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

Posted on behalf of Adam Foss, MD (MP4)

Greetings from the Haitian tropics!

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

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

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

Kenscoff

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

Road to Kenscoff

Adam Foss (MP4), Calla Brown (MP3), Hope Pogemiller (MP4), Abby Montague (PL3)

Fruit stand along the road driving to Kenscoff

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

Chapel at Kenscoff

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

Clinic at Kenscoff

School at Kenscoff

Mural at Kenscoff

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

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

Emily Hall (PL3) shares 3 memorable cases

 Posted on behalf of Emily Hall, DO (PL3)

To be truthful, I have no sense of who reads these blog posts. Perhaps you're

• a fellow resident or medical student thinking "Should I do my International Rotation in Tanzania?" 
• or a faculty member thinking "Emily, you should be spending more time talking about your experience at the hospital" 
• or my distant relative motivated by guilt, worrying about my well-being and thinking "how am I related to you, I would never associate with such impulsive travel plans and decision making." 

Regardless, I hope you've found my ramblings both interesting and of some value. 

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

CASE ONE: 9 year old with unilateral eye swelling. 

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

On admission, the intern overnight believed this was a case of cutaneous anthrax (despite there being no classic eschar lesion). Child was started on high dose Penicillin.  Two days later, child's fever and facial swelling was persistent. Differential diagnosis was considered including H. flu or staph pre-septal vs orbital cellulitis. Antibiotics were empirically broadened. Within 1 week she developed a classic eschar involving the superior eyelid and her fever curve normalized. She was discharged home on mono therapy with high dose Penicillin. She was instructed to follow up within 2 weeks; she was lost to follow-up, presumed continued resolution of her bilateral eye swelling. 

 

Lesson Learned: Trust your colleagues, regardless of their 'rank' in medicine. The intern overnight reported seeing a similar presentation of cutaneous anthrax. Despite this, many (including myself) thought broadly about the differential and given the sick-appearance of the child promptly advocated for empiric antibiotic coverage. In the end, the intern made the astute and correct diagnosis. In retrospect, he had much more to say regarding how he came to this conclusion and demonstrated a sound thought process that was initially overlooked. 

CASE TWO: 4 year old with chronic constipation

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

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

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

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

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

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

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

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

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

Posted on behalf of Hope Pogemiller (MP4)

Sak pase! 

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

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

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

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

Posted on behalf of Abby Montague (PL3)

Bonswa from Haiti!

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

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

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

St Luc

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

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

Place of worship

Ruins of a cathedral

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

View during dinner

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

Scabio, the resident cat, hoping for more leftovers

A plutard (see you later), 

Abby

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