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?