Week 2: Fresh, Clean Water and Nutritious Food

I spent my second week of my Haiti experience in the outpatient pediatrics clinic. Overwhelmingly, the cases were centered around the need for reliable sources of nutritious food and clean water. I saw many ramifications of that in the form of intestinal worms and kwashiorkor malnutrition. Also, almost every kid had terrible tinea capitis. This meant a lot of referrals to the (soon-to-be rebuilt) nutrition center for children and prescriptions for mebendazole, griseofulvin and metronidazole. After being pleasantly surprised by the relative luxuries that the town of Milot had in terms of availability of fruits in the mountains and fresh water, I was shocked to see how many children came in with distended bellies and no weight gain over the course of months to years with "failure to thrive" as the tumbled off their growth curves. In some cases, new mothers didn't even know how often to breast feed their children thinking that their children needed more sleep and would only feed 4-5 times a day. It needs to be closer to 10-12 times per day! That made me wonder if the babies would initially cry from hunger and then after a period of dehydration and weight loss, decide to conserve that energy and just sleep most of the day. It was also in the small single pedi clinic room with three other providers, a Haitian pediatrician, a Haitian resident (here for his year of social service) and a nurse practitioner from the States that I learned how History taking could be a team effort. Quite often, while I was talking with my patients, the pediatrician would interrupt my translator or whip around with a chastising voice and lecture the mothers about their children for five minutes in the middle of her own clinic visits. I'd watch the exchange, initially amused by the response to my (what I thought of as) fairly benign questions and advice. And when pressed, my translator would simply say "they disagreed with my translations." Sometimes women seemed reticent to offer their opinion on the medical situation unfolding. Other times, the translator or resident would chuckle at their responses and tell me "they think it is a Haitian thing." It took me a few days to realize that this actually meant that there were non-Western beliefs at work; Voodoo beliefs that the patients or their parents held and in some cases, delayed care in deference to voodoo ceremonies or treatments.

Week 1: Tdap, PPDs, and STI screening/_Counseling Needed!

We had an awesome urology team from FL and NJ, some stellar RN students from UCSD and a wonderful cardiologist+sonographer team who were volunteering at the hospital with us this past week.

I was stationed mainly in the outpatient clinic which was more like a walk-in urgent care day, but there were a surprising number of patients who came in for med refills for hypertension or mild acute complaints.  There was also some urgent/emergent care, wound care and urology mixed in-between clinic sessions.  Many of the wounds that I helped some of the nurses with were from motorcycle accidents and we opined the lack of resources for routine Tdap prophylaxis after routine injuries.  Children are vaccinated nowadays, but some of the adults have developed mortal cases of tetanus.

Here are some of the cases that I was involved in during my first week.


Cardiovascular/Pulmonary
Dilated Cardiomyopathy CHF with severe mitral regurgitation (mimicking as "asthma")
Active Pulmonary TB (pretty much all the PPDs I ordered for suspicion of TB were 20mm in size or greater)

ID
Testicular mass - massive hydroceles due to chronic filiriasis
Lymphatic filiariasis (Elephantiasis) of the legs
Cervicitis/UTI/pyelonephritis
Tetanus -- mild and severe manifestations (with neck stiffness and muscle spasms vs risus sardonicus and trismus/lockjaw)
Spinal compression fracture with cord compression due to Pott's disease with subsequent spasm and paralysis of the lower limbs

Derm
Tinea versicolor
Acne keloidalis nuchae
Cellultitis
Full thickness circumferential burn injuries

GI
GERD
H. Pylori (80-90% prevalence in Haiti, apparently!)

Heme/Onc
Severe anemia (Hgb drop from 7 to 4.7 in two days!) due to leiomyomata of the uterus (negative pregnancy test but had a 20 week size uterus!)
8x8cm Breast mass -- likely due to phyllodes tumor in adolescent, hopefully it turns out to be fibroadenoma

Urology
Penile reconstruction s/p explosive trauma (a bovie explosion during an elective circumcision)
Emergent secondary pseudophimosis due to a young boy slipping a metal washer around his glans (with acute swelling!)

Our evenings were filled with case presentations on some of the more interesting and pertinent primary care topics.
I didn't get to do much pediatrics, ED care or HIV/infectious disease, but I still have a few weeks to go!  There are still a few residual cases of cholera and I'm glad that my stools have held firm thus far.

And on that pleasant note, I'll be signing off!
CP.

Bonjou! Komon ou ye jodiya?

I traveled across the turquoise waters of Turks and Caicos on 1/12 and flew across the dark blue yonder.  A verdant delta emerged through the mists as we approached Haiti.  There were numerous small rowboats, speckling the waters below and we sailed across a landscape of concrete walled homes with rusted corrugated roofs.  I continued to peer intently out the window of this new land.   A cannibalized prop plane lay abandoned on the side of the runway.  We taxied over to a small airport/shed where our bags were collected into two trucks and we zipped down a paved road through Cap Haitien.

The colors of the small homes were bright with plastic detritus scattered across the landscape.  Trucks with wooden backs called "Tap-taps" were piled full of people in the cab and hanging off the back.  Apparently, when you wanted to get off the taxi, you "tap tap" the side and hop out.

At a crossroads between Cap Haitien, Milot and Dondon, the paved road of Cap Haitien gave way to a dusty gravel road with the occasional gaping pot hole.  Motorcycles with two or three passengers hanging on the back zipped in and out of the traffic, competing with oncoming tap-taps.  The road cut like a straight rut through the tropical landscape, peppered with small children carrying buckets of water on their heads, journeying to and from the local wells.

At a seemingly random location in our journey, we cut a right and arrived at our site.

The mission house site

Here I am in my dorm room on the campus, setting up my mosquito net.  It would take a few days before I   figured out how to use the hooks on the walls so the net wouldn't be lying directly on my face and legs.

There was a period over the course of the weekend that I felt a sense of "overwhelming quietude."  I think it was part of the transition into a foreign place without knowing the language, the culture, being struck simultaneously by the incredible poverty (but also the surprising degree of development)... there was just a lot of adjusting to do.

We walked around the town and drank in the sights and sounds of this bustling town.  This included a brief tour of Sans-Souci Palace, a site of regal beauty (and aqueducts!) and some fascinating history involving the first King of Northern Haiti after they won their independence from the French.

Boston -> Turks and Caicos, Providenciales

Renewal.

First off, I must remark on the wonderful climate shift there is, going from the frigid New England Coast to the balmy Caribbean. Is this even real?  Turks and Caicos has a surreal feel to it, but we have been met with warm weather and even warmer smiles here.

On the way to our modest accommodations (I use the term loosely, since our fellow travelers/vacationers have more beautiful and swanky beach-side establishments), BB and DB commented on a recent trip their friends had taken to Iceland.  It was a family who rarely travels, but they opted to go to a frozen tundra in the middle of winter to ice climb and hike on glaciers.

"Why not go someplace warm?" they exclaimed, relishing in the warmth of Turks and Caicos.

Why indeed.  T&C,PLS reminds me much of home, but MUCH flatter, and everyone here drives on the wrong side of the road.

"Iceland has one of the highest literacy rates in the world," I commented, drawing on random college trivia memory banks.

"Well, they do spend a lot of their time indoors.  That makes a lot of sense."

In the tropics, I'm certain the literacy rates are lower when there's so much else to do.  I'm reminded of the constant pull I felt to go outside and enjoy myself when I was studying in college and medical school in Hawaii as well.  The competing interests of learning and relaxing outdoors... UGH!  In many ways, living in Boston is a blessing as a resident where I can feel warm and cozy and guilt-free while studying and writing in my clinic charts.

Well, I'm off to relax in preparation for my learning later!

Signing off,
CP.