04-JUL-B-5

A FULL DAY OF TWO CLINIC SESSIONS AT THE HOSPITAL IN JIMANI, FOR AN IMPROVEMENT IN THE PROCESS

AND ONE MAJOR EXPLOSION FROM A SOURCE

WHO IS NOT GETTING ADEQUATE RESPECT AND ATTENTION

July 22, 2004

Today, we had a full day at the Hopital General Melenciano: a full day, that is, if you discount the hour and a half it took to reinvent the wheel in the morning, after setting up the system and having it taken down twice for the local staff who had encouraged the crowd to rush the doors in attempt to get to the promised shopping bag load of free medicines to be given to them all through the largesse of the local staff from the manna that fell from heaven. We saw large number of patients through the morning, and then broke for lunch with the usual “end of the day” that occurs in Southern America at noon, and we had lunch. We were going to run an afternoon clinic, but since no one was here, we sat around talking to each other then decided that we should all go to a place where there was a spring-fed pond and go swimming. As soon as everyone was excited about this impending event, a few patients dribbled in, following the 196 patients we had so far seen in the two half day clinics I the hospital, and then the dam broke. The crowd of people who came an hour after we had determined to leave were large and boisterous, and the tension from all this got to one of the team members who is abrasive and controlling and she got into a shouting match with me, which almost resulted in her being shipped out on the spot.

Suzie Zieger who had described herself to me as a New York Jewish girl who had previously found it rewarding to be a part of a medical mission of an evangelical mission organization had a “love of the Haitian people,” and as she spoke Creole, she joined the team as a translator. She is rather abrasive and loud, and wishes to have a lot of attention. When I met her in the airport, she reported later, I had not focused enough of that attention on her, as I was trying to sort out all the team with one of them missing to also try to determine if we had all the baggage, since I was tied up getting the several members of the team who had “Iran” stamped in their US passports as their place of birth. She said from that moment she could tell I “disrespected her.” I certainly did disrespect the outburst she came up with in the later afternoon, after we had gone through whole families of bereft individuals who were sole survivors, or made up families of nieces and others, the frazzled remnants of who remained after the flood waters had swept everything else away. I was deeply absorbed in these human interest stories and trying to piece back together several kids and related or unrelated orphans, when I had been told that someone with an “extra hole in his penis” had been sent in to see me. This is an easily understood congenital abnormality called “hypospadias” and I came over to a room where Suzie was dominating every interaction with her translation as the tool she used to be a personal advocate for several of the patients.

When I cam in she had said that I should stand aside since she had someone who needed to be examined, but not by me, and that she would be carrying her over to a private room for the examination to, as she said “Have her ass checked.” Since I am responsible for each interaction here, I did not think there should be some private patients off the side I did not know about, and she said she had already taken care of it and I did not need to know about it. I saw the boy with the Stage II hypospadias, and the small preputial flap that would be possible to correct this was explained. Suzie was irate, I believe, because this boy was having his privates examined by several students, and had gone over to the room where I had been working with two teams, and taken over the corner of it with a screen to examine the patient whose story was that she had swallowed glass and now had a painful fissure in ano—probably unrelated.

She was busily shooing people out of the way when I got to be part of that general process and she had raised her voice to tell me to get out. I then informed her that one of us would be giving orders and one of us would be taking orders and perhaps she had been confused about who was who. She exploded and said I was not to disrespect her, and she had been working very hard and was not being appreciated by me. I told her that I certainly did not appreciate her disrupting the clinic and causing this scene in front of a lot of patients who were the ones who have the problems that we are focused on, and that whatever problem she has could best be handled by absenting her from the team. I would be responsible for the care of the patients, the first priority, and also the medical education component, the second. The composition of the team and its harmonious working was a third, and if that was best accomplished by sending any disruptive member out, that would be done immediately.

We reassembled the patient groups into the teams as she sulked, and after we had seen the remaining patients we had a little talk which was resolved around the problem she had, “not enough attention is being paid to me, and I am working hard, and I get very emotional about these patients.” Well “as the one responsible ultimately for both patients and team, this will not happen again, or else we will be missing your translation services.” So, she is still on the team, but chastised, and as Huda said “Rather high maintenance.” With the rest of the team struggling to understand how the group can help people they cannot understand through a medicine they have a very tenuous introductory grasp of, to have another person whose demanding personality is an issue would not be a plus. So, we have had our “Doctor Bill Norton” leadership crisis already in this team, and so far, again, the leader of the team, who is supposed to show as much attention to the privates and sergeants as to the colonels and majors is supposed to do the stroking on a mercurial woman who is loud and demanding in requiring attention and stroking that others should better have of what seems to be a limited supply.

I will list the series of patient case presentations that the team members are presenting to each of us, and show that we have the full panoply of congenital, traumatic, inflammatory, neoplastic, and infectious problems in a tropical environment. The cases lend themselves well to good discussions of the pathophysiology of disease, and that is causing a lot of “Ah Hah reactions” in the group some of whom have not realized before what it is that they have been seeing in a textbook kind of way. The senior students particularly can put more of it together than the freshmen and behind them come the MPH students, but they have each found it rewarding to review the patients and to go over the reasons for our treating some problems the way we have and with whatever resources we still have left after rather profligate use of some of the resources. We will append the list of some cases and their various team presenters. .

DIDACTIC SESSION AROUND CASE PRESENTATIONS:

A Vista 29 year old with weight loss, night sweats, cough, no blood tinge—rub on physical diagnosis—Diagnosis, to be proven with a sputum AFB=TB; almost ALL the patients I saw with a diagnosis like this were made afresh, and none had known of any prior diagnosis, be it TB, HIV, diabetes, hypertension of early pregnancy—we were seeing virgin pathology.

B Laurie: a 6-year-old with sigmoid colitis and diarrhea with no change for months; the diagnosis? Endameba histolytica, and I differentiated those with colitis, from the invasive forms that give pyelephlebitis and amebic liver abscess that dissects to the tissues around it through he diaphragm and pericardium and pleura; I described the “zymogenes” that could distinguish them, and gave her long term metronidazole.

C Anthony presented the type II hypospadias, and we stressed the importance of not having him circumcised so that a repair could be done in about a year with a preputial flap—diagrammed for their understanding.

D Vesta: a patient with thalassemia—a hereditary hemoglobinopathy, compared to and differentiated from sickle cell anemia and sickle trait, with both thalassemia and sickling being found where malaria is endemic (“Thalassa” =”sea” doe Mediterranean kind of conserved hemoglobinopathy compared to equatorial African sickling.) The importance of the trait being passed along, with the nasty complication of Sickle/Thal combination being thromboembolus.

Second Round from our abundant hospital patient clinics:

A Siayavash: presented a kid with Ascariasis, with worms visibly confirmed by parents. WE differentiated the three round worms and used the Albendazole treatment—which Siayavash himself was eager to start on himself as soon as possible!

B Zeb: a fat faced little girl: we differentiated the Cushing’s Syndrome (look at nose and earlobes would be invisible) from the edematous face of nephritic syndrome, here most likely secondary to malaria and Blackwater Fever.

C Sanbol: a woman with a big belly, and a noncompressible mass of fluid filled cyst. We discussed the first law of hydraulics: liquid is not compressible, so diagnosis was made of ovarian cyst. This is not as big as the one I removed in Somaliland or in Mindanao, but it would likewise be easy to do, and we recommended carrying her to the local hospital to do it. She would have to talk with family, and we cautioned her about the problems of venous return interruption when she lay supine on her right side or difficulty breathing when fully recumbent.

D Adam; a blind child; we went over the reasons for blindness in a child, and ruled out cataracts, and she did not have meningitis consequences: this was corneal opacity from trachoma—the Chlamydia trachomatis, and the Five F’s: Fingers, Flies, Feces, Families Fomites

Again—the freshman medical students do not yet know how much they are learning and can take the next two years off in medical school if the rate continues at this pace. The MPH students are a bit out of it, even if we encompass the bigger issues of hygiene, clean water, latrine service, nutrition and economic support--over against the advice of one enthusiast: “We should simply be distributing truckloads of condoms!” As a Global Health Consultant, perhaps not knowing enough to treat any single patient would be the qualification for taking on the globe’s population with advice that should be sought out!

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