TIH: Kwonik (Chronic)

Oh-Six Hundred hours came too quickly. I awoke in my bug bivy to the crowing of roosters and beeping of portable alarm clocks, and stumbled outside to shower. Our showers were outdoor cement stalls, with buckets to fill with faucet water. The water used would be recycled through a complex system of drains and tubes, beneficial both financially and environmentally. The showers were constructed with privacy in mind, but I was hesitant. Considering that I am more "prude" than "exhibitionist", showering outdoors was another new adjustment. Would I be seen? Should I avoid showering? Again, this was Haiti. For the consideration of my teammates, I quickly washed and donned fresh scrubs. 

I discovered the delicious combination of Haitian coffee, powdered milk, and pure cane sugar in the kitchen, along with fresh mangoes, bananas, avocadoes, and soft bread. We made peanut butter sandwiches for lunch, and packed the bus for our first clinic experience together. On the ride to the site, I reviewed my notes on tropical infections. Would I be able to recognize Leishmaniasis? How should one treat Dengue fever? Having read journal articles and media reports of infections plaguing younger populations, I prepared for scores of pediatric patients. 

My first patient, surprisingly, was an older gentleman. In fact, he was 99 and a half years old. He did not have tuberculosis, Typhoid fever, or malaria. He was experiencing frequent headaches, intermittent periods of decreased sensation in his fingers, and wondered if he may have diabetes. I checked his blood sugar, tested his cranial nerves and reflexes, assessed his cognition and memory, looked in his eyes to view the retinal vessels, and listened to his heart and lungs. All normal. What was the next step? In the US, we may refer him to a neurologist, obtain a CT scan of his head, ultrasound his legs for possible clots, and consider a trial of medication based on those results. But, this was Haiti. This was an acute clinic. The attending physician and I educated him about dietary changes, exercise, and hydration. We gave him some acetominophen (Tylenol) to be used as needed for his headaches. He thanked us for our time, and carefully left with cane and medication in hand. 

That day, we saw 294 patients. Many had chronic problems -- GERD, low back pain, irritant conjunctivitis, hypertension. Quite a few had been seen by primary care physicians and prescribed medication, but they now needed refills and couldn't afford them. Our group did not stock medicine for these conditions; after we left Haiti, the patients would be in the same situation -- unable to afford a refill. Could an acute medical mission team effectively help patients with chronic conditions? 

The answer lay with my undergraduate training in health promotion and education. While the quick, more effective treatment may be in the form of a pill, we would be able to protect and prevent complications through education. The providers discussed methods to lessen acid reflux -- raising the head of the bed with books, avoidance of spicy foods and meals before bedtime, and eating smaller portions more frequently. A highly skilled occupational therapist taught patients how to lift heavy items while protecting the back. Small community education groups taught CPR, dental hygiene, oral rehydration, nutrition and handwashing techniques. Akin to the "teach a man to fish" proverb, we were impacting chronic conditions through short encounters. And the patients? The hundreds we treated were appreciative and content with receiving the knowledge, even though many exited the clinic empty-handed. 

[to be continued]

TIH: Bonjou (Hello)

Early on the first day of Kwanzaa, the 40 members of the International Medical Relief - Haiti team arrived at the Miami Airport. Given the large amount of people and luggage, we were extremely well organized. We moved through security with ease, and bought our last lattes, biscuits, and cinnamon buns of 2011.

I was thrust into a test of my limited French during the AirFrance flight. All announcements were spoken in French, followed by curtailed English summaries. I had expected to hear Haitian Creole, but learned that most affluent people from Haiti (those who could afford plane tickets and passports) were well-educated, and received academic lectures in French only.

From my prior trip to Africa, I knew a notable perquisite of international travel was the airplane food. During the 90 minute flight, I pretended to read the SkyMagazine (printed en Français), sipped hot tea and nibbled on a blueberry muffin, while poorly phonating "s'il vous plait" and "merci beaucoup" to the multilingual, impeccably dressed flight attendants. They collected our food trays as the aircraft descended over Cite Soleil, one the most dangerous and impoverished areas of Port au Prince.

Upon arrival, we were greeted by a small band playing guitars and steel drums; a warm welcome to an even warmer climate. We retrieved our baggage from claim, though it was difficult to maintain control of the luggage. The airport employees were desperate for American tips and insisted on our acceptance of their help. Some heated conflict developed outside the bus over the dispersal and amount of money given. Our security officers cleared up the confusion, and we headed to the base camp.

The base camp, run by a forward-thinking, community- rooted, eco-friendly organization, was prepared and ready for 40 volunteers to unpack and settle into the living quarters. We received a tour of the grounds, including showers and bathrooms. Already uncomfortable using public facilities, I was a bit squeamish with the system of placing sawdust in the outdoor latrine, rather than a flush. But this was Haiti, not America. I came to Haiti to provide care, not to ensure my own comfort. If this was how one uses a facility in Haiti, so be it. 


While some made beds and organized, a few volunteers walked 40 minutes to an orphanage to distribute chewable vitamins, toothbrushes, and toothpaste. I was fatigued, and opted to stay at the camp. When the group came back, they shared what they experienced. They passed a corpse in the road, apparently who had expired earlier that day. In the US, one last a lifetime without viewing a deceased body, but this was Haiti. Between the rogue violence, prevalence of disease, lack of access to healthcare, and the mass casualties from the 2010 earthquake, an average citizen may encounter a deceased body every day. Once at the orphanage, my teammates enjoyed playing and visiting with the children. They were excited to receive the items, and proceeded to eat the toothpaste and vitamins like candy.

At night, a group came to express the history of Haiti through spoken word and visual aids. They performed the history of Haiti, describing how the European lust for gold had triggered the slave trade, and graphically described the rapes, lynchings, and torture of Haitian native residents and African slaves brought to the Caribbean. I could tell that a few group members were uncomfortable with the implications of Christian missionaries and Europeans in these acts, but this was Haiti. How would we effectively understand the struggles of our patients, if we didn't acknowledge how history may contribute to their perceptions, expectations, and challenges.

We ate dinner, packed supplies, and slipped under mosquito nets for rest in preparation for our first clinic day. 
[to be continued]

TIH- This is Haiti

I had the opportunity to volunteer on a medical mission over the Winter holidays. While my 2009 trip to Ghana invigorated my passion for international medicine, I hadn't had the time to travel since then, due to clinical rotations and Step exam preparation. With the goal of completing a short-term mission prior to residency, I searched for organizations via Google. I stumbled upon International Medical Relief and applied.


International Medical Relief (http://www.internationalmedicalrelief.org/) conducts 1-2 week medical mission trips to India, Senegal, Haiti, Panama, Ethiopia, Kenya, Romania, Cambodia, Peru and others; utilizing physicians, nurses, therapists, dentists, healthcare professionals, as well as non-medical support staff to bring care to underserved rural and urban residents. IMR was present in Haiti only 4 days after the 2010 earthquake, and established partnerships since this point. I was impressed by the focus on teaching and training for disease prevention and management, rather than providing a month's worth of medication and retreating back to the US with no patient follow-up. The deep-rooted relationships IMR forms in countries also ensures that critically ill patients can be admitted, treated, and re-evaluated. The Haiti trip sounded like a perfect opportunity to impact lives and utilize my health education background while receiving mentorship from physicians committed to international medicine.


Several months of paperwork, conference calls, and vaccinations later, I was on my way to Haiti. The team met in Miami on Christmas Day to sort supplies become acquainted. It was exciting to meet my 40 teammates and begin organizing the thousands of donated medications and equipment. The altruistic synergy among us was incredible. We ate together and shared stories and experiences from varied careers. Most of us had never visited Haiti, while our team leaders had been very instrumental in medical relief immediately after the 2010 earthquake. Their passion and excitement for the trip was energizing. I was lost in admiration for their courage, compassion, and dedication during such a stressful, tragic emergency. They became instant role models. Early the next morning, we loaded up shuttle buses with passports in hand and arrived at the Miami International Airport. [to be continued] 


The following entries contain my notes and thoughts during my week-long medical mission. 
Please enjoy and comment freely!

Facilitating a Correction

  ** Names and details have been changed to protect patient confidentiality, privacy, and dignity ** 

Working in a women's correctional facility over the past week has been a very insightful learning experience. In many ways, there are no differences between care on either side of the barbed wire. Patients present for treatment of hypertension, diabetes, GERD, thyroid dysfunction, asthma, irregular menses, UTIs, and general health maintenance. Labs can be ordered on-site, and a relatively large formulary is utilized. Patients attend all appointments and are 100% compliant with medications. As in an "outside" clinic, patients with surgical needs are referred to the hospital. If not for the homogenous uniforms and locking steel doors, one would never know the clinic was in a prison.

I was allowed to examine Monica, a very friendly middle-aged woman following up with several chronic illnesses. Aside from her shackles, she could have been any patient seen in outpatient clinic. As we lightly conversed about the weather and the prison food, I realized that I had been previously acquainted with Monica. Several years earlier, I met her under a front page headline of the daily paper, her smiling mugshot juxtaposed by the grisly details of a cold-blooded murder. Her arrest and subsequent trial had been sensationalized in the media, due to the sheer cruelty and brutality of the crime. Oh yes.  

That Monica.

During my first year of medical school, we completed an exercise to identify possible prejudices we may have toward different groups of patients. We discussed the reactions we may have to treating homeless patients, welfare recipients, drug and alcohol abusers, criminals, unmarried mothers, racial supremacists, undocumented immigrants, and other difficult social populations. Through that exercise, I learned that I was uncomfortable with murderers and sex offenders. It seemed rather contradictory to provide love and care for someone who deliberately preyed on vulnerable people, or who ended a life in a planned, methodical manner. Would treating these offenders facilitate them to commit more crimes? This dilemma was discussed, but not resolved. We were advised to be cognizant of our biases, and maintain professionalism. 

Personally, I believe the doctor-patient relationship to be the crux of primary healthcare. Forming a bond with a patient is the key to obtaining an exhaustive history, and unearthing previously overlooked details crucial to treatment. How could I connect with a person who committed such a heinous act?

How was I going to effectively serve this patient? Employment of a defense mechanism seemed most appropriate. While I listened to Monica's heart and lungs, I considered my options:

• Denial - believing I had the names confused, and Monica was not the killer I recalled
• Intellectualization - considering the pathophysiology of Monica's chronic diseases 
• Conversion - involuntary development of blindness in order to avoid completing the exam
• Reaction formation -becoming overly accommodating and friendly to compensate for my negative feelings
• Idealization - convincing myself of Monica's innocence
• Suppression - curbing my thoughts and focusing on completing the exam
• Rationalization - believing that Monica had a justifiable reason for her crime
• Humor - joking with the patient to circumvent the elephant in the room

While I contemplated this and moved to test Monica's reflexes, she intuitively asked me how I liked working in the prison. "Are you OK with treating all these crazy people in here? That's gotta be hard." Without hesitation, I replied. "It's not so bad. Really, patients need care no matter where they are — hospital, clinic, prison, nursing home, on the street. I love helping folks, and making life a little easier for them". Wow. Where did that answer come from? I have no doubt that divine intervention was in play. How humbled and blessed I felt to realize that the Most High had used Monica to teach me such an important lesson. Monica was no more or no less deserving than any other patient. My calling is to heal and serve, not to judge. As a physician, my role is to provided objective, empathetic care to help my patients live with good quality of life and optimal health. After accepting this call, my objections to treat patients are moot points. It only took a day in prison to facilitate this realization, and correct my attitudes. 

Thank you, Monica. 

The will of God will never take you, 

where the Spirit of God cannot work through you, 

where the wisdom of God cannot teach you, 

where the army of God cannot protect you, 

where the hands of God cannot mold you

~ Author Unknown

Choices: The Question

  ** Names and details have been changed to protect patient confidentiality, privacy, and dignity **
Jenna presented to the prenatal clinic last week, looking younger than her stated age of 15. She was accompanied by her mother, who had a toddler in tow. The tension between mother and daughter was palpable. Through extracting the history, I learned that Jenna was 4-6 weeks pregnant, identified during a routine school physical, and she was unsure of her last menstrual period, as well as the sexual encounter which led to the pregnancy. We struggled through a family history based on Jenna's recollection, since her mother was not willing to contribute any information, and avoided Jenna's pleading stares by adjusting the younger brothers' jacket.

When the resident arrived, we took her to the examination room for a pelvic exam. Jenna had never heard of a Pap smear, let alone had one. She tolerated our poking, prodding, and manipulations well, though visibly disturbed to learn that she would have to endure more of these exams as her pregnancy progressed. We attempted to engage her with small talk around her aspirations, her social life, and her plans to watch the new "Twilight" movie, but she was quite withdrawn. It was understandable, given the circumstances. 

After the exam, we rejoined her mother. The disappointment in her daughter, guilt of the situation, and stress of keeping a toddler occupied in the office had taken their toll on her. Mother and daughter quickly engaged in a verbal altercation involving a newly received text message. My resident escorted sobbing mother and wailing toddler out of the room to calm them, while I remained with Jenna. 

So there we were. 

I asked Jenna if she had any questions. She shook her head "no". I briefly explained the purpose of pelvic exams, prenatal vitamins, and blood testing while she fiddled with the zipper of her hoodie. One remaining question ate at me, needing to be asked.

"Has anyone talked to you about whether or not you wanted to keep the baby?" 

Jenna's head flew up. "No, they haven't." She relayed that her boyfriend did not believe in abortion, but she wasn't sure what to do. She was scared to ask about her options for abortions, not knowing her mother's stance on the matter. Her pediatrician provided the prenatal vitamins and referred her to the office, without discussing the option of termination. Jenna lacked even the basic knowledge of medical or surgical abortions.

Should women receive information regarding the termination of pregnancy on their prenatal visits? Does the moral position of the physician matter? In my previous post Choices, I described the graphic nature of surgical abortions and my reconsideration of my strict Pro-Choice beliefs. I didn't want to encourage Jenna to have an abortion, but felt that she needed the information to make an informed decision. In the age of patient autonomy, all options for treatment should be discussed. Was Jenna too young to understand these serious issues? Possibly. Should I have waited until her mother was calm and ready for discussion? Perhaps. Would it be appropriate to refer Jenna to a clinic for more information? I'm not ethically certain. I felt it was my duty to at least ask the question.

After the storm had settled, Jenna's mother, brother, and the resident rejoined us. We scheduled an appointment for next month, which would still give Jenna time to decide if she wanted to continue the pregnancy. Mother was still a bit hostile, and Jenna still subdued, but seemed to be relieved that there were other options available to her.