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May 18th, 2019 by leahtourtellotte
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I completed 4 weeks in Haiti and now I’m back in the US. The change has been hard. I can’t help but keep comparing the condition there and here. We are so lucky here and I take it for granted every day. I have affordable electricity all of the time. I have water that I can drink practically anywhere and hot water whenever I want. I have wifi or 4g everywhere. I can go to happy hours and all you can eat restaurants in a variety of cuisines. I’ve already gone to see Avenger’s Endgame. To live just seems easier here.

I went on a tour the other day of our micro and chemistry labs at Eisenhower and thought back to the one room lab in Haiti. No cultures. No fancy machines. Labs that go in and out of availability. Numbers that print out on pieces of paper that like look old school cash register receipts. Here blood literally goes through one machine that takes it to other machines depending on the test and you can see little mechanical arms pipette chemicals and numbers result on computer screens. Cultures get stacked up in incubators. A machine runs analytics that can identify the organism. What a difference!

I had a likely TB patient the other day. Airborne precautions and N95 masks of course! In Haiti, we had run out of PPDs. Now not only can I do a PPD, I can do a quantiferon gold and AFB smears. I can also rule out other things like cocci. The chest xray has a consolidation; let’s order a CT. Now I can actually see that right upper lobe cavitating lesion. I can start RIPE right away and follow up that culture. As a clinician what I didn’t realize was how much I would miss relying on tests and imaging to make a diagnosis. In Haiti, I didn’t anticipate the anxiety I would have in questioning myself and hoping that I diagnosed appropriately.

How did I end up in what seems like a different world? And perhaps most importantly, how can these disparities be overcome so that others may live healthy and socially rewarding lives as we do?

Cervical Cancer

May 2nd, 2019 by leahtourtellotte
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Last week, I was very saddened by a patient who came to the clinic. She was 49 years old and postmenopausal, but was presenting with one year of vaginal bleeding. In my first world mind, my first differential was endometrial cancer… She had cervical cancer. She was also hypoxic in the 80s while on 5L O2 by nasal cannula and in renal failure with ultrasound confirmed hydronephrosis which indicated at least stage 3. Gyn surgery/hysterectomies are rather rare here, radiation is closest in the Dominican Republic, and chemo has some availability. However, she in particular clearly couldn’t tolerate it even if it were available. She was given lasix, but a foley catheter was placed with no drainage of urine. There was nothing more we could do and she was essentially brought home by her family to hospice.

What perhaps makes this even more sad and crazy is that I have seen two other patients with similar presentations. Cervical cancer and advancement of the disease has been made preventable with Pap smears, colposcopies, cone biopsies, and hysterectomies but these require pathologists, technology, and surgeons.

Here, as in other resource poor countries, prevention is performed with visual inspection with acetic acid (VIA). Essentially, a pelvic exam is performed with a speculum (steel and reusable of course) and the cervix is coated with acetic acid (regular vinegar) for 1 minute. Abnormal tissue stains white as the acetic acid reversibly coagulates nuclear protein. If that happens (VIA positive), a Pap smear is performed. This is collected on a slide and fixated with hair spray as that is easier to store and transport than the ethanol cups. These are sent to the US for pathology read and results come back in 3 months.

I did a quick internet search and found that, consistent with intuition, VIA is more sensitive and less specific than Pap smear. Percentages have of course varied by study, but it does seem that VIA has similar accuracy to Pap smear. I do wonder what other clinics in Haiti do for cervical cancer prevention. One can only hope at least VIA is attempted.

Clinic

April 27th, 2019 by leahtourtellotte
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Haiti Health Ministries is unlike any American conception of a clinic. As early as 7am, patients start arriving and waiting in line. There are several long benches outside and, without fail, become jam packed with patients.

 

The doctors meet at 8:30 for a little conference where our steadfast leader, Dr. Jim, talks about a topic we’ve recently encountered. Dr. Jim is an American doctor. He established the clinic with his wife who manages the clinic. The clinic has moved but they’ve been in Haiti for 20 years. There are two permanent full time Haitian doctors and a half time Haitian NP. There is an American PA, ultrasound tech, diabetes and lactatation educator, and two Haitian nurses that round out the crew.

 

We pray for the day and then head out to our clinic rooms about 8:45-9ish. Patients come inside and wait on benches along the hallway of the clinic rooms. Follow ups are assigned to days and not times (wouldn’t work here!) and we see patients based on order of arrival, whether they have an appointment for that day, and some triage. Without appt times, I just take however long or short of a time I need with the patient.

 

There is a room with two beds that serves as the emergency room. We are able to give oxygen, nebulizers, IV fluids, limited IV and IM meds, take an EKG, and wound care. One large room is designated as the lab. Lab tests are limited and can depend on availability. We can do rapid hiv, malaria, sickle cell, VDRL, PPD, hematocrit, CBC with a diff of lymph/neutrophil percentage, creatinine, glucose, pregnancy, prolactin, TSH and free T4, AST, ALT, potassium, and vaginal smear. Right now we’re out of TSH and free T4, creatinine, CBC, and PPD. Hemoglobin A1c is never available; I make medication changes off the fasting blood glucose from that morning. Another room along the hall is for ultrasound and X-ray. And the last room at the end of the hall is the OR. Dr. Jim has a schedule every day for biopsies and mass excisions. Lots of I and Ds are done too.

 

In a separate adjacent building, there is a pharmacy. The formulary is limited of course due to cost. We do have a pretty good arsenal of antibiotics: amoxicillin, augmentin, doxy, Bactrim, cipro, metronidazole, keflex, and IM ceftriaxone. Diabetes meds are limited to metformin, glyburide, and NPH 70:30. Atenolol is our only beta blocker. Warfarin is limited, so usually only given to those with mechanical valves. Topical diclofenac isn’t an option, nor are triptans. Our only inhalers are SABA and beclomethasone. I diagnosed a lady with hyperthyroidism, probably Grave’s, but found that she was pregnant. We only have methimazole. :/ Food is also stocked in the pharmacy for patients that cannot afford food.

 

Everything is very low cost. For example, a clinic visit is 20 Haitian dollars, equivalent to a little over 1 US dollar. An X-ray is 50 Haitian dollars, equivalent to 3 US dollars. Some labs are free, like pregnancy, hematocrit, and glucose. TSH and free T4 together are 80 Haitian dollars, equivalent to almost 5 US dollars. Medication prices are variable, many are free. Medications that are donated are not sold and are given for free. If a patient really cannot pay even those prices, then we will still see them/do labs/perform imaging/give necessary medications for free.

Pre-departure, travel, and Day 1

April 13th, 2019 by leahtourtellotte
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I was nervous as I prepared to head out for Haiti. I knew no one else there and didn’t really know what to expect. I was intimidated by the language. I don’t even know how to say hi, how are you? Even in Grenada, I could at least communicate with people and figure things out. My last minute attempts to learn some Creole were a fail, pushed back by packing preparation and credentialing forms I’ve been filling out for next year.

 

My packing preparation consisted of collecting items that Haiti Health Ministries told me that they needed. (I had a great lesson during the training course about donating what will actually be useful. For instance, all those donated bottles of water lead to a huge pile of trash and a lot of expense to ship when a filter or something else sustainable would be more useful.) I asked for donations from friends as did my supportive partner in crime. I learned that donations through venmo and then me subsequently buying stuff is way more convenient for people than them buying and bringing things in themselves. Friends were very generous and I went to several different Walmart and Amazon to amass a large suitcase full of medications, gauze, glucose test strips, infant formula, syringes, vitamins, and, in true Leah fashion, candies for the kids. (Starburst jelly beans for Easter!)

 

I missed my second flight from JFK to Port-Au-Prince because of a delay of the first flight. The airlines got me on the exact same flight for the next day. The annoying part was arguing with JetBlue and stalking the supervisor to get myself a hotel room. Unfortunately by then, I was too tired to hit up my NYC faves, La Bogota and the Chocolate Room.

 

Upon my arrival in Port-Au-Prince, I was surprised to get my bags and I went through customs swiftly. Sandy, the Haiti Health Ministries all purpose manager of sorts, was waiting for me. She was friendly and welcoming and I immediately felt more at ease with someone who knew what was going on and spoke both English and Creole. We hopped in a truck with a large cage in the back. We had errands to run in Port-Au-Prince which were interesting as I got to see more of the city. The city is surrounded by beautiful green mountains. Many streets are lined with vendors selling just about everything, from fresh fruits and veggies to toothpaste and toiletries to mattresses. Traffic was pretty crazy on some roads. Some buildings are still being repaired from the earthquake, but rubble is mostly gone. Ravines run throughout the city and are loaded with trash. But we did get caught behind a trash truck, so the country is working on that!

 

One errand required going to a local hospital. I wish I could have taken pictures but phones weren’t allowed and I didn’t want to violate patient privacy. The pediatric ER was about the size of our Resident’s lounge at Eisenhower and everyone was in one room. We were there to pay for treatment for one of the patients who had presented to clinic but needed to get admitted to the hospital. He was 15 years old and presented with paralysis and a very tender neck with a mass. He had a brother with TB and his PPD was positive, although he had no pulmonary symptoms. Cervical X-ray showed cervical vertebral fractures? and CSF analysis suggested TB. Pott disease? TB meningitis? scrofula? (Sorry for the sketchy details; I didn’t examine him or see his chart.) Even from across the room, I could see every rib and his legs were about the same diameter as my wrist. He was lying in one corner of the room with a mask on his face with about ten other nurses, doctors, and patients, and mothers in the room. We then spent at least half an hour going back and forth from administration to the cashier trying to get his lab tests and CT paid for before they would perform them. Welcome to Haiti.

Introducing Myself

March 25th, 2019 by INMED
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Hello! My name is Leah Tourtellotte. I am a Resident Physician and I’m starting my INMED service-learning experience at Haiti Health Ministries in Haiti beginning in April – May 2019.