Reflections on Contrasts and Similarities in Laos from Sansanee Craig (PL3)

Posted on behalf of Sansanee Craig (PL3)

Sabaidee from Laos!

I can't believe it's already been three weeks since we arrived! In retrospect, time seems to have gone by so quickly despite the slow-paced day to day living. Contrast seems to be the theme of this month. Contrast between the hotel we are staying in and the hospital wards. Contrast between the fully functioning drager ventilator in the PICU and the lab's inability to check blood gases. Medications are cheap and supplies are plentiful, but patients have to pay out of pocket for everything. The residents fill out prescriptions on rounds for syringes, flushes, medications, which the parents take to the hospital cashier and pharmacy, bringing back plastic bags of supplies. One Laotian mother said to me "We have everything in Laos, just not enough money". No portable cxr, defibrillator, or cardiac monitor in the PICU, but you can easily buy oral cefixime and IV tylenol. 

A typical day consists of seeing patients with residents from 9 - 12, lecture from 2-3, then studying/ reading in the afternoon. I'm spending this week at Mahosot, one of the three pediatric hospitals in the capitol. There are two others, Settathirat and National Children's Hospital, on the outskirts of the city. They tend to have more limited diagnostic capabilities, so more severe cases will be transferred to Mahosot. Right now, the general wards are full of acute diarrhea cases, likely Rotavirus. Most stay 2-3 days, then leave without issue. PICU has 3 patients: H. Influenza meningitis in a 9 month old boy, severe pneumonia in an intubated 2 month old female with Downs syndrome, and gross hematuria in an 8 year old (G6PD?). 

In the afternoon, I sit in on allergy clinic and am happy to see that eczema is eczema the world over and treatment is the same. Back on the wards, the residents ask me about the sensitivity of bedside cold agglutination testing for mycoplasma pneumoniae. Hm... I remember something about that in med school, but can't we just send PCR or serology? No? Let me go look that up in Pubmed and get back to you .... 

Not only is my lab technique knowledge being challenged, so are many presumptions on "western medicine": Silverman scores, not APGARs, in the NICU (French) and the Australians examine abdomens with the legs flat on the bed, not bent at the knee. The residents have to know so many languages! The Korean-donated library is full of Korean medical journals, radiology reports come back in French, Australian and US attendings round with the residents, and a Thai attending holds Grand Rounds once a month.

And yet despite the contrast in our training, it's fun to see the similarities: residents going out for dinner after work, complaints that evaluations aren't done in a timely manner, the chiefs agree making resident schedules is a headache, and the med students still get pimped on rounds. 

So long for now!

Sansanee

Danielle Brueck (PL3) tells us about the people she met in Tanzania

I suppose it is a common experience to struggle a bit with
how to explain and portray an experience such as this. Ok, ok, maybe I struggle
with the right words frequently in life.  For my last post, I described a
typical day here in Tanzania.  As I near the end of my time here, I have
been reflecting on what I will remember the most, and much of it comes down to
this -- the people.  That has been a recurring theme in life and most
frequently what I walk away remembering. I have been humbled and learned much
from the people I have encountered here.  In describing them, I hope you
will see the Tanzania I have grown to love.



From left to right Joseph, Emily Hall (PL3), Dr. Mantz, Danielle Brueck (PL3) and Maneno


Joseph:  Serving as the pediatric registrar, Joseph is at Selian Hospital
6 days per week with rare exception. He trained in China and is fluent in 4
languages (wow, I'm behind in life). When on call, he also covers medicine,
surgery, and OB/GYN.  He is smart and dedicated, challenging the interns
to think through a differential diagnosis themselves and not simply repeat what
others have said.  He enjoys teaching and has been ever so gracious to
accommodate and answer my frequent questions (which, no doubt, make rounds last
much longer).  If he is told the hospital does not have a medication, he
walks over to the pharmacy himself to check on the availability.  When he
finishes his own work, he can often be found in the outpatient department
helping others with the clinic patients that need to be seen.  During our
rounds, he will pick up a child and set him or her on his lap. He truly enjoys
caring for kids and reminds me of the simple joys found in pediatrics.
 Joseph excels and pushes learning forward in a system where it would be
easier to settle quietly into the background.  I admire the responsibility
he has taken.

Joseph teaching some local students about malnutrition


Maneno:  The intern on the pediatrics team, much of the "scut"
work falls to this guy. You would never know it, however, as he is persistently
eager to learn.  He wants more patients to come, saying that is how he
will learn about what to do.  Being from further away in Tanzania, he
stays in a room on the hospital grounds. But this doesn't bother Maneno; it
means he is available to see more patients. He asks the other interns to call
him if an interesting case arises. He is selfless, willing to pick up an extra
shift if others must go out of town or have another obligation.  Maneno
has reminded me how fun learning can be.



Cifa:  I met Cifa at church.  He is a generous Tanzanian who is full
of life.  He has fostered/adopted many Tanzanian children over the years
and truly has a desire to watch them succeed.  He cares for them and
teaches them to care for one another, the older ones assisting the smaller
children.  What struck me about Cifa is how passionate he is about caring
for the less fortunate of Tanzania and what little regard he seemed to have for
his own interests in this.  During my time in Tanzania, I read a book
called Toxic Charity (thank you, Dr. Kate Venable, for this excellent
suggestion).  It addresses the sustainability of charitable efforts and
discusses how to avoid creating dependency.  The book challenged my own
motives and forced me to ask myself some hard questions.  In the context
of reading this, I had such a moment of clarity when meeting Cifa.  He
genuinely embodied a sustained, grass-roots effort to impact those in need.



J:  J was just one of many patients I will remember from my time here.
 He taught me a lesson in communication.  J is 4 years old and has
been in and out of the hospital over the past several months and was admitted
for approximately 3 weeks during my time at Selian.  He has developmental
delays and is non-verbal.  Not knowing much Swahili, I have felt the
language barrier more than I would have anticipated.  For me, so much of
the joy of medicine lies in talking with people.  I have been able to have
fantastic and academically stimulating conversations with my colleagues here
but have truly missed just sitting to talk with patients.  With J, the
non-verbal parts of communication became even more evident to me.  I loved
walking in each morning to see his smile.  He would peer up from the bed
through the window at me as we gathered our things for morning rounds.  I
would duck down, then pop my head back up to find him laughing.  This game
never got old.  J was scared of us at first, but it turns out that coin
magic tricks and juggling are universally loved despite the language.



E:  We saw E in clinic one Tuesday afternoon, and he quickly captured our
attention.  At 4 years of age, he is extremely small (7 kg or about 15
lbs) with a disproportionately large head.  His mother brought him to
clinic for a completely unrelated complaint, and we wrestled a bit with how to
broach the subject of his odd appearance.  E taught me about the ethics of
practicing medicine.  I found his case particularly interesting from an
academic standpoint and had to ask myself if meddling in his previously happy
and fairly uncomplicated life was for his best interest or merely an indulgence
on my part.  He came back to our clinic 3 other times during my 2 months
here as we arranged to have some testing completed.  He was always a
joyful and cooperative child, bright and slowly taking in the unfamiliar world
of the hospital.  His family seemed genuinely appreciative though I
continued to wonder if any actual good or benefit would come from having a
diagnosis.  Sometimes, both abroad and at home, I feel better having an
answer for myself.  E makes me more aware of how my actions can affect
others.

Team rounds in the ICU discussing causes of heart failure



David:  David is a taxi driver and was the first person Emily and I met in
Tanzania and will be the last we say goodbye to as he drops us off at the
airport this evening.  He was immediately friendly and welcoming.  He
gave us just 2 pieces of advice to consider during our time in Tanzania -- pika
pikas (motorcycle taxis) are dangerous, particularly at night.  And be
careful of the local alcohol; it is strong and causes many a problem.  We
decided to heed his advice on both these matters.  David is an extremely
hard worker with a day job in an office and then driving as a taxi many
evenings.  He never complains but is eager to meet opportunities.  He
chooses good company and sets high goals.  His father once told him
"If you do not clean the dirty dishes at night, you will have no plates
for food in the morning."  His parents provided a constructive
environment where he learned responsibility and discipline, and he looks
forward to doing the same for his children someday.



The stories of others have long intrigued me, and these are just a few that I
will carry forward.  These stories inform and shape my own.  There
are many others (Tanzanians and ex-pats alike) who have made my time here a
wonderful experience.  I am grateful to have been so included and welcomed
here and will certainly miss the beauty of this place.

Calla Brown (MP3) talks about a joint effort to continue a project started by Ben Trappey

Posted on behalf of Calla Brown (MP3)

While Abby has been teaching ultrasound at St. Damien's, Hope, Adam, and I have been working on an evaluation project of a protocol for the admission of pediatric patients with severe acute malnutrition.  Ben Trappey, who is currently a Med Peds faculty member, our faculty advisor for the rotation, and also in the department of global pediatrics, did a four-week rotation at St. Damien's during his Med Peds residency.  While here, he worked with the staff to design an order set for malnutrition.  The order set was based on both the World Health Organization standards for the treatment of acute malnutrition and also on the Haitian Ministry  of Health protocol, and includes best practice guidelines like appropriate rehydration, feeding, and vitamin supplementation.  The staff at St. Damien's, including nurses and physicians, underwent an intensive training on its use in April of this year.  

One of the attendings asked us to evaluate the use of the order set.  We are evaluating two outcomes:  whether the order set was initiated upon admission to observation and whether the child survived to hospital discharge.  This evaluation is made easier by the department of Archives at St. Damien's.  All children who present with severe acute malnutrition, as defined by a weight-for-age Z-score of less than negative three or a weight-for-age Z-score of less than negative two with edema are entered into a book  and this data is eventually shared with the Ministry of Health.  

The Department of Archives

The Department of Archives has shared the book with us so that we can pull all of the charts from children admitted between January 1st and October 31st of this year.  From the chart we gather admission weight, gender, co-morbidities, and the above two objectives.  If the child did not survive to hospital discharge, we attempt to create a narrative history of the admission in addition to collecting objective data like vital signs, lab results, and blood sugar measurements, in order to understand as best as we can why the death occurred.  We will be collating and analyzing this data to share with the staff of St. Damien's.  Ideally together we will discover clinical correlates that could be intervened upon and then perhaps improve outcomes.  

Calla Brown (MP3) at The Department of Archives

Hope Pogemiller (MP4) at The Department of Archives

This quality improvement project has been interesting on many levels.  Firstly, we have seen many children who have been admitted for severe acute malnutrition, and in taking care of these children in partnership with the staff of St. Damien's, we have realized how critically ill a child with malnutrition can be.  Secondly, doing the project has inspired us to learn more about how treatment protocols for malnutrition were developed and what creative methods for its treatment have been implemented in different settings.  Thirdly, we have learned what a behemoth of a task it is to keep track of hundreds of thousands of paper charts in a navigable way.  We are still analyzing the data but we are excited to see what comes of this project.  Whatever the outcome, however, I think I can speak for all three of us when I say that we have learned a great deal.  

Abby Montague (PL3) creates a handbook on beside use of ultrasound

Posted on behalf of Abby Montague (PL3)

I am fascinated by ultrasound. In medical school I had the privilege of rotating at HCMC for an ultrasound rotation through the emergency medicine department. I spent a month learning everything from bedside FAST (Focused Assessment with Sonography for Trauma) exams and the basic bedside applications to looking for retropharyngeal (behind the throat) abscesses with intra-oral probe and confirming fracture reduction in the arm. Unfortunately, keeping these skills up during residency hasn't really been a priority due to the ready availability of excellent ultrasound technicians and pediatric radiologists. But I like looking at the images my patients get and guessing the diagnoses before the official read comes back. I occasionally would page through my Pocket Atlas of Emergency Ultrasound (by one of the HCMC faculty among others) to remember how I would do the studies myself.

Then I started preparing for Haiti.

Aside from X-rays, we knew an ultrasound machine was the only available imaging within the St. Damien's. I was excited about renewing my skills and asked Ben Trappey, our MedPeds hospitalist attending coordinating our trip, if the staff at the hospital would be interested in a little handbook on bedside use of ultrasound that I could do for my academic project.

They were.

After cramping my wrist at 5 am trying to get good RUQ views with the portable ultrasound in my call room, I had enough images for my project. I put together pictures of the buttons from our machines in the ED and on the floor for a mix of the way symbols appear and reviewed some radiology literature for images of clinical pathology. I printed up the guide on Saturday before we left and Ben presented it to our Haitian contacts when we arrived.

Ultrasound machine with Abby Montague's newly created bedside use of ultrasound booklet easily accessible on the side

One of the first ultrasounds we did here was evaluating a child with TB for pleural effusion (fluid around the lung). It was so grossly abnormal at first we couldn't find our landmarks. As we kept looking, we realized we were probably seeing TB cavitations within consolidated lung tissue (holes in the lung). It was impressive. The next was a child with abdominal distention who ended up having a complex cystic mass that was so large we couldn't tell if it was coming from the liver or the left kidney (on opposite sides of the body). Kids don't come to the hospital until they are really sick and their imaging findings, whether chest xray or ultrasound, tend to be dramatically pathologic. At first, the staff just asked us to go do the ultrasounds which couldn't happen until most people were gone for the day. Gradually, they started crowding around to look at the images in real time.

One of the new residents was the first to accept the transducer. Each ultrasound, I would pass it around to see if anyone wanted to practice, receiving a lot of smiling and head shaking with French explanations I couldn't understand. The resident, Renee, was admitting a child she suspected had intussusception (intestine stuck within intestine). After explaining my lack of training with intestinal imaging again (having attempted an appendix ultrasound the first week), I asked her to just start looking since we had equal lack of experience in this case. I shamelessly endorsed my ultrasound guide and showed her the pages about the difference between the probes and the standard probe positioning. She started scanning the abdomen and found a tubular structure with a target appearance in cross section. Never having ultrasounded a child before, she recognized the characteristic finding without prompting. The staff all came around to look and we had a long discussion about the next steps. With no fluoroscopy available, the child would need to have a reduction through an open abdominal surgery. A stunningly textbook history and suggestive abdominal film would have sent the child for reduction regardless. But I can't describe how satisfying it was to watch the resident add to her own clinical suspicion using ultrasound with minimal help.

One day I was asked to ECHO a cyanotic newborn. I am comfortable with the subxyphoid view but I couldn't remember the orientation of the alternative views of looking at the heart. The very same Pocket Atlas I used in MN had made its way to Haiti prior to our arrival and and I grabbed it from the stack of English textbooks on the registration desk to re-orient myself. Renee and I talked through the chapter on cardiac imaging, each tried a couple views and came to the conclusion the right ventricle was small and we could not determine much else. But the physician I had handed the book to was now flipping through other chapters to see what was possible with this machine they've acquired and now wanders in our direction to look over our shoulders whenever we bring the ultrasound out from radiology.

I have not stopped being completely anxious about people relying on our novicely obtained images. We are asked on a daily basis to ultrasound outside of our scope of familiarity - like the ECHO's for congenital heart disease, the intestinal ultrasonography, and examinations for biliary atresia. I've only turned down one request to look for peripheral pulmonary stenosis since I don't even know how to find the pulmonary arteries. But the giant septated pleural effusions are becoming more familiar and a new staff tried her hand at visualizing one today.

I've revived an old love and maxed out the space on my flash drive bringing home images to share with Ben. But I wish I had an image of the look on Renee's face when she found the right angle to visualize the heart. I felt like I really had brought something to give. Our Haitian colleagues have been most generous in sharing knowledge, skills, and gracious acceptance. My hope is that in this small way, we've shared something worthwhile in return.

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.