Photo by John Carroll–November 13, 2020
I am scared each morning I go to work in Haiti. The Haitian traffic in the 3 million person capital of Port-au-Prince is always very congested and absolutely insane. Making a new lane by driving up on the sidewalk while scattering pedestrians and market women in our wake is almost a daily occurrence.
But the drive to the clinic is not what really scares me all that much. It is the little patients who are waiting for me in the pediatric clinic that scare me the most.
Will I be good enough for them? Will I make a sound diagnosis and choose the correct treatment option? Will I be patient with the mothers and listen to them as I should? These are just a few of my questions each day before clinic.
So out of fear, I silently pray in the vehicle (or on the moto) that God smartens me up for the day.
When we arrive at the clinic, the security guard opens up the metal door to the clinic yard and we enter. And this makes me apprehensive too because sitting there on wooden benches in front of me can be 600 moms and children who are silently waiting for the clinic staff to arrive. I know that this crowd represents a lot of work and that each mother and child will have their own story to tell.
I am afraid.
Once in my office, I take my stuff out of my knapsack and arrange it in strategic places on my desk. I go through the exact same ritual each day as if this will help me improve my clinical reasoning in some strange way. And after I have done this, the smiling-and-always-happy triage man leans in and puts 15 dossiers in a nice neat stack on my desk just under my nose. He has already positioned the moms and their children outside of my door on benches in the same order as their dossiers appear on my desktop.
And the fun begins.
I call the first child by yelling out all four of her names. Prince. Lovely. Toussaint. RodeMika. And hearing their child’s name, the little slum mothers come hustling into my office cradling their little ones or dragging in their toddlers by their hand. The babies and kids are in various states–many are happy and playful, some are screaming out of fear because they know they don’t want to be in clinic (any more than I do), and some are ominously silent and lethargic and are threatening to die.
So I begin by asking mom why she brought her child to the clinic in the first place. And mom answers in Creolized-French in muffled tones behind a face mask. And because of the mask, I struggle to hear her at all. And now for the first time in 40 years, I cannot read her facial expressions hidden behind the mask. I feel very impaired from the get-go.
This is not my first day at work in Haiti, but I am afraid anyway. I want to do the right thing for each baby and I am worried because I think I may not if I can’t even take an adequate history. So I take a breath and start over with mom, asking her the same questions while I make her repeat her answers to see if I can better understand her concerns about her baby.
When this history taking mercifully ends, I start the physical exam.
After taking the baby’s vital signs, I observe the general demeanor of the baby and then examine her scalp and skin, look in the ears, mouth, and throat, feel the neck for nodes or masses, listen to the heart and lungs, press on the abdomen, etc.
After this, I am forced to commit to the diagnosis. But I question myself. Do I think I really know what is wrong?
Do I need labs? The labs most likely will not be done the same day and maybe not even the same week. Diagnostic imaging such as chest x-rays, sonograms, and CAT scans are not available on a STAT basis (and usually not on ANY basis) for my patients. How much do I trust my pre-test probability of disease especially if there will be NO tests to determine the post-test probability of disease?
It is what it is and I make a diagnosis.
And what happens if I think the baby needs admission for sepsis or meningitis or some other “stupid disease” from the slum? Should I write a referral to the hospital across town? Should I treat with IM antibiotics knowing there is a small chance the mother will make it to any hospital with her sick baby even if she agrees to go? And if she does make it to the hospital, I know the baby may well be turned away for lack of beds.
A tortured life it is.
I explain these scenarios to the mother and tell her to come back to see me the next day with the baby if the baby is refused admission. And to the sickest babies with an infectious process, I do give a shot of a strong antibiotic with a long half-life before they leave my clinic. And the Haitian mom always tells me that they will return with the baby the next day as I press some money into her hand putatively paying for their transportation to the hospital, but in reality, bribing her to come back with her baby to clinic the next day.
As she leaves my office with her child, I usually don’t feel content at all. And I am worried about the sickest babies–the ones with no margin for error. I ask myself if I did everything possible under the harsh conditions of the slum.
And so the scared doctor remains scared. But I try and control my fear the best I can so I am able to return the next day and begin again.
John A. Carroll, MD
Source by blogs.pjstar.com