Greetings from Saint Damien's Hospital, Week #2

from John Heimerl, MD, 3rd year pediatrics resident at University of Minnesota:

Another week has passed here in Haiti. It has been a busy week.

Since my trip to Saint Damien's overlapped with the team from Brown University, I was put to work in one of the hospital wards for the week.

Initially, I was working with Dr. Vaz from Brown University.

We divided the patients up and tended to them one by one.

Seeing patients in the Orange Room on the wards at St. Damien's Hospital for Children

By the end of the week, I had developed quite a relationship with the parents and patients. A few of the children have been here for months.

The girls' room has a three year old with cardiomyopathy and TB who has been in the hospital for more than six months.

A few of the days she would sit on my lap as I worked my way through the charts.

Another girl had a right-sided empyema with a chest tube in place. After having the tube in for a week we got a CXR, and it showed no change. While the chest tube and collection system are the same we would use back home, there was no suction attached to the reservoir to assist with draining her plural fluid.

After she had had a few days of fever while on broad spectrum antibiotics and I had realized no more fluid was draining via gravity, I decided to see what I could pull out with gentle suction and a 60cc syringe.

Thirty-five mL of purulent fluid later, she was feeling much better and has actually continued to drain into the reservoir.

Following morning ward duty, I've spent afternoons assisting in the urgents (ER), where we are seeing all sorts of pathology--things I will never see in the U.S.

A few of the patients I have seen this week include a girl with CXR consistent with miliary TB as well as malnutrition of all sorts, from kwashiorkor to extreme marasmus.

One child I admitted over the weekend was 16 months old and was on breastmilk till 1 year of age, then apparently was fed cookies and juice. My interpreter made it clear to me that is was not "natural juice", which I thought was slightly humorous, as the nutrition value would still be minimal. Needless to say, this child should improve with proper nutrition, and along the way we will ensure the family receives some education.

A few patients have not made it.

On Saturday a six year old with pneumonia experienced complete respiratory failure.

I taught a Haitian medical student, who happened to have been walking by the boy's bed, to properly bag mask, then gathered the necessary intubation supplies and determined how to operate the ventilator. The intubation actually went remarkably well, however, I discovered that I had not paid enough attention to the respiratory therapists back home, and I didn't properly secure the tube.

The episode seems to have been a good learning experience, both for the med student and the nurses, though unfortunately, as expected, this child did not survive.

I did think it was a start at transitioning to the next level of care, and hopefully over the next couple of weeks, we can continue to teach the nurses.

I have had the opportunity to do a couple of day trips on my days off.

Last week I went with the Brown team to the beach.

Friday, I took a half day and was driven around the city. 

Public transportation in Haiti is called a "tap-tap".

We drove by the National Cathedral, which lays in ruins from the earthquake.

After the drive we had a wonderful, authentic Haitian lunch...

...topped off with fresh sugar cane.

Sunday I had the day off and went to the Kenscoff Orphanage for the 25th anniversary of NPFS (Nos Petit Freres et Soeurs, "Our Little Brothers and Sisters") the organization that supports St. Damien's and multiple orphanages.

Father Rick (pictured) and the archbishop attended the anniversary celebration.

Kenscoff is a breathtaking mountain retreat from the city. We made the trip with children from another orphanage that's located next to Saint Damien's.

This amazing view was taken from Kenscoff Orphanage, looking out over the adjacent hillside.

Following mass there was entertainment and dancing.

One more picture: this local artist makes these pieces out of 50-gallon steel fuel barrels.

Dr. Heimerl's First Week in Port au Prince, Haiti

Written by John Heimerl, M.D., 3rd year pediatrics resident

Chapel at sunset on grounds of St. Damien's Pediatric Hospital; Port au Prince, Haiti.

Well, I have embarked on my seven-week experience in Haiti. I arrived on Monday, January 16.

My flight was slightly delayed in getting to Port au Prince, due to the airport controller delaying our landing.

This circumstance allowed for us to circle the island prior to landing, and I recalled my first year of medical school when we read Tracy Kidder's Mountains Beyond Mountains.

It is no mystery where he got the name for his book: there are mountains beyond each ridge of mountains. It sure is beautiful topography.

Most of the population lives in the coastal town of Port au Prince, but houses and huts are scattered among the deforested slopes of the mountain.

I can only imagine how far residents must travel for water and supplies, especially since there are very few visible roads.

We ended up landing after dark and headed to St. Damien's Pediatric Hospital, where I'll be rotating. I imagine the distance was not very far, but the stop-and-go traffic made it seem further. We eventually arrived.

I was greeted by Sister Judy at the entrance of the hospital and met the two attendings and residents from Brown University that I'll be staying with, who have agreed to take me under their wing for a couple of weeks.

Recently the hospital upgraded from canvas tents to prefabricated houses. The prefabs each have three rooms with a small communal space and bathroom. Oh--did I mention they are air-conditioned? (The only such place in the hospital.)

As with any working communal living situation, I was told of the short list of house rules and also told that this side of the house was against the labor ward, so to expect screaming at all hours of the night.

Nevertheless, I had a great first night's sleep.

On the following morning I got to work and began with observing the triage process. Patients begin assembling at 0645a.

From triage, patients are sent to various places depending on how they look, their chief complaints, and their temperature.

Some are sent home with Tylenol, others sent to the adjacent clinic to be evaluated, others are sent for further triage, to the malnutrition unit, or to the cholera tent, if they have severe diarrhea.

The sickest are sent directly to the emergency department. I am told this triage process continues throughout the day. 

The services are free.

The hospital, which serves kids 3 months to 12 years old, is a complete pediatric hospital with OR, Lab, XR, blood bank, NICU, an ICU (Critique), wards, oncology (the only such unit in Haiti) and ED (Urgents).

I will be spending most of my time in the Urgents, which also functions as a extended-stay unit; after evaluation, they may stay for several hours or for days.

The mornings are spent rounding, first on the patients who are boarding in the Urgents, then with the new patients.

Mostly we are seeing meningitis, pneumonia, sickle cell crisis, malaria and other tropical diseases. Mixed among these are the more routine pediatric admissions.

I've been spending the mornings this week working in the general wards. Each room has a name that corresponds to the painting outside it, so today I was in Balloons and Watermelon.

Each room houses around ten patients. Each day there are a couple of new patients who made it up from the Urgents. My rooms had kids with chronic heart disease, sickle cell, meningitis, and pneumonia.

January 10th marked the second anniversary of the Haiti earthquake.

You can see evidence of the destruction in the adjacent buildings and on the patients who have scars or are missing limbs.

I am told a large ceremony was held that day at the hospital. Saint Damien's was built in the early 2000s prior to the quake and, due to its Italian engineering, sustained minimal damage.

I am told there were some cracks in the cement walls. Most have been repaired, but in one hallway, they have left the damage exposed as a mural of remembrance.

Dr. Muthyala Checks In From Arusha, Tanzania

Kilimanjaro, as seen from Mount Meru

20/12/2011

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

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

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

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

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

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

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

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

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

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

Then back to rounds.

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

Brian

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

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

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

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

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

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

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

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

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

Ajinapa village; more children to screen for G6PD

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

Ilota village school

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

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

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

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

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

Photo courtesy Google Maps and Wiki Commons

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

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

This warrior fought with and beheaded Elemoso.

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

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

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

Dr. Tundun Williams - Week 1 In Lagos, Nigeria

Lagos is home to over 7 million people who call themselves "Lagosians". They are kind of like the New Yorkers of Nigeria. They dress to impress, drive... how shall I put this...purposefully, and are all vying for a bit of the wealth that is for the making in this city which remains the business capital of Nigeria.

Lagos is inhabited by the uberrich, who live in sprawling mansions on gated estates, as well as the destitute, who make do in shacks that house up to four families and have one communal bathroom.

To say that the wealth in this city is unequally distributed is stating the obvious.

I spent the majority of my time this week at the Massey Street Children's Hospital, a government-run pediatric hospital in inner-city Lagos.

I soon learned that the action at Massey was in the ED, a two-room facility on the second floor of the outpatient building, which was located across the street from the inpatient department.

After nearly losing my life trying to cross the street while dodging public minivans (danfos), three wheeled cabs (maruwas) and motorcycles (okadas) on my first day at Massey, I mastered the art of road-crossing in Lagos, which consists of venturing forth at a time when the road is relatively clear and then holding your ground in the face of any oncoming traffic until you are given the right of passage. You must show no fear.

The in-patient building at Massey

The busy street between the two buildings at Massey

The doctors in the ED were glad to have me on board. Part of the art of practicing medicine in the developing world is learning to improvise, and improvise I did. I performed an LP on a 6yo with a 20-gauge needle (stylet, schmylet), used the elastic band on the bottom of a pair of gloves for a tourniquet and did many other things that would never have crossed my mind in the US. 

I saw several cases of very classic kernicterus, a case of cholera and malaria galore.

Since Massey is a government-run facility, basic supplies like gloves, IV cannulas, syringes and needles can be obtained for free from the hospital pharmacy with a doctor's written prescription.

If the pharmacy happens to be out of stock, however, patients are responsible for purchasing their own supplies and bringing them to the hospital. The cost of medical care can be mammoth and is one of the factors that prevents the average Nigerian from seeking timely treatment.

Inside Massey's ED

A toddler at Massey with left lower lobe pneumonia. The cuts had been made in his village when he started coughing and then complained of abdominal pain.

When I was not at Massey, I pitched in to help Tina (Slusher) with her sunlight phototherapy study. At the end of this week, I will head to the small town of Ogbomoso, where I will be spending the majority of my time.

Dr. (Henk) Vreman and his helpers setting up the sunlight phototherapy tent frame

Down time at an ice cream parlor

Andy Keenan: A Day At Selian

Fourth-year Medicine-Pediatrics resident Andy Keenan is currently abroad in Arusha, Tanzania, completing a month of peds and a month of internal medicine at Selian Lutheran Hospital. Here's his most recent blog entry:

Things are going great here in Arusha, albeit with unpredictable internet.

Selian is a small hospital just outside the village of Ngaramtoni, near the town of Arusha.

It is a semi-private entity that receives support from the Lutheran Church and the Tanzanian government. Among the hospitals in Arusha, it does not offer as much subspecialty care as Arusha Lutheran Medical Center (ALMC), but often acts as a referral center from small local and regional hospitals.

The hospital is made up of a number smaller buildings, with an administrative offices, outpatient/casualty, pediatric/adult medical ward, OB/GYN ward, surgical ward, radiology, and a number of other smaller buildings for support services and living areas.

Each day starts with chapel at 0815. Some people skip this, but it's a good way act as a part of the hospital staff, and you'll get some good Swahili practice. It's also a great place to find people in the morning.

After chapel, there is morning report in the same building. They usually briefly review the hospital stats (admits, discharges, transfers, deaths), and admissions from the night before.

More complicated admissions are discussed in some detail. This can get sometimes get pretty animated, and is usually conducted in English. It can be a good time to learn about management styles, and the staff here are generally interested in resident input, as well.

Occasionally MR is followed by a presentation by one of the attendings, interns, or other staff.

Usually after MR we'll go over to the radiology building to review x-rays. It's a pretty open format, and they will often ask us to read the films. I hear the term "micro nodular" a lot.

Rounding can vary widely depending on who is present, what you view your role as, and several other variables that I have not been able to define for myself yet.

Usually the team is made up of an intern, a doc who has finished internship and is working in that department (senior medical officer), and an assistant medical officer (somewhat similar to a PA here).

Like in the U.S., the level of knowledge for interns can depend on the time in their training cycle and interest in the given specialty. They are my main resource for how things get done in the hospital.

The senior medical officers are also an excellent resource. Many of them have an interest in eventually pursuing specialty training in their field, so they are great to work with.

The assistant medical officers (AMOs) have a wider range of clinical skills. I've been told that many were initially trained to primarily manage common infectious diseases, but that their scope of care has increased significantly.

Some AMOs are among the longer-standing medical staff of the hospital.

When a patient is admitted, they come through Casualty, where they are evaluated by an AMO (usually) or intern (occasionally), who starts the initial workup and management, with the ward or on-call intern to review after admission.

This is where you can find the age and weight. The weight is especially important, as there is not a functional scale in the Peds ward. Often under DOB it just says the year, which can be a challenge when coming from the Peds side and it just says 2011. With the prevalence of malnutrition it can be more difficult to eyeball the age based on the size and development stage.

After evaluating the patient, the orders and documentation are done on the fly. Usually the nurse is updated on any changes or discharges, and you move on.

After rounds, the schedule gets a little more variable.

Most of my regular duties are on the wards, which are usually done by 12:00 or 1:00. My team (intern) is on the hook for reviewing admissions until 1530 when I'm not on call. Some post-rounding options are clinics, ultrasound, heading over to ALMC, or working on research.

The bus driving back in to town usually leaves between 3 and 4 in the afternoon. Given the challenge with getting back in another manner, I have been arranging my schedule to allow for this.

That's a day at Selian!

A memorable week in Bolivia

Dear all,

I've now been in Bolivia for six weeks, and the last one was certainly memorable.

I'll get the negatives wrapped up fairly quickly:

1. 
   My driver's license was confiscated by Bolivian police because I wasn't carrying the hard copy of my passport when I traveled between Cochabamba and Oruro, but fortunately I reclaimed it after a tense encounter at the station.
2. 
   My wallet was confiscated by parties unknown in Oruro during the Carnaval festivities after I had foam sprayed in my eyes and was shoved from two directions. Unfortunately, the money was not reclaimed, but fortunately I was able to cancel my credit and ATM cards before anyone tried to use them. And fortunately Rachel was able to help me out via Western Union.
3. 
   I decided to drink juice of "canela" at Carnaval. When I got to the bottom of the glass, I realized that it just didn't taste right. Evidently my intestines agreed, and they protested vigorously for the next 6 days.

So my moral of the story is--"When you go to Oruro, bring your passport but not your credit card, wear a money belt, and consume only saltine crackers and Coca Cola."

Or just don't go.

Despite the above challenges, I am still enjoying my time here.

Before the Oruro fiasco, I accompanied one of the MAP teams to the village of Morochata, where I had previously failed to get to during heavy rains.

I observed and participated in a workshop where the staff of Morochata Hospital (functionally, a community clinic) learned about how to help parents take care of children with developmental disabilities.

The MAP team, "Aprendiendo de las Diferencias" (Learning about Differences), focuses on eliminating the stigma that often makes children with physical and intellectual disabilities second class citizens in their families and in society.

The team also wants to empower families to be the best caregivers and therapists they can be in order to maximize their child's potential.

During the workshop, I also demonstrated the maneuvers to evaluate for congenital hip dysplasia in neonates, though my model was a grown man.

On the other weekdays, I have continued to see patients at the clinic in Chilimarca. Thus far, I have seen over 260 patients, including many well child checks, respiratory and diarrheal illnesses, musculoskeletal injuries, and even a case of Bell's palsy.

Miguel, my last preceptor in the clinic, is no longer working there as of last week.

Instead, a new doctor named Gustavo started on Wednesday. However, on Friday he, too, was unable to come to clinic because of a renewed transit strike (giving me the opportunity to see 26 patients on my own, including 17 well toddler checks in a 2-3 hour span).

At this point, I have no idea whether the strike will still be on tomorrow. The issue is that the drivers want to raise the fare, but the people don't want the fare raised.

The drivers have a valid point--the price of gas is going up, the price of everything else is going up, they aren't able to make money at the current rate.

The people also have a valid point--they don't want to pay more.

Thus, the literal impasse--complete with road blockades on the weekdays.

Personally, this hasn't affected me as much because I live right next to the clinic. But it is wreaking havoc on schools, offices, clinics, etc.

The plan for Monday is to attend the weekly MAP team meeting and then get oriented at the Center for Children Who Have Been Victims of Sexual Abuse (CUBE). We will be doing health maintenance there later in the week.

With luck, transit will cooperate; otherwise, I may stay behind in the clinic. For the next couple of weeks, I'll be doing more rotating around the various MAP programs, pitching in where I can.

This past weekend, I went to the village of Tuini Grande, which, despite its name, is very small.

It is a very rural area past Morochata in a rugged and hilly landscape that is beautifully green (thanks to the last two months of rains).

I participated in a workshop about sorting trash into organics, combustibles, and toxics, and the MAP capacity-building team is going to go back in 2 weeks to help the community organize a clean-up and waste assortment effort.

We stayed at the home of Asunta, a health promoter I've written about previously.

She is a pretty amazing woman who does just about everything--gardens and farms, raises chickens, runs a knitting workshop, oversees efforts for water filtration and latrine use in her village, and provides health care to the children and adults in her community.

I can now also attest that she is an excellent cook, which was extremely necessary since we hiked 3 hours uphill to her village yesterday from the nearest accessible road.

(Incidentally, within the first 10 minutes of that hike, my left leg went knee deep into the mud, suggesting that I should spend more time looking at the ground than the gorgeous scenery.)

I continue to be impressed and humbled by many of the Bolivians around me who are working so tirelessly for their communities.

In some small way, I hope to approximate their energy and approach in the future. I am doing well, and owe that mainly to the help of my neighbors Emilio and Ada, who ensured my safe return from Oruro, loaned me money until Western Union came through, helped me get my driver's license back, and have been nothing short of guardian angels.

Big thanks also to my supportive family back home. Unfortunately, today's friendly internet cafe computer lacks a USB drive, so I am unable to share with you my most recent batch of photos. I will try to send them soon.

Much to my delight, Rachel gets here in one week and she'll spend several days seeing each of the programs here (clinic, school, CUBE, Capacitation, Learning about Disabilities) before we embark on a week of vacation around La Paz and Lake Titicaca.

Thank you for reading along.

I wish I could better capture my day to day life here. The last couple of weeks were good for me in that I am not romanticizing my experience as much as I was initially, but I still very much appreciate the opportunity to be here and to see an integrated model of health promotion in a resource-poor setting in action with all its incumbent challenges.

Being here has definitely been a transformative experience for me, and I hope to be a better doctor and friend when I return.

Best to all,

Brian