Rainbows and reflections from Hope Pogemiller (MP4)

Posted on behalf of Hope Pogemiller (MP4)

On our walk to the villa one day after a brief rain, we were startled by the beauty of 2 rainbows stretching across the sky. We all stood back by the walls of the compound next to the road and excitedly pointed at the rainbows. We shouted excitedly to a man passing by, and he smiled and taught us the name for rainbow in kreyol as he walked. Everyone from security guards to cooks to patients are pleased with attempts to learn kreyol, and it is amazing how patiently they repeat words and help us to construct phrases each day. 

A double rainbow

Hope Pogemiller (MP4) and Adam Foss (MP4) at the compound

As we bid farewell to so many favorite colleagues and community contacts, we often receive a wish that our final few days be multiplied 100 fold. We are surrounded by an intense love of Haiti that is shared by so many Haitians and aid workers alike.  The spirit of Haiti has crept into our souls, and even in our final days of this month we are practicing kreyol at dinner and planning our return.

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. 

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