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

Adam Foss (MP4) tells us about his typical schedule at St. Damien's

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 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 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

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.

Bonjour from Adam Foss (MP4), Abby Montague (PL3), Calla Brown (MP3), & Hope Pogemiller (MP4) in Port-Au-Prince, Haiti

Posted on behalf of Adam Foss, MedPeds 4th Year Resident

Bonjour from Port-Au-Prince, Haiti. We are settling into our routine and trying to learn quickly on our feet. It is a different pace than what we are used to, but we are adjusting well.

Arriving in Haiti

Calla, Mahsa, and Hope have been spending their time at the adult hospital called St Luc (Luke), and I have been spending several days there as well. St Luc is a hospital built after the earthquake in 2010 in response to the immense influx of patients to St Damien's. The hospital houses an emergency area (Urgence), cholera treatment area, general medical ward, and an ICU. There is a radiology department that has the capability to do CT scans of the head and X-rays of any body part. In our short time here we have seen anything from strokes (ischemic and hemorrhagic), heart failure, HIV, advanced AIDs, Tuberculosis, PCP (a pneumonia seen in patients with late stage AIDS), diabetes and heart attacks. The hospital is a local safety net for the area and provides care for patients that would otherwise not receive any medical care.

Adam Foss (MP4), Hope Pogemiller (MP4), & Calla Brown (MP3) at St Luc Hospital

Abby and I have been spending time at St Damien's, a pediatric hospital. We have been seeing a full range of pediatric patients from newborns with fevers, severe malnutrition, diarrhea, and pneumonia. The pediatric hospital has an emergency area (Urgence), PICU, NICU, oncology ward, and general pediatric ward areas. We have been spending time in Urgence working aside the local staff pediatricians and pediatric residents.

Abby Montague (PL3) at Saint Damien Pediatric Hospital

Dr Trappey, our staff guide from the University of Minnesota, has been here several times and has been a great asset. He has been busy between both hospitals and helping us develop our ultrasound skills.

Sunset at night near the hospital

Look for more to come!

Adam, Abby, Calla, Hope

Emily Hall's (PL3) Dreams Take Flight Again in Tanzania

Posted on behalf of Emily Hall (PL3)

If you had asked me 20 years ago what my life would look like if I were to become a doctor--flying into remote areas of Africa and providing medical care to those in need would have been on my short list of career ambitions. Decades later a dinner conversation and some networking led to the opportunity of a lifetime. 

I was invited by the Flying Medical Service (a NGO based in Arusha, Tanzania) to fill a last minute need to see patients in rural Tanzania. A pilot, a pilot in training, a local chief medical officer, and I traveled for two days landing in remote areas to see patients and provide medical care. Much of my role was to complete prenatal assessments and serve as a pharmacist of sorts--counting pills and dispensing medication. It wasn't pediatrics per say, but I was eager to be involved and willing to help in any capacity. Despite no formal plans to see pediatric patients there always seemed to be a sick child (or many) in each location inviting me to jump into a more familiar role.

We landed in various regions of the country and I felt literally "dropped" into the Maasai culture. The beauty of the villages and people mesmerized me. Their dress and way of life is so contrasting to anything I'd witnessed before. It was such a privilege to be immersed into the culture in this way. They believe pictures capture and take away their soul; so out of respect, I did not photograph any people during my visits. However, the images of the experience are imprinted in my memory. I apologize my writing ability cannot portray the pictures recollected in my mind--you'll just have to trust me: it was incredible.

Aerial view of a Maasai village as we fly low alerting inhabitants that clinic will soon begin

Returning from this experience I couldn't contain my enthusiasm. Bush flying had proved to be all that my childhood dreams had imagined. It provided an element of danger, fulfilled the desire to do good work, and allowed me to be surrounded by like-minded people. A few weeks later I found myself discussing the opportunity with a midwife at the hospital over tea. She herself has lived quite an adventurous lifestyle, which is reflective in her career endeavors, and I was eager to hear her perspective of medical humanitarian aid. 

I left the conversation identifying with her ambitions and taking away a new understanding of why some people are drawn to global health. In a career field so formulaic -- blended with my personality that is anything but -- I crave to connect with people to have alternative medical perspectives. The global health community embodies this notion. People who have sought and created an alternative career path surround me here and being in Tanzania has allowed me to learn from many who have found their way in medicine despite not conforming to a linear trajectory. 

On reflection, I realized the rigors of medical school and residency had quickly quieted my childish idealism. The perceived ability to make a change in the world and the naïve enthusiasm that surrounds such big dreams was a feeling I had nearly forgotten. Returning to Africa has been oddly rejuvenating and in some ways has given me permission to again have lofty and alternative career goals. So again, I find myself making a list of career ambitions. This time, becoming a Bush Pilot/Physician in Africa probably won't make the shortlist but I'll credit the experience with making me a bit more prepared for whatever opportunity comes next. 

Emily beside the Foreign Medical Service plane

A Day in the Life of Danielle Brueck in Tanzania at Selian Lutheran Hospital

Posted on behalf of Danielle Brueck (PL3)

The task of trying to capture in words all the sights and sounds of this place is daunting.  The days have started to carry much familiarity yet never quite enough to feel like home. Tanzania - as a country and as a people - is beautiful.  I have felt very welcomed and am grateful to have this opportunity.

In an attempt to capture the experience of the past month, I will walk you through an average weekday.  Please allow for some creative licensing on my part to help condense the experience of many days down into one day, recognizing that each day is not actually as glamorous or exciting as this may lead you to believe. 

6:15 am: Wake up.  Eat some toast and surprisingly good peanut butter.

6:45 am:  We are supposed to be leaving.  I am living with Emily Hall (Peds Resident - PL3) and Caroline (Medical Student from Holland).  I realize I am the only one actually ready, probably because I wake up the earliest every day.  Then I realize this is because Emily and Caroline can actually walk much faster than I can and plan to make it to the hospital in less time than I thought possible.

6:55 am:  Actually leave our place and set out on our 7 km hike to Selian Hospital (uphill both ways, obviously).  During our walk, we have the excellent opportunity to practice our Swahili with the school children who are walking along the fairly car-devoid back road.  We are met with "mzungu" (Swahili for white person) and "how are you?" and are spontaneously hugged or touched.  This is often followed by much laughter from the children.

Walking to Selian Lutheran Hospital

8:15 am:  Arrive at Selian and attend chapel.  The singing is beautiful and allows us all some time to relax after the long walk.  Chapel is attended mostly by the medical staff (nurses, interns, etc.) of the hospital, and they are most welcoming to us as we fumble to figure out which hymn number we are supposed to be singing.

Selian Lutheran Hospital

8:45 am:  Morning Report starts which entails a brief reading off of the admissions, discharges, and deaths for the past 24 hours.  I hold my breath a bit, hoping that the neonate with seizures and hypopnea is still alive.  He is not called out when the deaths are read, and I feel relieved.  An interesting admission of a patient with sagittal sinus bleeding after trauma is discussed.

9:00 am:  X-ray rounds.  The power is out so we step outside to view the x-rays in the light of the sun.  Interns take turns giving their impression of the films - pneumonia, congestive heart failure, femur fracture.

X-ray Rounds at Selian Lutheran Hospital

9:20 am:  Round in the ICU.  There is just one Pediatric patient with likely bronchiolitis but requiring oxygen therapy.  We check her vitals and finagle the adult pulse oximeter to pick up a reading on the child's foot.  She looks better today.  Perhaps this whole bronchiolitis peaking on day 5 thing is true here too.  Maybe I have learned something in residency; I feel excited that Emily agrees that the right upper lobe infiltrate on the chest x-ray could just be shifting atelectasis.

9:40 am:  Chai break.  Besides, they are cleaning the hospital floors.  I begin to wonder whether it is a worldwide phenomenon to clean hospital floors during prime rounding hours.  Oh well, chai sounds great.  And the floors do need cleaning.  

10:00 am: General Pediatric Ward rounds.  Emily and I are working with a fabulous intern and his supervising equivalent of a senior resident.  We grab the paper files (charts) which the nurses have neatly stacked for us and the equivalent of a WOW (workstation on wheels) which is a huge cart with drawers filled with cotton swabs, discharge forms, pulse oximeter, etc.  The children, many of whom have been sitting outside in the grass, trickle back into their beds as they realize we are starting our rounds.  Some of the patients come with complaints that are familiar to us - chronic constipation, bronchiolitis, diabetic ketoacidosis.  Yet we are also challenged with more unfamiliar cases - Kwashiorkor malnutrition, cutaneous anthrax, tuberculosis.  We scratch our heads a bit about how to treat diabetic ketoacidosis with subcutaneous insulin and not an insulin drip.  The patients , their parents, and our fellow Tanzanian colleagues are kind and patient with us, answering our many questions.  The intern is eager to learn, explaining to us how he has been taught to approach a problem and then asking questions about how we would approach this problem.  The more senior resident helps guide and make management decisions on each patient.

11:30 am:  Baby checks.  We head over to the obstetrics unit and inquire if there are any neonates with acute concerns.  Two are currently being treated for likely sepsis with a presentation of fever and increasing fussiness.  There is no microbiology lab or ability to grow cultures so empiric therapy is given.  We are happy to see that the neonate with seizures and hypopnea is much improved today.  After seeing the neonates with acute concerns, we also do a routine exam on all new babies.

12:30 pm:  Lunch of rice and beans.

1:30 pm:  Follow up on interventions, labs, imaging.

3:00 pm:  Time for the long trek back home.  I think I am in better shape than I have been since residency began.  Maybe I will walk to work in Minnesota.  Then I remember it is at least 40 degrees colder in Minnesota, and I take that thought back.  We stop at a roadside stand along the way to buy some fresh vegetables for dinner.

4:00 pm:  Arrive home.  I am grateful we have such a wonderful place to stay with fairly consistent/reliable internet access.  Check emails, read.

6:00 pm:  Time to make dinner.  I realize the great amount of time and energy that this can require and remember why I cook so seldom at home.  I envision the many canisters of beans at our apartment in Minnesota and recount the innumerable times we have vowed to use these.  We all enjoy each other's company in the kitchen as we cut up our fresh vegetables and cook some rice and beans.  We actually sit at the kitchen table to eat and don't feel rushed to a flurry of other activities.

10:00 pm:  Time for bed.  I am starting to enjoy this whole sleeping thing.

There are already many exciting memories from this place, and I am eager for more to come as we finish up our second month here.  It has been a pleasure to work with, and learn from, our colleagues here.  I continue to think through how global health will have a role in my career moving forward.  Regardless, opportunities such as this strengthen my clinical skills, offer new perspective, and challenge my ability to think critically.  I am hopeful these moments will become a part of how I practice medicine and allow me to provide better care to the children I encounter, regardless of location.

Jambo from East Africa - Emily Hall in Tanzania

Blog Post written by Emily Hall, DO, 3rd Year Pediatric Resident

Jambo from East Africa!

I have spent the first few weeks in Arusha, Tanzania settling in and acquainting myself with the resources, medical facilities, and the community. As true with all my adventures abroad--this has not been what I expected, but equally holds exciting potential and opportunity. In future posts I hope to tell more tales of adventures. However, before things get too exciting...let me explain my perspective of life here in Arusha so if you are considering this as an International Elective you will know a bit of what to expect.

Danielle (another U of MN Pediatric Resident who most of you know) and I initially started our work at Arusha Lutheran Medical Centre, which is located in downtown Arusha and offers more specialty hospital and outpatient clinic care. They have a small NICU which was impressive to tour and have a total of 2 pediatricians on staff in addition to a pediatric registrar. In contrast, we observed and in the past few weeks have found our place at the Council Designated Hospital also known as Selian Lutheran Hospital (subtle name difference to the former mentioned). This hospital is in a semi-rural location in a village just outside Arusha serving both Maasai, Waarusha tribes, as well as people of Arusha. We walk to the hospital with beautiful views of Mt. Meru along the path. (see photo below) The resources here are limited in comparison to the Arusha Lutheran Medical Centre.

Mt Meru

We have been working with two Tanzanian trainees in pediatrics; one of which received his medical training in China the other from Dar es Salaam, Tanzania. Our primary physician contact here is from Australia; she has been a truly wonderful mentor. We round with two nurses and the four of us trainees. Together we have been discussing and collaborating on patient management decisions with particular consideration of differing International Guidelines of management and factors relating to a resource limited setting. This type of work and learning environment has taken a few weeks to develop, but has recently started to come together in an exciting and highly educational format. Later in the week the physician from Australia has been joining us--by this time we have had some autonomy to make decisions and can discuss in more details questions or concerns regarding patient care that have been debated in her absence. Additional training opportunities have included pediatric HIV clinic, pediatric general clinic, and serving at rural outreach clinics.

There have been several very interesting patients and cases, some of which are still a bit of a mystery. Perhaps in the coming weeks Danielle or I can write about one or two interesting patients to give you a taste of the variety of medicine and the diagnostic approach here at Selian.

Arusha provides quite the balance of work and fun. There are limitless things to do in the city and in the country. It is my hope in the coming weeks we can provide a bit of insight on both the medical and culture opportunities we have explored.

Until then, wishing you all well in Minnesota or wherever this missive finds you.

Emily Hall, DO, PL-3

U of MN Pediatric Resident

Bomberg reflects on his 1 month rotation at Shawno Medical Center

Posted on behalf of Eric Bomberg, MP3 resident.

This last week has been busy as usual. I helped deliver a baby for the first time since medical school, and then being the pediatrician that I am, was first in line for newborn assessment and resuscitation. I have really enjoyed working at the Shawano Medical Center, and have had the opportunity to care for many adults and children here. 

We had one patient come in during my last call with a history of anoxic brain injury who was having fevers and possible seizure activity. As we do not have many specialists around, we had to transfer to another hospital. These experiences really show me how much of a luxury it is to be at a large academic center with specialists that can come 24 hours a day.  And they have taught me a great deal about the challenges of working in a hospital where the resources are limited in this respect. There are specialists that we are able to call for consults but most of them are only around on a very limited basis.

Photo of the clinic

View on the Menominee Tribal Reservation

Driving on the reservation

I finally got my car back from the shop. I hit a deer on the freeway about 2 and a half weeks ago and it took this long to repair. This is extremely common in Shawano County and most people have experienced this at least once. Happy that is finally taken care of. Green Bay is the closest major city to us, which is about 45 minutes away.

This last weekend I spent one day kayaking on the Wolf River which I have never done before and then spent spent some time looking exploring Green Bay.  I visited Lambeau Field and got to explore the shoreline of Lake Michigan a bit.

Lake Michigan shoreline

Greenbay

Lambeau Field

I have really enjoyed being able to explore the reservation and have now been around most of the area by this point. The land is beautiful, full of forests and lakes. Much of the housing looks similar as most of it was built through HUD housing projects in the 1970s.

Heading back to the Twin Cities in the next couple of days. This whole experience has been unreal.
Eric