Elizabeth asked me, “So are you learning more than you ever thought?” The answer will be yes every time. However, today it’s more focused on public health operations, both the victories and the struggles.
A huge victory is how organized things are. So far, clinic has run smoothly. Our interpreters are very helpful and triage has been on point. They are all ready to be fully assessed by the time they get to us as providers. I definitely feel like the rate limiting step is me though! I feel a little annoying asking Steve and Shelly questions every 5 minutes, but they are of course gracious and willing. Hopefully by the end of the week or even mid-week, I’ll have the guidelines and the return cards nailed.
The medicine here is definitely more consistent with what I’ve learned about medicine in the developing world. I almost feel a little spoiled having worked in Jamaica – I thought they had very little there, but there is even less to go around here. This makes the guidelines so important. They help us make clinical decisions better and allocate resources so judiciously. In my clinic at home, I’d definitely get an A1c every 3 months on someone who had fasting sugars of 180. In Haiti, there’s just no way. A1c’s are saved for those who have persistently elevated sugars – if they have 2 A1c’s over 12, they are discharged from their DM care; the rationale for that is when their A1c’s are that high, they will need insulin treatment, which we can’t do. The guidelines state we should not do partial treatment either, so we can’t provide oral meds either. A few folks use this as impetus to improve their lifestyle and get their sugars down.
The most major medical difference I’ve noticed today has been the maternal/infant morbidity and mortality. We saw a 6 mo old baby who had severe hypoxic ischemic encephalopathy. Mom had been in labor for 2 days; eventually she delivered, and somehow survived, but baby has been severely brain damaged. I saw a baby whose mom had died in childbirth, which was really uncommon in Jamaica.
It’s interesting to see what people’s affects are. Some appear bright, happy but a lot seem to be flat, almost beaten down by life. I’m fearful of what their home lives must be like. Everyone is chronically dehydrated because of limited safe drinking water for citizens; I wonder if that contributes at all. Almost everyone has headaches, none of which have been concerning yet.
9/13: Day 3
I saw some sicker folks today. Two adults had TERRIBLE asthma, and all we could really do was give them inhalers and oral steroids. One lady definitely improved with a DuoNeb, but she still sounded AWFUL. Thankfully their pulse ox’s were normal.
I saw another elderly lady with a carotid aneurysm. Nothing to do for this fairly high mortality situation. She was so sweet, which makes it hard to know there is nothing you can do for her.
I’m definitely getting a re-education in peds as well. I can’t say that I’ve heard a heart murmur in a baby since 3rd year of med school; today I heard 2 pretty impressive ones. Thankfully, they were most likely VSDs and will resolve on their own. That’s what I hope anyway – there is no other intervention available.
More disturbing were the actual sick babies. I saw one baby today, a 2 month old, who had almost no muscle tone. She was a chunkster but had an unusual roll – a pronounced nuchal fold. I had Dr. Trainor take a look at her and we agreed she had a syndrome. We’re not sure which, maybe Turner’s, but there’s not much to do about it anyway. We told mom that if she still was weak (our translation for hypotonic) when she’s older, she can go to the nearby clinic that treats kids w/ CP with PT/OT type services.
There was a very sweet little girl with sickle cell who mom states “had a heart attack.” In her dossier (but on only 1 page), it stated she had a history of MV failure. She didn’t have that distinct of a murmur, but she had impressive hepatomegaly with possible mild scleral jaundice. Considering everything she’d likely been through and everything she possibly COULD go through, she was still bright and seemed happy. And very ticklish????
As I just re-read what I’ve written, I noticed I said some version of “there’s nothing we can do” so many times. I’m definitely not used to this and I found myself frequently slack jawed throughout the day, and let’s be clear, I loathe that feeling. I like to have all the answers and right away. Even in Jamaica, we could at least refer people to the local hospital in Montego Bay, which offered a fair amount of services. There really is just nothing available here. No chance at radiology, specialists, cardiothoracic surgery. We don’t fix umbilical hernias in kids here – it’s not a wise use of resources since per our surgeon, they rarely cause problems, even past 2 years old.
However, this makes the healthy people, particularly the kids, so much more miraculous. For example, the 3 mo old twins I saw who were MEGA chubby. Mom was breastfeeding like a champ, the babies were happy, developing well and well above average for growth. Another fat and happy baby I saw had polydactyly – 6 fingers on each hand! One was sticking straight out medially. He didn’t mind though – he still gave me several huge, toothless, drooling grins.???? It’s certainly not helping my baby fever at all….
At the end of the day, I also have to reflect on our team’s camaraderie. None of us could do this alone. I know it’s been a somewhat steep learning curve, even having done 2 medical service trips before. It’s such a gift to have a multidisciplinary team, especially given all the weird pediatric issues I’ve been seeing. I’ve definitely relied on the other providers a lot in the last few days.
Ultimately, it’s ridiculously hot and humid, the bugs are in my grill, but I’m so lucky to be here.