She sauntered into the exam room like the twenty or so patients before her. At first shocked to see white skin, but, let's be honest, she had already heard about the blan at the clinic from the community. Her dossier was limited and very much in Kreyol. Name. Date of birth (she actually knew hers). Her place of residence. And whom was responsible for her. Probably not as applicable to this twenty six year old, but obviously important for the "timoun" (children) we see in clinic.
"Sa gen?" John starts off, knowing me well enough that he can go ahead and get the encounter started without me saying anything. "Oh tet fe mal... vant fe mal... la gripe..." She went on. John knows he doesn't have to interpret the basic stuff for me, but does so out of professional courtesy. I begin in with my exam. Head looks pretty normal. Eyes are normal and her conjunctiva are pink. Teeth are rough, but better than most. Ears are clear. Neck is supple with a few smallish lymph nodes, likely from her teeth. Her heart is regular and her lungs are clear. Hmmmm, her abdomen is a little more plump than normal. Like, American plump. "Ou ansent?" She smiles sheepishly. "Wi." "When was your last period?" John rattles off the Kreyol version. You'd think after all this time I would know that phrase. "Nine months ago." I pull out my iPhone and when she offers the actual date I plug it into my OB wheel app. She's 32 weeks and 2 days. "Are you feeling baby move?" She says yes. #FunFact I've had women in Haiti tell me they've felt movement at 12 weeks. #JustGas
"Konbyen fwa ou ansent?" "Twa fwa." I feel around on her abdomen trying to locate the uterus. I look through her patient chart and find two other visits documented during this pregnancy. One in June and one in September. Interestingly enough neither documented heart tones. She's on the chubby side even for an American woman, so I'm struggling to find a defined uterine fundus. Hmmm... I grab the doppler and flip it on. Nothing. I smack it. There's the static. I place it on her abdomen and start searching. Mom's... Mom's... Mom's... Nothing over 80 beats per minute. She's still smiling. Dr. Ulysse is sitting at the desk behind me and I call her over for assistance. I ask the patient if she's had any bleeding this pregnancy. "Wi." At five months along she had two days of bleeding but it stopped and hasn't recurred.
Dr. Ulysse palpates the patient's abdomen aggressively and looks over at me. "Li pa ansent." And she laughs. She rattles off a lot of Kreyol to the patient that leaves me completely lost. The patient's demeanor never waivers. I finish my clinic note as the patient exits.
There are a number of things I would be doing right now if this situation were happening in the states. First, we just told this patient that she likely miscarried. That is relatively devastating news to some young women. But in Haiti it's just, "You have a cold." or "You lost your pregnancy." and the world keeps turning. From a medical standpoint I would order both a urine and a serum hCG test. I would order a transvaginal ultrasound if either of those were positive. And I would check the patient's blood type and antibody status. Typically we have a sono in the clinic room with transabdominal probes, but not this trip. It's getting repaired and/or replaced in Port-au-Prince. Also, turns out, we don't have any urine pregnancy tests available. This was the fifth patient who came in reporting a missed period that I couldn't tell was pregnant or not. Generally it's okay to write for a month's worth of prenatal vitamins and have them come back to the clinic for either the pregnancy test, a sono, or both. However, in this particular case the test was relevant as she could have retained fetal parts.
Dr. Ulysse and I settled on making a referral for ultrasound in Port-au-Prince. But this brings to light a much larger issue - needed supplies. I had no clue that we were out of such a basic test or else I would have been freaking out every walgreenns clerk in Wichita because some random dude would be buying handfuls of urine pregnancy tests. Instead, I brought several vials of local anesthesia and a few IV start kits that I had accumulated during my shifts at Wesley hospital. Turns out the clinic is loaded up with both of those things, and my contributions will likely expire on a shelf.
I've had several people send me supplies to take down on my trip and they are absolutely wonderful. I couldn't thank them enough for their generosity. And I've never had this sort of instance come across, but several stories of #AidGoneWrong exist in our world of nationally broadcasted disasters. Whether we are talking about Hurricane Sandy devastating the U.S. Eastern seaboard or a giant tsunami striking the coast of India, people are aware of the devastation immediately (thanks Twitter #Hashtag) and feel compelled to contribute. But when people are sending Hurricane Sandy collection centers their tattered clothes that they've been meaning to throw out for years then something is amiss. Old Halloween costumes and half used scented candles have also made the list of less-than-helpful donations.
WTF were people thinking? I know it's easy to get swept up in the desire to "help" but at some point you gotta ask yourself, "How is my gift going to be used? Is there an active need for this donation? Would it be more efficient to contribute cash? What larger implications could my gift have (i.e. am I going to impair a local business or economy with a donation)?" #CashIsKing in most places. Haiti, not so much all the time. But certainly I've learned that I can buy school supplies down here for cheaper than the states. I can buy toothbrushes and toothpaste for very reasonable prices, even with the "blan tax". Medical supplies are so hit and miss that I would hesitate to rely on buying those specialty items in country.
But it's no secret that countries like Haiti are heavily reliant on foreign assistance. This could be direct aid to the government as well as NGOs operating with donations from generous civilians. Certainly both ServeHaiti and CHI couldn't operate without the generous contributions of donors and volunteers. This entry isn't to request donations, but it is to encourage you to choose wisely how you donate. Although it is probably inefficient, I always suggest personal travel. The experiences you glean have the potential to change you. But for some travel isn't feasible. So I encourage anyone interested in "helping" to pray on their decision and ask themselves the questions above. If I had asked the right people the right questions I could have provided better care to the patient instead of dropping off more clutter.
Friday, November 13, 2015
Monday, November 9, 2015
Gratèl
Gratèl. Gratèl. If yesterday was the day for obstetrics in clinic then today was the day for rashes. One after another. Moms bringing in their little boys and girls with various skin conditions. Pitiriasis versicolor. Scabies. Impetigo. Eczema. It was enough to make me an unofficial dermatologist. Although I am horrible at trying to identify rashes. Especially the erythematous rashes on dark skin. There's no erythema! If you're lucky you can see a faint purple hue to the skin, but that's the extent of the color change.
The first patient was actually an adult male. He was 24. But he was here with his mom. #SeparationAnxiety #PeopleProllySameTheSameThingAboutMe His main complaint was dizziness and what I perceived to be near syncope when changing his position. Near syncope is that feeling where you get a little tunnel vision, your legs get wobbly (wobble baby wobble baby wobble baby wobble), and you feel like you might pass out. It's a super common complaint both in Haiti and the U.S. #FunFact people don't bwe enough d'lo. If you're dehydrated, it's tougher on your pipes to keep that blood flow and maintain the pressure of the blood feeding your brain. No brain flow and obviously you're gonna pass out. Kinda protective in a way if you think about it. If you pass out because your body can't get blood to flow to your brain, then by being on the floor you eliminate the force of gravity. So cool. But he was fine. It was 1 pm and he hadn't peed all day. #SignPost I obviously did the mature thing in my counseling... I told him mom to make him drink more water. I tossed in a script for iron pills because he seemed a little anemic, but that was more to keep them coming back. His story is only relevant because he had such an impressive display of tinea versicolor on his trunk. I just happened to catch it, but it was diffuse hypopigmented coalescing patches with annular borders and slight scale. It's a harmless rash, but from a nerd standpoint it's really cool to see under a fluorescent light (No clubbing for this guy).
Then came the scabies patients. You can just see them scratching themselves in the waiting room. Digging their nails all over their trunk, axillae, arms, legs... basically anywhere they can reach. You just have to wonder what the patients next to them are thinking as they share the bench. No, "share" offers a poor mental picture of the reality of the clinic waiting bench. It's like when you have four friends for two seats at the football game, but everyone's standing, so you think you can get away with it. Well, imagine if everyone in the row did that. And now think about that first TV timeout when people go to sit down and suddenly it's getting really cosy. That's what the clinic bent is like. Nothing is off limits either. Breastfeeding. Coughing. Contracting. Bleeding. Vomiting. Eating. All in the comfort of your neighbor's lap.
I really tried to talk myself into thinking one was pityriasis rosea, but just to make sure I consulted with Dr. Ulysse and she just looked at me like, "Are you stupid? This is scabies for sure." Fine. #CommonThingsAreCommon #DiagnoseWhatYouCanTreat so he got a topical agent to try and eliminate this parasite from his skin. One problems. It's a really complicated set of patient instructions. And it's one of my biggest frustrations with Haiti. Compliance in the U.S. is like 10%. That's right. Those of you out there thinking, "Well, he's certainly not talking about me!" How many times has your doctor prescribed you dietary changes and exercise? Stretches instead of pain pills for muscle aches? Rest for sore joints? Avoidance of stress and meditation for anxiety and depression? Avoidance of caffeine and screen time before bed for insomnia? And have you ever missed a dose of your meds? If people did everything doctors said at 100% then we'd have no patients.
But to sit and try and instruct a mom, who prolly has to take care of like four other people in the household (conservative estimate) and just hiked two hours with an itchy, infested toddler on her hip, on how to make wash the patient, cover them in this medication, and then repeat it for two more days, and then wait a week and repeat it once again, and oh by the way boil any sheets, toys or clothes that could have come in contact with the kid.... Ugh #RunonSentencesAreFun Speaking of fun... Mom, you should probably repeat the process with everyone who has shared a bed, or been in close contact, with the patient. She literally laughed at John when he finished the instructions. And God bless John. He's give "my" instructions on scabies so many times he doesn't even need my prompt. He does it all on his own and I can trust what he's saying. #GivesMeMoreTimeToDocument #ThatsKindofAJoke We even tried the Ebberwein "Teachback" method (I'm sure he has a patent on it), but it was an epic fail. Oh well, it was our last patient in a rather tumultuous clinic day and I had to go to the bathroom. #WellHydrated
With such a large team here I never know which restroom is gonna be open, but I found the one in the guys' bedroom vacant. Now, if you've ever cared for a patient with an itchy rash, especially if you suspect some sort of infection as the etiology, you get just a little itchy yourself. And sure enough, I had held this boy with scabies in an effort to build some rapport and by now... My shoulder blades were squeezing together a little... I was swinging my head down to rub my neck and shoulder together... Just feeling a little creepy crawly. Even as I type this the same crawling sensations are running over my skin. It's expected. You know it's going to happen. And even though you know you didn't contract whatever infectious rash afflicted the patient you just can't help it. But as I stood to use the restroom I couldn't help notice a new sensation. No, it wasn't burning when I was peeing. It was on the outside of my left arm... in several places. My hands were a little occupied, but I tried to shake the sensation out of my left arm and dismissed it as paranoia. And then I looked down. And sure enough, three little mites, or bugs, or something were crawling all over the amazingly well-defined tricep area of my left arm #HaitiFit #SarcasmAgain.
WHAT DO I DO?! I can't swat at them because I'd lose control and spray the floor. I tried to hold the stream, but I couldn't. WHY DO I HAVE TO BE SO DAMN HYDRATED?!!? It was torture. Seconds felt like hours as I just knew those things were making their way to what they saw as a permanent home. Burrowing under my skin and building a mantle place to hang all of their family photos. "Quickly... Quickly... Quickly..." I thought, as my stream started easing up. Kegels, ENGAGED!! And as soon as I felt control, my right arm went flying around and smashed my new hitchhikers. #CrisisAverted #StillMightTakeAScriptForIvermectin... #IStillFeelItchy
The first patient was actually an adult male. He was 24. But he was here with his mom. #SeparationAnxiety #PeopleProllySameTheSameThingAboutMe His main complaint was dizziness and what I perceived to be near syncope when changing his position. Near syncope is that feeling where you get a little tunnel vision, your legs get wobbly (wobble baby wobble baby wobble baby wobble), and you feel like you might pass out. It's a super common complaint both in Haiti and the U.S. #FunFact people don't bwe enough d'lo. If you're dehydrated, it's tougher on your pipes to keep that blood flow and maintain the pressure of the blood feeding your brain. No brain flow and obviously you're gonna pass out. Kinda protective in a way if you think about it. If you pass out because your body can't get blood to flow to your brain, then by being on the floor you eliminate the force of gravity. So cool. But he was fine. It was 1 pm and he hadn't peed all day. #SignPost I obviously did the mature thing in my counseling... I told him mom to make him drink more water. I tossed in a script for iron pills because he seemed a little anemic, but that was more to keep them coming back. His story is only relevant because he had such an impressive display of tinea versicolor on his trunk. I just happened to catch it, but it was diffuse hypopigmented coalescing patches with annular borders and slight scale. It's a harmless rash, but from a nerd standpoint it's really cool to see under a fluorescent light (No clubbing for this guy).
Then came the scabies patients. You can just see them scratching themselves in the waiting room. Digging their nails all over their trunk, axillae, arms, legs... basically anywhere they can reach. You just have to wonder what the patients next to them are thinking as they share the bench. No, "share" offers a poor mental picture of the reality of the clinic waiting bench. It's like when you have four friends for two seats at the football game, but everyone's standing, so you think you can get away with it. Well, imagine if everyone in the row did that. And now think about that first TV timeout when people go to sit down and suddenly it's getting really cosy. That's what the clinic bent is like. Nothing is off limits either. Breastfeeding. Coughing. Contracting. Bleeding. Vomiting. Eating. All in the comfort of your neighbor's lap.
I really tried to talk myself into thinking one was pityriasis rosea, but just to make sure I consulted with Dr. Ulysse and she just looked at me like, "Are you stupid? This is scabies for sure." Fine. #CommonThingsAreCommon #DiagnoseWhatYouCanTreat so he got a topical agent to try and eliminate this parasite from his skin. One problems. It's a really complicated set of patient instructions. And it's one of my biggest frustrations with Haiti. Compliance in the U.S. is like 10%. That's right. Those of you out there thinking, "Well, he's certainly not talking about me!" How many times has your doctor prescribed you dietary changes and exercise? Stretches instead of pain pills for muscle aches? Rest for sore joints? Avoidance of stress and meditation for anxiety and depression? Avoidance of caffeine and screen time before bed for insomnia? And have you ever missed a dose of your meds? If people did everything doctors said at 100% then we'd have no patients.
But to sit and try and instruct a mom, who prolly has to take care of like four other people in the household (conservative estimate) and just hiked two hours with an itchy, infested toddler on her hip, on how to make wash the patient, cover them in this medication, and then repeat it for two more days, and then wait a week and repeat it once again, and oh by the way boil any sheets, toys or clothes that could have come in contact with the kid.... Ugh #RunonSentencesAreFun Speaking of fun... Mom, you should probably repeat the process with everyone who has shared a bed, or been in close contact, with the patient. She literally laughed at John when he finished the instructions. And God bless John. He's give "my" instructions on scabies so many times he doesn't even need my prompt. He does it all on his own and I can trust what he's saying. #GivesMeMoreTimeToDocument #ThatsKindofAJoke We even tried the Ebberwein "Teachback" method (I'm sure he has a patent on it), but it was an epic fail. Oh well, it was our last patient in a rather tumultuous clinic day and I had to go to the bathroom. #WellHydrated
With such a large team here I never know which restroom is gonna be open, but I found the one in the guys' bedroom vacant. Now, if you've ever cared for a patient with an itchy rash, especially if you suspect some sort of infection as the etiology, you get just a little itchy yourself. And sure enough, I had held this boy with scabies in an effort to build some rapport and by now... My shoulder blades were squeezing together a little... I was swinging my head down to rub my neck and shoulder together... Just feeling a little creepy crawly. Even as I type this the same crawling sensations are running over my skin. It's expected. You know it's going to happen. And even though you know you didn't contract whatever infectious rash afflicted the patient you just can't help it. But as I stood to use the restroom I couldn't help notice a new sensation. No, it wasn't burning when I was peeing. It was on the outside of my left arm... in several places. My hands were a little occupied, but I tried to shake the sensation out of my left arm and dismissed it as paranoia. And then I looked down. And sure enough, three little mites, or bugs, or something were crawling all over the amazingly well-defined tricep area of my left arm #HaitiFit #SarcasmAgain.
WHAT DO I DO?! I can't swat at them because I'd lose control and spray the floor. I tried to hold the stream, but I couldn't. WHY DO I HAVE TO BE SO DAMN HYDRATED?!!? It was torture. Seconds felt like hours as I just knew those things were making their way to what they saw as a permanent home. Burrowing under my skin and building a mantle place to hang all of their family photos. "Quickly... Quickly... Quickly..." I thought, as my stream started easing up. Kegels, ENGAGED!! And as soon as I felt control, my right arm went flying around and smashed my new hitchhikers. #CrisisAverted #StillMightTakeAScriptForIvermectin... #IStillFeelItchy
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