Thursday, October 16, 2014

Wednesday in Leogane 2014

Wednesday I walked over to the Children’s Nutrition Program of Haiti (CNP) – Kore Timoun de Ayiti – to meet up with Tarin the director. I had met her the prior night because Dustin (Engineering 2 Empower) has a girlfriend who is a CNP intern. Tarin offered to bring me up to speed regarding the program’s development since 2009 and show me their malnutrition identification clinic/outpost on Wednesday. (I was familiar with CNP’s “hearth” community health worker model back in 2009 when I was hanging out with my friends Kara and Courtney who ran the program.) As Tarin explained, their programs have effectively knocked severe malnutrition out in the rural mountainous divisions of the arrondissement of Leogane. Now they are now looking to address the urban severe malnutrition issues in the town. Part of their outreach is a referral site where those mothers and babies identified as malnourished can come for follow up. –Plumpy nut peanut butter/Medika Mamba, weight, arm circumference, basic triage assessment. Those with severe acute malnutrition get a dose of amoxicillin, medika mamba if they can eat it or a special milk enriched feeding formula if they can’t, and a referral to a medical clinic in Ti Grove. The program is as fantastic as it was in 2009. It is too bad that the Haitian government does not have the funds or resources to replicate their system on a national scale.

My first real case as a doctor in Haiti came at the CNP outpost while Tarin was explaining their system to me. (during my time at Hospital Universitie Mirabalais, the ER director asked that I would just shadow/accompany during my time there and make suggestions so technically this baby was my first... but who's keeping record anyway? no pun intended) A mother arrived from the mountains, referred by one of the community health workers (aka Monatrices) who determined that the baby had malnutrition. This baby girl was about 4 months old 15lbs with no obvious signs of acute malnutrition (no redish tinged hair, edema, underweight, glassy non-focusing eyes) but had a case of impetigo around her mouth and cheeks and a nasty fungal infection in the folds of her neck. Mom wasn’t sure exactly what her baby girls name was which was sad but often the case with rural Haitian families who wait to name their children. We explained that these infections were likely because she was drooling and spitting up all over herself with no one to dry her. When she said she pa gen lajan – didn’t have money for the trip to Ti Grove, the time for the wait, or the consultation fee, or to actually purchase the medicine that they would prescribe….everyone looked to me………doctor? Which medicines? What dosages? I recognized quickly that she should get an antibiotic and some miconazole antifungal powder. CNP had plenty of amoxacillin so we gave her a first dose and a 5 day supply, then walked her down the road to some pharmacies looking for miconazole powder. After the third pharmacy only sold miconazole crème I settled for clotramizole powder. I gave her 100 goude (about 2 dollars) for her moto back to her mountain town, reiterated my instructions for when to take the amox etc...and she left.

I reflected during my sweaty half mile walk back through town to the residence - curbside consult, compromised treatment plan, tenuous follow up. Grateful for whatever, no HIPPA violation or lawsuit threat- type of patient. Part of me enjoyed it. Part of me didn’t feel good. I would have felt better if I had had my smart phone to check the mg/kg dosage of Amoxacillin, or if I had thought to give her Augmentin instead, or had known for sure that clotramizole would suffice for miconazole. However, I am confident that had we not intervened the mother would not have taken the baby to a doctor as recommended and consequently not received any medicine. At some point when I am more confident these encounters will be easier. In the mean time the ethics of sending inexperienced doctors to Haiti to face these “sink or swim”/”now or never” moments ought to be considered. Are these encounters Win/Win situations or singly profitable for those gaining valuable medical experience. If they are Win/Win scenarios why not encourage medical residents to spend large quantities of time in the developing world?

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