04-JUL-C-4
A STUDENT
FULL-STRESS CLINIC DAY WITH OVER 350 PATIENTS SEEN IN THE MARMONTE DISTRICT
“CONVENTION” CHURCH,
AND A DOZEN
OTHERS UNDERGO TREATMENTS
FROM OUR
STOCKS OF MEDICAL AND SURGICAL SUPPLIES,
AS I MAKE A
QUICK DIPLOMATIC SORTIE TO HINCHE TO MEET WITH (ABSENT) HEALTH MINISTER RAUL
RAPHAEL,
AND RETURN FOR
A RIGOROUS MEDICAL EDUCATION DEBRIEFING TUTORIAL SESSION
We started off the morning by a sortie over to the Dispensaire at Thumonde, where we had sent several patients for treatment. Several of them did not appear, such as the woman with the pilonidal cyst vs. abscess, which we were gong to I and D if it were the latter and refer her for excision if it were the former. Bryan’s “Haitian grandfather” whom I had seen last year, had a necrotic area on his toe which I suggested we should debride to get it started on wet to dry gauze treatments to postpone the inevitable amputation which will be forthcoming, suggesting that he could have this done by a member of the team as I assisted, since he wold require little anesthesia for unroofing a necrotic eschar. It became quite a big deal in a crowded hot room with everyone dripping into the wound with perspiration as a lot of people encouraged by our presence had hoped we were going to be setting up shop in Thumonde’s Dispensaire for the day.
Zeb and Adam had go involved with a
fellow who had an old steel ring on his finger, and had had it there a long
time, with a swelling that presented the ring from coming off. The simple thing to do would be to use a ring
cutter—which, of course, is not present.
I helped them put in a digital block with lidocaine, and then there was
a search for an instrument that could cut the ring. Each of the EMT scissors and cutting
appliances did not work, so that patient was bundled off to
The irony
at the Convention Church when we arrived at the “parking lot” with all the
straw saddled burros lined up and the milling crowd of hundreds of people, is
that I have to cover everyone closely like a blanket, yet am requested to come
to the seat of the Central Plateau at Hinche to meet with the Health Minister
Raul Raphael, who had met with me last time and had given me a present: “Here
is Marmonte district—fix it!” So, I told
them all to hold all diagnostic or therapeutic puzzles until my return as
rapidly as possible, and left four teams of quaking freshmen clinicians as I
scurried down the road with Marie Cherie and Huda to see the Health Minister’s
office in the district hospital. He had
just left for the
As we approached the hospital an eerie sight was happening as we drove in. A group of men was carrying a patient bed with a body covered by a sheet. This is a society that does not require birth and death certification, and the populace is very familiar with both processes which are accepted as natural events, so they are not “specialists’ concerns.” But are public. The ritual involved carrying the patient in the bed to the shade under a tree where there were a number of family, each of whom could see and confirm for him or herself that the patient was quite dead, and then proceed to cover the body with blankets to prepare for burial soon. This was the closing cycle of the life process and was not thought of as unusual.
We quickly stopped at an outpatient clinic where scores of people were sitting outside under a shade tree and they were called up patiently one at a time to see the office staff for DOTS treatment of HIV and TB of the MDR kind. This is an operation run by Zanmi Lasante (PIH) and the Health Ministry, since the drugs are coming form the Global Health Fund, now that the embargo on impounded money is lifted. It is a smooth and professional operation now, given the resources it has. Photographs are not encouraged, but I witnessed the whole queue of HIV and TB patients getting the kind of treatment and attention by their “accompaniateur” that made the program a success. The latter is chosen by the patient, unless they have no suggestion in which case one is appointed.
We made
quick rounds of the TB wards which were well turned out with the nurses and
other staff well organized. It was a
good infrastructure in a country otherwise bereft of any such—and this is made
possible by an infusion (continuous?) of outside support. We passed a airstrip where three times a week
a light plane run by MAF (the same Mission Aviation Fellowship I had used in
the
I scurried back ASAP to rescue the teams who were starting to accelerate as they saw the even larger crowd outside the door thickening as I arrived. I saw a very large number of patients quickly by rotating around each of the four teams, and made quick dispositions of the patients who kept on coming for what may be our busiest clinic yet. I will detail those patients through the reports of the students, who have a “social obligation” tonight which is the incentive toward finishing soon. The incentive on the part of the patients, who have endured quite a few more rainy seasons than the students, is they want to be seen and on their way home before the afternoon rain starts pelting down.
We did manage to clear the last patients just a s the skies opened up so that we got the benefit of the rain on the rugged roads back, crossing through the streams and gullies in the Nissan 4 WD SUV’s—about the only place anyone who was currently riding in one could honestly admit that they were really needed!
AND TEACHING
CONFERENCE ON CLINICAL PROBLEMS
A-1 Mike: a man with a tender left lower quadrant for months, with occasional diarrhea. I found a palpably tender sigmoid colon—with the diagnosis that was quite obvious for this period of time, since he had received some nonspecific treatments a couple of times without a relief of the persistent problem “He has an acute metronidazole deficiency.” We could feel the tender colitis of the kind that comes from a persistent amebic colitis. He as yet had no other tenderness to suggest the pyelephlebitis nor liver abscess, and in another world we would have done more that the stool “O & P” but done the zymogenes that might determine if this is the type to invade.
B-1 Anisha: a young child with a large lymph node in a strange place—above the elbow on the inside of the arm. This is the “epitrochlear node” and the reason for the medieval practice of the “syphilitic handshake.” In those days before your daughter was paid court by a young swain, a father would shake hands with him and extend the hand up the inner arm to check see if he had evidence of a ”gum” in this very node, which might make him an unsuitable suitor.
We reviewed the differential of lymphadenopathy in kids and the “Rule of Sevens”= 1) Seven Days=inflammatory; 2) Seven months= neoplastic; 3) Seven years= congenital. This kids’ node was inflammatory, and we saw another child with a filed of large nodes that might have us concerned about a lymphoma which would cause us to get a WBC thinking of Hodgkin’s or leukemia since the report was of a gradually expanding set of masses over a year.
C-1 Adam: a five year old boy with a problem of a large red thing coming out of the child’s anus with an ability of the father to get it back in for several days at a time. This sounded horrific to the group and they were all thinking that this represented a snake size worm. In fact, it was a matter of parasitic infestation, but this is due to the Trichurias trichuria—the whip worm. As I had demonstrated in a photograph I had taken in Nigeria 38 years ago when I was in the stage of the senior medical students on this excursion, the long red thing is the angry mucosa of the rectosigmoid prolapsing with the little white worms attached. This is intussusception of the kind that occurs at the sphincters and can be successfully reduced as the father had been doing, and then for the rest of the night the buttocks can be taped to help it stay in so it does not get so edematous as to be difficult to reduce the next time. Meanwhile, we dosed him for the worms, This kind of intussuception was distinguished from the kind that happens to younger kids with a less well developed fusion fascia and an ileocolonic intussuception with the ileum being the intussusceptum and the colon being the intussucipiens, with “currant jelly stool” passed by the devitalized mucosa. This is reduced often by the barium enema that makes the diagnosis, provided it is not down too forcefully.
D-1 Anthony: s forty year old with a hernia; we have now reviewed each of the abdominal wall hernias from inguinal: direct, indirect, inguinal and femoral, and ventral, epigastric, umbilical.
I tried to induce a round of public
health cases for which they were told to prepare through the day to make the
second
A-2:
B-2 Neely: Four children were seen with what I confirmed as malaria; how were they getting their meds and who wound be following them? She suggested a mobile clinic for this specific benefit. I had offered that the malaria was a cyclic phenomenon dependent on the cycles of Anopholes mosquito breeding, dependent on standing water and the rainy season. She wanted bed nets soaked in pyremethium, which I suggested implied that the children had a bed. Such a technique requires a continuing follow-up on a valuable commodity, the net, and its re-soaking in the drug treatment. There is a better way to control the mosquito with large ecologic implications, and that is the residual application of DDT. It bioaccumluates, so there is a hazard up the food chain, as Rachel Carson et al have warned, but in an environment as desperate as I was in during the beginning of the rains in Maputo Mozambique, with very high death rates among children and pregnant women, I was ready to call of my ecologic concerns since the endangered species at that time was human, DDT has superb staying power and can hang on a long time more than the pyremethium, but it is a choice made by the developed world in which little input is sought form the most affected in the third world. Once again, to cite an old saw of Paul Farmer’s, we are here to consider more “O for the P”= “Options for the Poor” who are denied almost all choices. I pointed this out twice, when a recommendation was made to a mother of an anemic child that the child should be fed more meat, and I had recommended a good caviar and a particularly good vintage; and second that a family go down to Cange to the hospital, and I had recommended that they might be better served at the Brigham at Harvard which was equally accessible to them. Every day we focussed on the theme: “O for the P.”
C-2 Zeb: He had a memorable comment translated to him by a fifty year-old mother: “Hunger is killing me.” She was given half of a protein bar, and immediately she went off to the side and broke it into pieces and gave a small piece to her kids and grandkids—the self-sacrifice of every mother on planet earth. He asked if there were nutrient programs that could be set up to aid her? I asked if he thought the food distribution so provided would be apportioned any differently? As invariably as the nutrients delivered via the placenta, nutrients got into the hands of any mother are going to go most likely first to the children. So, raising the level of nutrition generally, will still leave some behind, who cannot, or choose not to use them for themselves—as they themselves are better examples of “O for the P.” and dependents.
D-2 Martha: a 13 year-old girl presented because of some
unusual source of bleeding—she had been surprised by menarche. This brought out Martha’s question: How do
young people get sex education information in
After this, again somewhat tortured attempt to get them to think about the population as opposed to a given patient for public health questions, we will try form here to integrate public health into the medical discussions to bring them up to the standards of the information value we have in clinical case discussion.
A-3 Siayavash: The value of the medical discussion of clinical cases immediately became apparent with the presentation of a 7-year-old boy with an occluded left nares with a very large nasal polyp protruding from the choanal opening of the maxillary antrum. In this case this was not a malignant tumor, but an inflammatory reaction to some antigen or infection in the maxillary sinus and along the turbinates protruded to occlude hi airway on that side. This can successfully be treated by any agent that shrinks down the swollen mucosal membranes, including the kind of nasal spray (e.g. Afrin, neosynephrine) or lidocaine with epinephrine, or even cocaine—the original indication for the ENT use of this topical agent to shrink mucosa. It is so effective in shrinking mucosa, that habitual users will cause such ischemia to the point of infarction and complain of the annoying habit of a whistling noise from a nasal sepal fistula. We treated him with an antihistamine, and suggested that in another world, if this were in effective he might have an “SMR”—submucous resection—of the turbinate to free up the airway. I would recommend a supply of the Afrin to medically manage this until it goes away later.
B-3 Laurie: A child had “chin infection” around the mouth where she had been sweating a lot. There seems to have been a lot of “prickly heat” in the little kids who had never known an A/C or talcum powder or dry nappy. But this one had gone on to get the staphylococcal superinfection seen n impetigo.
C-3 Duc: a patient with headache, vertigo, fever and shaking chills: a reason to look into “FUO” here, or as the British might say Pyrexia, instead of “Fever of Unknown Origin.” In most little kids, a fever might represent an infection as the subset of inflammation—and in them it is a good bet to look at the respiratory system. URI’s are common, especially when the ears are thrown in with tonsillitis and big inflammatory reaction sin tonsils and adenoidal lymphoid tissue. The serious problems ( and the second in the Top Five Causes of Death World Wide I had emphasized earlier: DAMMM = 1) Diarrhea, 2) Acute Respiratory, 3) Malaria, 4) Measles . 5) Malnutrition) is LRI—lower respiratory tract infection. This was apparent in several kids who had grunting, retraction, use of accessory muscles in effort breathing, and wrinkled forehead and open mouth—these were easy diagnoses even before the stethoscope was put there, let alone a chest X-ray (and one had been used in diagnosis of our own staff person—Zeb!)
Kids are not likely to have fevers from accessory GI tract infections like biliary or UTI’s (urinary). Besides, this one was not focal, with the complaints reflecting a generalized reaction to something. If the person has a crisis—such as an organizing pneumonia, or a biliary colic, or a urinary tract obstruction, a “chill” can be part of it, but there was no evidence in this case. So, we are left with the most common condition for this set of symptoms—and number three on the list of DAMMM. A shaking chill in a several day pattern of fevers is a sign that hemolysis is taking place as the red cells are lysing and the plasmodia are showering through the blood. She was successfully treated for malaria.
We pointed out that the falciparum are the one of the four kinds of malaria that exist here in Haiti and this kind is the worst since it can go into the “sleeping” phase “Hypnozoites” hanging out in the Reticuloendothelial system and lurking for an event later to trigger their release. The sudden contraction of blood volume causes the reservoirs in spleen and liver to be opened up, and a shower occurs with a shaking chill form this release of the sleeping hypnozoites—an example which happened big time in the case of a post partum woman who made a perfect demonstration of the blood loss followed by shaking chills and fever.
As nasty as falciparum malaria is, there is but one ray of hope here in Haiti—it is all still sensitive to cholorquine, as opposed to the kind I encounter all the time in Africa and Asia, where it is uniformly resistant to this first line and relatively safe agent, and I have to use second line and more toxic treatments.
D-3 Anthony: an elderly man with a foamy growth around his mouth; this showed the differential diagnosis of such a lesion. He is beyond the age of impetigo, and not likely to have herpes lesions (unless he had another immunosuppressive condition, for which there was little suspicion) and only babies wold get a fungal infection like candida, right? Here is an example in which life has turned in one of its circles, and he indeed did have “thrush.” He was treated with our topical antifungal.
The didactic sessions were as deep as their were broad in spectrum, and incorporating the public health issues in to the case reports was a more successful way to add credibility among those struggling with the large volume and wide complexity of issues as happens when the clinic door swings open, and “all comers” descend upon the bewildered teams