Excerpts from the Third World, Part III…..

Its another rather uneventful day here at Mayberry hospital. I’ve emailed everyone I can think to email and scheduled one more interview at Big Fancy Prestigious Hospital. Still waiting to hear back from the other programs I really want to interview at. The wait, and the interview scheduling process, are interminable. I’ve already been forced to schedule two inteviews during an elective rotation with (desperate) hopes that the attending will be understanding (please, PLEASE be understanding). Apparently quite a few programs wait to gather applications and get MSPE letters before offering interviews, plus, if programs really aren’t interested they usually send a letter of rejection (or so I’ve heard). So, I’m stuck waiting. Frankly, I just can’t wait to hear back from whoever I’m going to hear back from, get stuff scheduled, plane tickets and hotels paid for, and relevent attendings begged for time off. I need to get stuff nailed down. I’m like that.
 
So, while I’m waiting, more excerpts. I left off just getting into the swing of things in Haiti, time to get to the good stuff…..
 
 
Today was our first day in the OR. Two cases scheduled and added a csection in the morning. The section went off without a hitch. The second case was an abdominal mass which we suspected was a large fibroid uterus. Lesson #1 today – abdominal masses in Haiti, diagnosed with decades old ultrasound and no CT, can be anything. The mass turned out to be a gigantic ovarian tumor, luckily, benign in appearance. We removed it easily, leaving the uterus and remaining ovary intact and most likely highly functional. Major victory.
 
We scrubbed in on the second case immediately after lunch. It was another abdominal mass, unfortunately not such a victory. It was immediately apparent that something was terribly wrong when we opened. We had a very difficult time opening the peritoneum and when we did finally get in, cancer, EVERYWHERE. I have never seen anything even close to that bad of an abdomen. We ended up debulking as best we could and closing. I felt like crying at work for the first time in a long time afterwords. I’d been immediately drawn to the patient, their quiet dignity and kind demeanor, and I had so been looking forward to a curative procedure for them. It was heart breaking, a brutal reminder that OB/GYN is NOT all about beautiful babies, joy and happiness.

One of the two OR's. From the hospital's blog.

We went back to the clinic after the surgery. I excused myself to check on L&D quickly, and then detoured to the pediatric ward to drop off some candy with one of the nurses, and blow up a few balloons for kids sitting in the hall. It was enough happiness to shake off the shock of the terrible surgery, put on my business socks, and head back to clinic.

We saw about 20 patients before the day was over. I got to tell one mother the sex of her baby and got a big hug for it. We scheduled a couple more surgeries and I got to practice my growing list of useful French and creole phrases “quelle age ou?” or how old are you and “eske tu fem mal” or where does it hurt? Much to my own delight and that of the patients.

Tonight I needed to get out so I went with my roomie and some of the other volunteers to the local cantina and then to a house party at one of the other dorms. I drank a few liters of the cane sugar coca-cola (on call here people) and mostly watched the others party it up, dirty dancing (Compe? is the style I believe, whatever, looked like dirty dancing to me) to the Haitian music, laughing, yelling, and talking about the latest dramas (which, of course, I had been completely oblivious to in my usual work/nerd bubble)…..

 

 We did our first emergency csection yesterday for a case of prolonged labor and cephalopelvic disproportion. I got to do the actual delivering the baby part, and a lot of sewing and it was AWESOME. We saw almost 40 patients in clinic again and I finally had to ask our interpreter if this was a typical number of patient visits in a day. He was pretty equivocal, and I suppose he wouldn’t know because the staff physicians don’t use interpreters so he isn’t usually there. We ran into the chief of medicine at the end of the day today so I asked them too. They were pretty vague as well, and told us that they do try to keep the numbers managable by delegating routine care to outpatient clinics in the out-lying villages. The OB/Gyn clinic at the hospital is only supposed to see more complicated cases. Even with the delegation, I suppose it would make sense that there are so many patients because there is only one OB/Gyn physician here at any given time for a population of hundreds of thousands (?), even more since the people migrated out the Port-Au-Prince area after the earthquake. I really hope no one thought I was complaining. I am just…awed I guess at the sheer number of patients and the pace of clinic the regular staffers keep up with on a long term basis. I suppose being able to work without an interpreter would expedite things, but still, Wow.

Today was another surgery day. We did two cases in the morning, with a straightforward and relatively easy TAH to start, followed by probably the second worse abdomen I’ve ever seen, after the case on Wednesday. Thankfully, not cancer this time, but adhesions EVERYWHERE. The patient had obviously had some previous surgery but I have no idea what kind of operation would cause a mess like that. We did the best we could and closed. Technically I don’t think we have to do clinic on surgery days, but so far there is no way we can’t. We saw 20+ patients in the afternoon after surgery, my attending had to leave to do several D&C’s, so I stayed and saw the easier patients on my own. (Yes, on my own. Trust me, I know, Yikes. BUT at this point I have a really good idea of when I’m in over my head and I leave those situations to the expert, and how else are we going to see everyone?)

Even though we try to see and treat people as quickly and efficiently as possible, patients wait for hours, sometimes days to be seen. At any given time during the day the benches or stretchers outside the clinic door are packed with ladies, obviously waiting for us. I asked on the first day if someone was, hopefully, triaging them. I still really wonder because we just see whoever our interpreter or the nurse brings in next, and often its hospital employees for things like pap smears. Hmmmmm.

Patients camped out in the hall. From the hospital's blog.

I also noticed early on that the patients we see are very well groomed and dressed. Always in what seems to be their Sunday best, dresses, hats and heels. I wondered too if this was something unique to our clinic, like do people always dress up to see the gynecologist here? Is that a thing? I mentioned it to another volunteer who said he didn’t think so, Haitians take a lot of care and pride in their appearance and upon further observation I see he is right. They dress colorfully and joyfully as they can (I have not seen one pair of sweat pants here) and are pretty much uniformly a very, very handsome people. Despite knowing that now, I still feel honored that our patients seem to dress up to visit us.

Not only do they seem to dress up, but even after the long wait, every single patient is extremely polite and happy to be seen. It breaks my heart a little. To be rushing through the day and see the next sweaty, tired, potentially very ill, or very pregnant patient (who I’ve probably seen sitting in the hall all day) ushered in, and as soon as I smile and say bon soir, I get a big, grateful smile in return. The last patient today for instance, I’m sure I’ve seen waiting a couple days this week, she comes in hugely pregnant, her chart completely screwed up and so happy that we stay for her. I got to tell her she’s having, by all appearances, a healthy boy. Big smile, happy exclamations, many thanks, and not a word or any sign of frustration or impatience of what she’s probably gone through to hear it. I told my attending yesterday that if this was how the clinic at home functioned we would have a riot on our hands in no time.

Smiling patients, make me smile. From the hospital's blog.

 My attending and I actually managed to round on our own without our interpreter tonight. I was pretty stoked though I’m sure it was not the most thourough rounds ever. Between the two of us we managed. I took the lead asking if patients were eating, drinking, peeing or having pain and he filled in with the more complex ‘are you passing gas ‘and ‘do you want to go home tommorrow.’ Good enough any way……

 

Right. So we had the day off today, and after breakfast, rounds to inform the on call about our patients, a short walk and a nap, I was totally bored. I ate lunch and had to resort to studying to pass the time….And that’s been my day. I found out after the fact there are actually quite a few exciting activities going on like a massive soccer match (I did hear the uproar from the hammock, but assumed it was some sort of riot and did not feel the need to immediately head for the ruckus to personally investigate) a few of the volunteers attended, and trip to the beach tommorrow but the car is past full (I guess even the roof seating is already spoken for. Dangit!!). I really need to make some friends here…..

The hammock on our house's front porch. A favorite spot to hang out (literally) and pass the time.

Today was so much better!! I can’t believe the weekend is over now that I’ve finally figured out how to enjoy days off here! I started on my friend-making mission immediately after getting up this morning, sitting down and conversing with our fellow volunteers instead of retreating to my room like the socially-handicapped individual I tend to be outside of the hospital. I managed to arrange a hike with my attending and another volunteer and we set off in the heat and the sun at about 0730 (there is a reason people head up there before sunrise usually – A) You get to see the sunrise from the top of the mountain and B) It’s friggin’ HOT – not that I really mind after 13 years in the upper Middle States). We met a couple Haitian girls along the way, resting in the shade with their loads, and they joined us the rest of the way up. I’m pretty sure it was because they were worried the crazy blancs were going die if they left us to our own devices, nevertheless they were very sweet and it was nice to have more company as we struggled up to the top. The view was AMAZING, you could see pretty much the entire valley and river and the the tiny little campus of the hospital.  

The view from the top.

After the hike and lunch I took a nap, woke in pool of sweat, and hastily bucket showered before joining some other volunteers for a trip to craft shops in the market. First we went to a small shop filled with local crafts – paintings, jewelry, purses make with some kind of wrappers, metal work, sculptures, and paper made with banana peels and sugar cane. Then we walked a little further to a shop that looks like a jail (because it had been at one time turns out) which was full of locally crafted, beautiful ceramics and rugs.

Afterwards I went back to the pool for (my 3rd? daily) swim and ended up talking to a very nice general surgeon who has been around the world and back (probably a few times) on medical missions. A very jovial, down to earth guy with an endless supply of fascinating tales. There were two Haitian girls aslo at the pool and I was very frustrated to find I’d spent hours studying and practicing creole and couldn’t talk to them at all. I could have asked them if they had pain, dysuria, diarrhea or vaginal bleeding but I had no idea how to ask where they were from. Way to go Nurse, MD.

The pool. Ohhh how I miss the pool....

Our new roommates arrived later in the evening. Mine is a GP from the West coast, and I like her already because she comes with loads of mosquito combating sprays and gadgets…and I just made another friend (yay!!!!) a Haitian surgical intern I’ve seen around but never really talked to. He promised to help me with my creole if I help him with English. Score!…And off to bed now, I can still hear the drums from a nearby Buddist (I think he said Buddist, at first I thought Voodoo which would make more sense, huh) ceremony for the god of love I was invited to check out, but I think I’ve made enough progress today in my personal Campaign For the Socially Impaired. Mission accomplished. Back to work in the morning!!!!

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Excerpts from the Third World, Part II……

I’ve been back almost exactly a month now. I’ve taken Step 2 CK (in 6 hours flat thank you very much, I wanted to be done NOW) and finally submitted my residency application this week. I’ve finished all the work I’d left waiting at home, the initial rush of activity has died down and now, frankly, I am bored. I just finished my first week of my internal medicine sub-i, and while my attending is pretty much the nicest guy ever (I chose to follow him for a reason) and I really enjoy the solely hospital-based work, business is sloooooooooowwww. After the constant, almost 24/7, fast-paced, challenge of work in Haiti, all of my rotations at home since have been, well, boring, by comparison.

As I sit, all day, waiting in vain for an admit, something, anything to do, checking my phone every two seconds for interview offers, I think of Haiti.

Week one……

Morning conference is in the hospital’s library every morning at 07, the medical staff gathers and led by the chief of medicine, the going’s on in the different departments are reviewed (the number of cholera cases still, thankfully, trending down) and then there is a short educational presentation……

The hospital's main courtyard.

After conference we go to the med/surg ward to round. We’ve had a couple post c-section patients to check on. We ask about pain, activity, diet, flatus, admire the babies (okay, that’s just me), check incisions and write notes and orders. Then we head to Maternite (labor and delivery) to check on patients there. The nurses handle most of the vaginal deliveries, so the MD’s role is mainly to check in and write orders……

After Maternite we go to clinic. The OB/GYN clinic consists of a block of 4 small rooms in the hospital, just down from L&D. The rooms are, for lack of a better term, grungy. There are 2 offices and 2 exam rooms all connected, divided by makeshift curtains. In the exam rooms there are a couple of exam tables, an old ultrasound machine, and in one corner a pile of ‘sterile’ packages that I ransacked this morning to find a cache of speculums and something, anything (*besides* a 20 ga hypodermic needle, ACK) to break a patient’s waters with. We have sink for handwashing with a faucet that refuses to completely shut off, and now after sweet talking the nurse, a nice new bottle of Spanish (?) antimicrobial soap to go with it……

The central corridor. From the hospital blog. Patients wait for hours, sometimes days, in the corridor to be seen in the differnent clinics. At night hundreds of people camp out in the halls, sleeping on the floors and benches.

We work with a nurse and an interpreter. Our interpreter, I have decided, is pretty much a used car salesman in interpreter’s clothing. I have no idea how he ended up with us and I suspect he requested it for some (probably borderline nerfarious) reason. He immediately hit on me on day 1 as soon as my attending wasn’t around, and though I flatly shut him down, he started today off with a bold request that I give him my clinical reference book and, while I’m at it, take him back to the US with me when I go. Then he called me “a mean old lady” when I firmly told him no, stop asking me stuff like that or I will ignore you. Luckily he had other things to occupy his time including trading in (what I can only assume was) black market perfume and diapers between patients and hitting up patients for their digits or chatting on his cell phone while I’m in the middle of history taking. Our translator, the con artist.

When he is not busy with other matters, our interpreter does push us to see as many patients as possible. So far we have been seeing 40-50 per day. We are so busy I’ve been quickly thrown into seeing patients with simple issues on my own, consulting my attending when necessary, writing notes, orders and scripts. It’s been overwhelming and a little scary, but in the way that the most amazing learning experiences are overwhelming and a little scary. I am learning at warp speed here. Honestly, it grates against my previous training to some extent. I am concerned that we give patients the best quality of care possible, but we just don’t have the resources, time, lab, microscopes, etc to be as thourough as I’ve been taught I should be. Part of me hopes also that I’m not inadvertently learning some bad habits, but here we are doing the best we can with what we have. Everyone is….

The observation ward, sort of the equivalent of an ER. From the hospital's blog. It is always full, often to overflowing.

There has been a good variety of patients so far. Mostly gynecologic complaints and high risk OB’s because less serious issues like routine prenatal care are dealt with in outreach clinics. We see alot of people with heavy or irregular periods, patients who have had miscarriages, and for some reason A LOT of patients for pelvic masses. We have 5 surgeries scheduled so far to remove huge fibroids (the last one we scheduled today looked like she was 9 months pregnant, in fact we all thought she was pregnant until she told us she was there for her surgery for fibroids). We have a couple c-sections in the works as well. The surgical suites have just been remodeled and are actually very nice. I am really excited about our first cases tomorrow. A day in surgery anywhere is a good day…..

A couple highlights in clinic so far were getting to tell someone for the first time that they are pregnant (a happy surprise for both of us, and a good reminder that the number one cause of amenorrhea in a woman of childbearing age is pregnancy, way to go genius), getting to tell a patient (and actually being able to tell on ultrasound!!!! getting LOTS of ultrasound practice) the sex of their baby, and an extremely fastidious elderly patient with a pessary, ripping ripping our interpreter a new one (Afterwards he demanded that I fire her. No way pal.Too. Funny.)…..

Haiti does not have much to offer as far as local goods, but they do have a long tradition of unique, characteristic and very beatiful art. Mostly paintings and metalwork. This is an example hanging in the hospital's main corridor.

The hardest part has been the language barrier. Communicating with patients is my specialty, hands down my best, most useful skill for proivding the best quality care and expressing compassion for, and connecting with patients. I was really at a loss yesterday without it. Today was a little bit better, I can say a few phrases in creole or french now (today I learned how to ask – does it hurt when you pee – an extremely useful phrase in a gyn clinic, pretty proud of that one) and tonight I actually sort of ended up translating for my attending when we went to check L&D one last time after supper. That felt so good and I hope, hope, hope that it keeps getting better. It felt so great to actually understand and be able to communicate, even a little, with patients and staff today. To see them smile at the connection. The best.

Children playing outside the hospital. From the Hospital's blog.