Spoiler alert: This post is LONG--and even abridged from my actual report-- and intended mostly for people who are thinking about applying to the fellowship and/or my family. It serves an example of what you are expected to do in terms of reflection during the fellowship. It is also a status update on my heart.
This report encompasses the time roughly from September 10, 2010 to October 22, 2010, or about six weeks of my time here. During this time I switched from working in Pediatrie to working in Maternite (a move I will talk about more later) and will thus focus first on Peds before switching over to describe my time in Maternite.
My heartfelt impression of pediatrics, when the place floats into my head, is that I love it there. I adored most of my patients and parents, as well as valued the experience of doing so many history and physicals, exam maneuvers, and clinical decision making. I noticed that I tend towards tough love and need to work on my judgment as far as when to take a complaint seriously (ie my baby breathes funny, has diarrhea all day, has a red anus) and when to offer reassurance. Overall I had moments, even whole afternoons when I experienced what Mihal Csikszentmihalyi's concept of “Flow” as part of good work, the notion that you are so present in what you are doing you don't even notice the passage of time. I also felt impossibly lucky at times when I realized that this is going to be my life-- I really get to take care of babies, kids, families for the rest of my life. How could I have possibly gotten so fortunate as to stumble into this job?
In terms of my actual medical work in Peds, I feel good about what I was able to do in regards to seeing a good daily load of patients and in individual cases where I felt that I made a difference. Here are some of the stories of my patients whose care and lives I became more involved with:
1. EB, a 4 year old asthmatic that I saw during three separate hospitalizations for crises in August/early September. I read about what medications were available in Gabon, measured her peak flow, tried out different doses until we seem to have found the combination that is working for her right now. It is so nice to listen to her lungs now as opposed to the first time I heard them wheezing and crackling three months ago.
2.CE, a malnourished, HIV positive baby that was with us for three weeks trying to get her nutritional status corrected. I ended up getting the family food and other resources as well as getting to know the entire extended clan well.
3.KM, a sick little 8 year old boy. I did my first LP on a child in him, which turned out to be a champagne tap (!) and we treated him for meningitis. He got so much better after the tap we joked either that it was therapeutic or that he suffered from Stockholm syndrome and fell in love with me because I was his tormentor.
4.Baby B, a premie baby that Dr. Florian and I performed CPR on my very first 15 minutes in Pediatrie (literally on the very first day of my time at HAS!), who ended up surviving that arrest episode, as well as two others, gaining 700g in the hospital and being discharged right as I switched to Maternite. We, me and Florian, tried in vain to get the mother to name the baby after me, or even him, but to no avail.
5.Drepa Mom, a kid whose electrophoresis showed homozygous SS, and when I offered to do a teaching session on sickle cell with her and the child came back the next day at 8am with tons of questions, eagerly accepted all my handmade handouts, and generally seemed like a superstar involved parent.
There are two cases that linger with me as mistakes that I made that may have negatively impacted the outcome for the patient. Not that I want to dwell on these cases, but they both gnaw at me for different reasons. The first case was a child with diarrhea and vomiting that I saw in consultation who came back to the hospital over the weekend (4-5 days later) severely dehydrated and ended up dying one day after being admitted. This bothers me because I did not have a high enough index of suspicion for a severe illness, apparently, and must not have given good instructions about warning signs that necessitate coming back to the hospital. In the second case, I gave a mother positive HIV results for her and her baby and she fled the hospital in the middle of the night because she did not believe me/HAS. In this case, I should have approached the counseling scene differently, maybe waited until Monday to give the results rather than doing it on a weekend, maybe brought a nurse or HIV counselor with me to avoid/buffer the mother's denial response. As a final set of comments on the Pediatrie:
1. I love the nurses there and think that they do a great job and deserve recognition for that fact.
2. There should be continued focus and development on neo-natal care at HAS, both nursing/medical care as well as the hospital's technical capacity to care for premature infants. Neo-natal death is a huge cause of mortality in Peds and could be a shining success for the hospital, like the TB project, in the sense that it advances our goal of creating a culture of results. Maybe we could get a neo-natologist to come consult or dust off some of Dr. Cumming's stuff (Yale peds person that created neo-natal curriculum and monitoring sheets here) that sits on an abandoned shelf in the Pediatrie.
Throughout my three months here I have worked with the PMI every Thursday, which has provided a nice thread of continuity to my fellowship time. An interesting case has emerged from one of our sites, Bellevue, which is accessible only by pirogue. The first time I went to that village, there was a 4 month old baby with recently developed hydrocephaly, I referred the kid to peds, where Dr. Florian saw him and suggested the mom try going to Owendo, the children's hospital in LBV. When we went back as the PMI six weeks later, the kid's head was bigger and I got in touch with Bongolo Hospital, in the south of Gabon, because I had seen a patient with a VP shunt in peds who received the operation at Bongolo. This case, to me, begs the question of medical evacuation from PMI sites/Schweitzer as well as the possibility and desirability of a collaboration with Bongolo Hospital. I am currently trying to get the patient down there for the VP shunt surgery, have already been in touch with the surgery team there, and they have okay-ed him for surgery even if his mother cannot find the 120,000 CFA that they charge. We should also make this resource more widely known to/for our patients, especially in peds as they have a neurosurgeon there doing the hydrocephaly operation. This seems like it would be a great link up, win-win type of deal. I am so glad to have consistently voyaged with the PMI, gotten to know those nurses well, done my first true solo consultations as a physician and gotten a better sense of the geographical and emotional lay of the land in the Moyen-Oogue. It also piqued my interest and ever-running internal debate over free versus low-cost health provision, as people in the villages are much poorer, on average, than the people who can make it to Schweitzer as patients. It puts disparity and questions of value and fairness into my mind. Also every time we got out, I think of the old Quaker proverb that my Busia, Polish grandmother, used to write to me at the end of some of her letters. “I expect to pass through this world but once. Any good, therefore, that I can do or any kindness I can show to any fellow creature, let me do it now. Let me not defer or neglect it for I shall not pass this way again.”
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