start the day.

Fortunately, my attention turned to a 9-month-old who was carried in by the security guard. He had been seizing in triage, but had now stopped. I did a history and exam and, for the first time, actually thought his neck was stiff on exam. I did a lumbar puncture, and when he was getting an IV he had another seizure, which we were able to stop. Before long he was tucked in for the day. I have been working on a seizure management protocol and followed the protocol exactly as I had written it. Ironically, I would be presenting the protocols to the staff in a few hours.

The next patient was a 10-year-old who weighed 30 pounds and was severely malnourished. It was almost too much to bear on my last day. There are so many levels of complexity in caring for each patient--cultural, financial, transportation logistics, etc.

Around lunch I was able to excuse myself. I had a presentation to prepare for and had seen enough pathology for one day. I spent the evening with a couple of volunteers at a restaurant as my final goodbye. Haitian food sure has a spice that I am going to miss.

Just prior to heading to the airport, I was able to go to a celebration at the nearby school. They had completed construction of a gymnasium, and a celebration and dance followed mass. The children were super cute dressed up for the occasion.

Children at Father Watson Angels of Light School (FWAL)

As I complete this letter, I am nearing my arrival to Miami.

My first trip to Haiti was an adventure. It was the international experience I had been looking for: a diverse patient population and resources to treat them with. Prior to leaving today, I stopped by the Urgents to say goodbye to Dr. Augustin. I gave her my Pediatric Emergency Drug Reference Card from Amplatz. She thanked me for my assistance and for the "very useful gift". I already miss Ayati! Hopefully, I will be able to make it back next year.

When I told Sister Judy I would have to find another niche, her reply was that I could work in the New Saint Mary's hospital in Cité Soleil with her or work in Fonds des Blancs. Both of those options sound amazing, and I look forward to my return trip.

4 Residents Join MEDICO Team in Jalapa, Nicaragua

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



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

Bienvenidos a Nicaragua

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

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

Bili bed constructed by previous residents on this rotation

The OR at our hospital in Jalapa

Our hotel

John Heimerl: 1 Month in Haiti

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

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



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



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

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

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



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

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



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

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

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

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

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

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

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

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

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

The fish pond at the fish farm.

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

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

Aquarium at the fish farm operated by Operation Blessing.

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

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

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

Cité Soleil Hospital

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

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

New permanent houses built by NGOs in Cité Soleil.

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

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

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

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

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



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

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

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

Peterson and his new oxygen machine

Till next time....

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. Muthyala Checks In From Arusha, Tanzania

Kilimanjaro, as seen from Mount Meru

20/12/2011

Today was a regular day on the pediatric wards at Selian Hospital in Arusha, TZ......

The day began with a Continuing Medical Education given by the palliative care teams at the hospital. In the middle of rounds, a nurse informed us about a very ill child that had been brought to the outpatient clinic.

We rushed to the clinic, where we found an infant apneic. At this hospital, the nurses have minimal pediatric or neonatal resuscitation training, so nothing had been done. Quickly we

began bagging the child, found otherwise good vitals, and obtained a history.

A one-week-old boy, born at home without any prenatal care, was doing well until a few days ago, when he began to have fevers and had a seizure today.

The family initially presented to an outpatient clinic, where the child was given oral amoxicillin (a capsule of amoxicillin was opened and given to the child orally) without any improvement.

The child had a strong pulse, good chest rise with bagging but was coughing. Bulb suctioning resulted in the removal of about 2-4 ml of pink fluid, which was thought to be not blood but the amoxicillin that the child was aspirating.

There was no oxygen available in the outpatient clinic, so the child was taken (while ambu bagging) to the pediatric ICU. Oxygen via nasal cannula was started, and the child began to breath spontaneously.

The child was found to be hypothermic and there is no incubator so the mother was instructed to place the child in direct contact with her own skin. After this his vitals stabilized.

We started empiric treatment for meningitis (without an LP or blood cultures, because neither is available or reliable at the hospital) but first taught the ICU nurse how to dilute a vial of 250mg of ceftriaxone into 150mg doses, and then instructed how to mix D5NS and D5W to make D5 ½ NS for maintenance IV fluids.

Then back to rounds.

Doing well here in TZ, have one more month before coming home.. Happy Holidays, everyone!

Brian

Brian Muthyala doing x-ray teaching at Selian Lutheran Hospital in Arusha, Tanzania

Dr. Tundun Williams - Weeks 2 and 3 in Ogbomoso, Nigeria

The literature states that the prevalence of G6PD deficiency in Africa is anywhere between 15-30%.

Risk factors for hemolysis include use of mentholated products in the first six months of life, illness, certain drugs (e.g., Primaquine, sulfa drugs, Quinine) and fava beans (the jury is still out with regards to whether Nigerians eat fava beans).

We screened children at schools, churches and small villages. The screen included asking simple screening questions and collecting blood samples from children under the age of 16 years old. Samples were processed back at the hospital lab.

By the end of the third week, we had exceeded our goal of screening 1,000 children.

Initial analysis of our data shows a prevalence of 10-19%; differences in prevalence appeared to be related to ethnic group.

Parents of deficient children will soon be sent notification letters telling them what to avoid and how to recognize symptoms of hemolysis. Lab personnel have been taught how to do the simple G6PD screening test. We hope they will continue to screen children long after we leave.

The Baptist seminary elementary school, one of the first sites we visited to perform G6PD screens.

Ajinapa village; more children to screen for G6PD

Adodo village. These boys were insistent on striking fighting poses.

Ilota village school

Our host, Dr. Daniel Gbadero, speaks to children at Ayegun Baptist Church.

At Baptist Medical Center Staff School. This is Samuel, looking very sharp in his school uniform (the bowtie is optional, and as you can see, is worn by only those young men with discerning taste). You wouldn't know it from this picture, but Samuel is a giggler. He was particularly amused when I asked him if he had ever had tea-colored urine.

When the generator was not running, the power supply was unpredictable. Here, Troy Lund and I are running hematocrits on a battery-operated Hemocue machine by lantern light.

We used the fluorescent screening method for G6PD deficiency. Patients who have adequate G6PD activity produce NADPH, which fluoresces under long wave UV light. The spots that do not fluoresce represent patients that are G6PD deficient.

Ogbomoso, a town of just over 1 million inhabitants, is located in Oyo State (in Yoruba-land), about 150 miles north of Lagos.

Photo courtesy Google Maps and Wiki Commons

Like all other Yoruba towns, there is a story behind the origins of Ogbomoso. It is said that a mighty warrior named Elemoso once habitually terrorized the inhabitants of present day Ogbomoso.

The people got fed up with being pillaged and decided to send a warrior of their own to defend their city.

This warrior fought with and beheaded Elemoso.

The alaafin (king) of Oyo heard of this feat and was impressed. He dubbed the warrior "Ogbori Elemoso" (he who beheaded Elemoso) and crowned him soun (regional king) of his hometown.

Over the years, the name of the town, originally Ilu Ogbori Elemoso (the place of origin of Ogbori Elemoso), has contracted to just Ogbomoso.

We chose Ogbomoso as the site for the G6PD deficiency study because of Tina (Slusher)'s long-standing ties with the Baptist Medical Centre, where we have guaranteed access to a lab.