Friday, October 15, 2010
Aurevoir, mes amis!
Today was our last day of teaching and seeing patients. We made rounds in the ward pavilion this morning, checking in on the sixteen year old with falciparum malaria who looked extremely ill yesterday and has begun to improve on anti-malarial drugs. This is a diagnosis that is not hard to make-the parasite is visible in the red blood cells under the microscope. But you have to think of it. We also stopped by the bedside of the child with Down syndrome who wanted to play. She is awaiting a placement from the social services workers. And we checked in on a few of the sad babies with severe congenital anomalies and no hope of survival.
Then we got to the serious work starting to see the out patient line that seemed particularly long today. It is extremely stressful to look at febrile, toxic-looking kids, one after the other, try to extract a history from people who only speak Creole and have limited experience with medicine or the hospital. What a frightening place it must be. I can only wonder what they really think is going on in their babies’ bodies when we try to explain “infection”, “pneumonia”, or “virus”. At home “virus” tends to set the mind at ease. But here, it doesn’t seem to match what the mother fears or wants most.
Oslers’ theory of one unifying diagnosis is out the window. So many have malnutrition, anemia, HIV, bacterial infections, skin infections, trauma both physical and psychological, and then on top of that they have a relatively minor virus (often the presenting chief complaint) and just the hardship of daily life-heat, lack of sanitation, water, long waits in line for medical care, and problems with shelter.
Occasionally a smiling mother and child sit across from me on the folding chair and when I review her chart I realize she is there for follow-up and the child is notably better. Thank goodness. Has she had her vaccinations? Is she in school? Oui. Oui. Next.
Around noon, my own energy began to flag, my blouse was drenched in sweat and I was on fire. The line before me just kept growing, the sewage truck was at work just outside the window, babies were crying, a father was angry and restless at the registration window. There was no more water in my bottle, and I couldn’t manage the intense concentration necessary to understand the Creole any longer.
Then I looked at the faces one by one and realized that they had waited many more hours than I had worked;that many were holding 15 pounds of 105 degree frighteningly limp flesh and that soon I would be able to leave. I saw the next several children, dispensing prescriptions for acetaminophen, blood tests, stool samples, xrays and vitamins.
When I got up to leave to give my lecture, the line was still there, but the doctors were all headed in my direction, and patients would just have to wait. The personnel shortage is remarkable. There are very few nurses and in this place their training is hardly that of clinician albeit one of dedicated caregiver and shlepper.
I taught the staff how to think about adolescence-its stages and milestones. How to talk to teens so they will answer back and how to assess their problems. All issues of sexuality elicited discomfort and some questions. Of most interest to them were the issues of confidentiality and privacy and how to manage them. Like many pediatricians, most of them have chosen this profession because they like little ones. Like many pediatricians, they would often rather not have to deal with the answers that emerge from "big kids" when they are asked the age-appropriate questions.
Later in the day I was invited to the monthly meeting of the Haitian Pediatric Society. About 40 docs from around the country come to PAP for this meeting with colleagues held in the Plaza hotel, an oasis in the center of town near the famous wrecked palace. Not only was the Plaza spared but the conference was in an air-conditioned room! I presented a talk on menstrual disorders in adolescents, once again encouraging the physicians to continue to care for teens because their compassionate pediatric approach is what teenage girls need most rather than the scary and grownup world of the gynecologists’ office.
If people wonder why US pediatricians would elect to come here to Haiti, they need only spend time with these physicians who are smart, fun, dedicated, worldly and always thinking about the differential diagnosis even if they have no lab or technology to prove it. And they go to work every day in the conditions that exhaust me within a few hours. This is where they have chosen to live and work. For it appears that most of them truly would have a choice but are dedicated to Haiti and the profession. Twenty pediatricians emigrated after the quake, but this is the solid core. What a privilege to have known them this week.