Be Careful What You Wish For...

Thursday I got to take a few hour break from my medical record data collection to spend time with real patients. But instead of being super happy about getting to take part in patient's care, instead of feeling proud that I was helping patients navigate the hospital system here, I am feeling disappointed in myself. Again, Haiti continues to throw corny proverbs in my face that seem to be much truer here than in my sheltered life back in the states. I had hoped the whole week, last week, to get to sit down with more patients and hear their stories. I was hoping to get a few good case studies that I could use in my presentations when I get back home. I already have a few presentations scheduled and so I figured the infectious disease teams, medical students, and NGO volunteers back home would find walking through a patient case or two much more interesting than a bunch of medical record system data collection. I am not saying I was standing there with my fingers crossed that a bunch of sick HIV+ and TB-infected patients would have to come to the hospital last week. But if patients with severe conditions waltzed through the doors of HIC, I was ready. Questions set. Computer in hand, ready to take notes and photos.

And then my wish came true. Thursday, a very sick HIV+ baby was referred from Dr. Robin at Port Salut. Since she has become a new friend and a fellow blan working in Haiti, I told her I would sit with the mom and dad while they were admitted. I promised to take care of any questions they or the doctors and interns might have had about the baby's condition. And so I sat and listened to what the doctors had to say. And the more I listened, the more frustrated I became. They had me take the baby to go get a chest x-ray and while the pediatrician looked at the results, the interns took all of the vital signs. They listened to his chest. They asked the mom about the baby's symptoms. The more questions they asked, the more it became clear to me - they didn't read a word of referral chart that Dr. Robin had prepared for them, even though she took the time to write it in Creole for everyone. Baby had a bad pneumonia of some kind, was HIV+, and had O2 sats of 45% without oxygen (it improved when he was on oxygen). He needed oxygen, to be prophylactically treated for PCP pneumonia, and potentially other supportive care. Dr. Robin's clinic didn't have the ability to house inpatients because her clinic had just opened in November. So she sent him to me. But it was becoming clear to me that the doctors and interns were treating this baby like a new patient who just walked through the door, having never seen a doctor before. I showed them the papers again and explained, he needed oxygen. The doctor exclaimed - "non, pas maintenant." I questioned why he "didn't need oxygen now" and was told that he had a viral pneumonia and there was no need for oxygen. Hmm... so that's why I hear the baby grunting in respiratory distress? And peer-reviewed research has shown that even radiologists in the states, despite all their training, cannot accurately tell a viral pneumonia from a bacterial pneumonia. Yet, somehow with one look and a quick listen, this doctor tried to? I advocated some more for the patient, talked with the mom, and then left the hospital feeling like I was fighting a loosing battle.

Friday morning I tried my luck one more time. A different doctor told me the patient didn't need either bactrim or oxygen. He told me the patients O2 sats were probably 90%. "Hmm, really? Does your unit have an O2 saturation monitor?" "No." "Then how do you know his sats are 90%?" "I just know. They're probably 90%." So now we are magically guessing patient's vitals... Awesome. After Dr. Robin and I had a few different conversations Thursday night and Friday morning, it finally looked like the best option was to give baby and mom oxygen and transport them home to Port Salut. Their medicines would be delivered to their home, Dr. Robin's clinic staff would do home visits to check in, and we would hope for the best during our Sunday away at Peak Macaya. And so Friday I participated in the battle between the pediatricians at HIC, saying the baby was receiving appropriate care, and Dr. Robin, telling them what baby really needed. I normally try to blend in at HIC and not use phrases like "Well, in the US we would do it like this..." But Friday, I had to take Dr. Robin's and the patient's side. I knew if care would continue as it was, that the baby would not make it through the weekend. Heck, even if care turned around, he had been deprived of correct oxygenation for so long who knows what type of condition he would be in.

As if the HIV baby's care fiasco wasn't enough, Friday I found out that Baby Joseph and his mom were both diagnosed with TB. Luckily, one of the TB doctors I work with at the infectious disease clinic did a wonderful job of seeing them right away, as soon as Dr. Cleonas and I started to suspect it. It turns out that mom had TB in the past and now it's back in full swing. She received medicines in the past for TB, but I didn't have enough time before clinic closed to ask her if she stopped treatment early (it's the first item on my to-do list once clinic opens tomorrow).So my four-day weekend ends with feeling a little guilty for both patients - for not putting the incessant-cough-for-3-weeks pieces together, for not thinking that a negative PPD screen would not be accurate enough to rule out TB when the baby is malnourished, for not trying harder and demanding oxygen and bactrim, for wishing to get to participate in more HIV and TB patient care. The only difference between the two patients over the 4 day weekend - Baby Joseph is still alive and fighting, the other baby isn't. So I guess I have two case studies now. Complete with blan vs. Haitian healthcare dynamics. Complete with a discussion about the HIV+ baby's father's frustration with the care they received at the hospital and his own slew of guilt. Complete with the deep insights I and the baby's parents received from Dr. Robin yesterday at his visitation. So now that I have my two cases, I have a new wish this week - that no new HIV or TB cases walk through HIC's doors...

  Baby Joseph's mom and him, soon after they found out about their new diagnoses. She was so happy that Dr. Cleonas and I were concerned enough about her and her baby that we came to find her at the TB clinic. She happily agreed, not only to have her photo taken, but to let me share her and Baby Joseph's information for a case study. Looks like I could learn a thing or two about simple happiness from my patients...