Room for improvement

July 21, 2012

I have discussed some of the many ways our care has improved over the last year. This weekend we discovered an area where we need to focus some more efforts: procurement of supplies.

On Saturday, we ran out of many antibiotics. We had no ampicillin, ceftriaxone, penicillin, amoxicillin, bactrim and a slew of others. To deal with the crisis, most families gathered money from all potential sources and purchased them at an outside pharmacy.

This morning I arrived and found a three year-old patient lying on the exam table. He was motionless with a dusky color. He did not look good.

As I hurried over, the father said to me, “We arrived last night and he was sick. I didn’t have any money to buy medicines but it is coming. It should be here in a few minutes. Can you just help him live for a few more minutes?”

I reached down and felt his cool body. He had no pulse and his pupils were fixed and dilated. He was beginning to stiffen…… He had been dead for a while.

When I told the father, he fell to the floor and sobbed.

A little breathing room

July 20, 2012

Our ward has an official capacity of 40 patients but we frequently swell to more than 70. Sick children and their caretakers can occupy nearly every foot of free space.

Last year, I had to make my way through each patient, quickly examining them and hurrying through a plan. It was poor care to say the least. However, this year, each doctor (there are four of us) takes only two rooms and we spend quality time getting to know each story.

I’ve had a maximum of 25 patients and on some days, I have only eight or nine. Now I have time to ask more important questions, teach the nurses, walk the junior doctors through difficult cases AND sit down for lunch at noon.

Grand Rounds

July 19, 2012

I spent the majority of my medical education learning at the patient’s bedside. Great mentors showed me how to take a history, demonstrated proper ways of completing an exam and, most importantly, taught me how to treat patients. Some of the things I know may have been initially acquired in books, but I solidified all of that information at the bedside.

In order to continue this wonderful medical tradition we initiated “Grand Rounds” on our pediatric ward. Yesterday, we assembled all of the doctors, most of the nurses and all of the students into a large team. We talked about each patient one at a time, detailed each plan and let students ask questions. For two and a half hours, we all learned from each other. And, in just two and a half hours, we took a large step forward in improving care for our patients.

We will continue to have Grand Rounds every week.

Some people find hope in dire situations

July 18, 2012

Last night a young, pregnant woman presented to the hospital with headaches and severe hypertension. She was very sick and needed to have her baby delivered right away.

As the head popped out, it was obvious this was not a full-term pregnancy. The child appeared to be 10-12 weeks premature.

We brought the small baby to our neonatal unit and placed him under the warmer. After we stabilized him, I told the father, “Your baby was born very early and may not live…but the doctors downstairs needed to deliver him to protect the life of your wife.”

He smiled and remained quiet.

After a few hours, the child died. He just slowly stopped breathing. I approached the father and told him the news.

Without hesitation, he said, “No problem at all. Thank you for saving my wife. I hope we can have another one together.”

A slew of little ones

July 17, 2012

Over the past two weeks, we have had a handful of babies born at least two months premature. A couple in particular have been difficult to keep alive.

One was born at home and did not come to the hospital until he was one week old. By that time, he had a severe blood infection and was dehydrated. We worked aggressively for a few days giving antibiotics, oxygen and fluids. Fortunately, he is now doing fairly well. His weight is up 200 grams!

The second one was born in the hospital. She was doing fine for the first few days of life but when we started feeding her, she began to have spells of apnea (not breathing). One week ago, her mother frantically called me to the bedside. When I arrived, I was a bit surprised. Just minutes before the child was fine and now she was as blue as a smurf and not breathing. When I placed my stethoscope on her chest, I could only hear 20 or so beats per minute. We scrambled around and started a resuscitation. Lo and behold, after about five minutes, she was pink and breathing on her own.

Interpretation

July 16, 2012

As I was finishing rounding today in room B, a shy and sad appearing mom approached and asked, “Can you please help me? My baby is sick.”

In her arms was a small child, appearing to be a bit under a year-old with big, round eyes. She was alert and in no distress but her skin had the look of chronic malnutrition. She had swelling on the sides of her face and she was coughing frequently. I had an idea what she had but needed to explore a bit more.

I directed the mother to a bench in the back of the ward. As she slowly walked over, I noticed a man behind her carrying another child, this one about the same size. The four of them sat close to one another.

As I pulled up a chair, I questioned, “Is this her sibling?”

The mother replied “Yes, but she is not sick.”

“Are they twins?” I asked

“Yes, this one (the sick one) was born first. She (the healthy one) was born second. That was nine months ago.”

Huh, I thought to myself. There was now a crack in my theory. I was thinking my patient potentially had a chronic illness such as HIV and/or tuberculosis. But this sick patient was the same size and same developmental level as her healthy twin. Something seemed odd.

As I asked more questions, I discovered my new patient had frequent fevers, a prolonged cough and weight loss. On exam, she had an obvious pneumonia. This led me back to my original line of thinking.

I sent her for an x-ray……30 minutes later I saw an image classic for tuberculosis. Then I took her to the lab. Within five minutes, I got results….positive for HIV.

I sat for a bit and scratched my head. Then I decided to get help from another doctor.

I approached Patrick, the director of the Family Practice residency. I said, “I’ve got this set of twins that are the same size and developmentally equal. One has HIV and TB and the other seems healthy. Can you talk with them and see if I missed anything in the history? Something seems odd.”

After a few minutes, Patrick pulled me aside outside of his office. With a slight smile, he said, “Good job with the TB and HIV diagnosis. But they are not twins. The sick child is three years-old and the healthy child is nine months-old.”

Then, as if he could see the self-doubt in my face, Patrick said, “Well, when I first saw them, I thought they were twins too.”

I sent the family home and gave them money for a taxi to return in the morning. This time I will have an interpreter and then run tests on everyone.

Calling in the troops

July 4, 2012

Just after I arrived this morning, the security guard approached me and said “This child is very sick. You need to see him now.”

As I looked down, it was obvious the child was very ill. Then, as I examined him, he took his last breath and his heart stopped. He was dead.

I knew resuscitating him was futile, but I still yelled, “We have a very sick child. I need your help!”

Without hesitation, three nurses and a resident doctor rushed to the bedside. One nurse started chest compressions and the doctor started breathing for the child. Another nurse quickly got an IV started and the last nurse prepared medications. It was a beautifully run code.

They continued to try to save the child’s life for approximately 15 minutes. Unfortunately, he did not respond and so they stopped to allow his family to hold him.

I was flabbergasted with the resuscitation! One year ago, I would have been lucky to get one nurse to casually walk over and provide assistance. Today, they worked like a well-oiled machine.

They did not save this child’s life, but there will be a time very soon when they do.

A nice beginning

July 2, 2012

Today was my first official day back at work. Wow, things are different!

Last year, I covered the pediatric ward for most of the day by myself; up to 70 in-patients and scores of out-patients. It was a bit overwhelming, to say the least.

Now we have four doctors all day long; two pediatricians and two generalists. It is such a nice change and patient care is much better. I am really looking forward to the next 6 months.

Then and now

June 30, 2012

We all know kids grow. However, watching my own kids get bigger is always amazing. It feels like just yesterday, they were too small and weak to sit-up and now it is hard to keep up with them as they run in the yard.

Below are pictures we took nearly eight months apart. For some reason, I felt it was necessary to wear the some outfit.

This is the first time I ever held them!

Now they are looking a lot bigger

A pleasant surprise

June 26, 2012

Last week, I had to return to Boston to tie-up a few loose ends before we start the next 6 months down here in Haiti. I completed a few tasks at work and got my apartment organized.

When flying home, I received an unexpected upgrade to first class. It was a really nice treat. Just after settling-in, the man sitting next to me arrived. He looked familiar but I initially couldn’t place him.

Long story short, we had engine problems and sat on the runway for a long time. During the down time, my next door neighbor and I chatted about kids, global health, sports and politics. After a while, I finally realized who he was…

For the last 12 years, he has been a frequent visitor on my TV. Mostly on Sunday, but a few Monday visits. He is an NFL player.

Despite his celebrity status, he was extremely nice, humble and overwhelmingly dedicated to supporting those less fortunate. Meeting him was a very pleasant surprise.