Sunday, November 14, 2010
I made the recent decision to become a lactation consultant. In 2012 the required criteria will change to become more stringent. I decided now was my chance to do it. I had most of the requirements already, save one. I need 500 hours of clinical time with a lactation consultant, following her, learning her trade. I need to complete those 500 hours in six months, the deadline for the lactation consultant exam. That's 80 hours a month, 20 hours a week, to eek out of my already packed schedule. I'm up for the challenge. I had my first full day last week with Charlene Burnett, a long time friend and lactation consultant. In one eight hour day, I followed Charlene as she taught two breastfeeding classes, one to inpatients, and one to outpatients. She was called to the pediatric clinic twice to do on the spot consultations with moms having breastfeeding troubles. She did morning and afternoon rounds on all the breastfeeding inpatients, consulted constantly with the staff nurses on their patients' status, and conferred with the quality improvement nurse on gathering breastfeeding statistics to document all her efforts. She also oriented me to the unit, processes, procedures, and culture of the floor. I've know Charlene for many years, but I've never seen her in her element. She was like poetry in motion, zipping from one place to the next, swooping in to save the day (or sore nipples as the case may be) her white coat standing in as her superhero cape. It was all so impressive seeing an expert, high functioning lactation consultant at work. I was actually brought to near tears, as I watched her work with an African-American young mother back in the Pediatric clinic with her week old infant. The young woman's mother hovered near by taking in every word, with a look of concern for both her daughter and infant grandson. Charlene asked the young woman questions to gauge her concerns, then asked to see her breastfeed her son. Charlene watched the woman nurse for a minute or so and asked more questions. The entire time in a low soothing tone, she also spoke to the infant, giving information about breastfeeding basics (of course this information was intended for the mother and grandmother, though she was addressing the infant- very cute). After asking permission to touch the woman's breast (as she was careful to do all day with every patient), she showed the woman how to more effectively position both her breast and her baby to prevent sore nipples. She had immediate positive results and you could see the relief on both the mom and grandmother's faces. She ended the visit with a few positive encouraging words. The entire visit was no more than 10 or 15 minutes, and yet this young mother had turned a corner. I had no doubt that that short visit would reap benefits in keeping this mother nursing her baby for a longer duration. She was more confident and empowered than the worried, anxious mother we had met when we entered the room. Charlene had even convinced the skeptical grandmother that her daughter could give her grandson adequate nutrition. Leaving the room with mother and baby happily nursing, we stopped at the desk for Charlene to give her report to the pediatrician. She explained in a few words what the problem had been and the tools she gave the mother to manage the situation. The pediatrician looked at her with gratitude and relief, and thanked her. She garnered respect from all her peers, it was clear that everyone saw the value in the service she offered. We quickly moved on to the next task at hand. During the outpatient class, three new moms sat around a table nursing their babies of varying ages and chatting excitedly about how their breastfeeding had evolved from the previous week. After each mom had shared, Charlene asked about their difficulties and then worked with each mom individually on her particular nursing issue while I chatted with the others about their baby's progress and development. She ended the class by giving each mom a gift before sending them on their way. (She had written a grant and used the money to purchase breast pumps, nursing pillows, fancy burp blankets, etc.) Later that same day, I watched as Charlene gave instructions to a Latina patient in Spanish (!) on getting her newborn on the breast. I loved getting an up close personal view on the impact an LC can have on the families she serves and her work environment.
Though I have no plans to work in the hospital setting, I'm looking forward to being able to provide this level of guidance and assistance to those who need it. My plans for my LC credential include educating staff nurses on breastfeeding basics, and breastfeeding supportive behaviors, and creating research to measure educational effectiveness for nurses. My research and experience has shown me that staff nurses in labor and deliver, nursery, or mother/baby are often the weakest link in the breastfeeding support chain. I'd like to dedicate my efforts to strengthening that link.
Tuesday, November 9, 2010
-A refugee woman is slapped and pulled from the bed by her hair by her husband, just hours after giving birth.
-A young woman labors all night with premature labor, induced by a kick to the abdomen she received from her boyfriend. Though the baby is rushed to a high level neonatal intensive care nursery, he dies early the next morning.
These are just a few of the cases of Intimate Partner Violence I saw personally during my stint as a labor and delivery nurse. One of the things I found most shocking about my job, was how often I would interface with violence. It was not something I expected to encounter as a labor nurse. I quickly learned that if I was going to work with women, I was going to encounter occurrences of violence.
Intimate partner violence is defined as: violence that occurs between a victim and perpetrator who are current or former spouses or partners. The Center for Disease Control (CDC) recognizes four types of intimate partner violence:
- physical violence-the intentional use of force involving hitting, punching, kicking, etc.
- sexual violence-the actual or threatened use of force to compel a person to submit to sexual acts against their will, attempted or completed sex acts with a person unable to avoid participation, communicate unwillingness, or understand the nature of the act, and finally, abusive sexual contact
- threats of physical or sexual violence
- emotional abuse-use of humiliation, name calling, deliberate embarrassment, controlling their activities, isolating from family and friends, controlling or withholding resources including financial
- coercive control and intimidation- acts perceived as threatening or violent
For maternal and fetal health, the consequences of undetected IVP can be grave:
-miscarriage (less than 20 weeks gestation)
-infant injury or death from maternal trauma (more than 20 weeks gestation)
-maternal stress and depression
-self medicating with smoking, drug use, alcohol (all linked to poor infant outcomes)
-decreased or delayed prenatal care (also linked to poor outcomes)
-maternal injury and death
-child abuse or children witnessing abuse
Unfortunately the cost of intimate partner violence doesn't stop there. The Women's, Infants, and Children's Health Committee that I co-chair recently published a report on the literal costs of domestic violence in our city. A 'point in time' survey was sent out to law enforcement, healthcare agencies, shelters, the courts and other agencies to determine the services and fees provided related to domestic violence in a 24 hour period. The total estimated costs of domestic violence for one day in our city was $61,000, or an estimated 2 million dollars a year! About 94% of the funding was provided in services to victims, the other 6% in perpetrator expenses. Of those receiving services for violence, about 6% were pregnant. This cost of IPV snapshot was quite eyeopening.
When I attended the obstetrical complications workshop last week, Ms. Otemba reviewed the following information important for nurses who are on the front lines of assessing for IVP.
Cues to IVP
- delayed prenatal care
-noncompliance to therapeutic regimens
-frequent ER visits
-somatic complaints (headaches, pain, fatigue, stress)
-fearful, evasive affect
-characteristic injury pattern (head and neck, torso, different stages of healing)
Appropriate assessment means universal screening for every patient. Let the patient know that you ask every patient these questions and they should be asked in private without any family members presents.
"Within the year, have you been hit, slapped, kicked or otherwise physically hurt by someone? Since you've become pregnant? Has anyone forced you to have sexual activities?"
While these questions are appropriate to ask every patient, to get patient disclosure we have to create an environment where it is safe to disclose. Privacy, brevity (the abuser may be lurking near by), trustworthiness, nonjudgmental attitude, acceptance are all a part of what we have to offer patients in order to facilitate disclosure. Most healthcare providers may have discomfort asking these questions, or may not know what to do if the answer is yes. It is important to have a plan.
You ask your patient with suspicious injuries if she has been beaten, and she answers, 'yes'. Now what?
-Emergency management: It's imperative to know your community resources. Here in my city, we have the Bridge SPAN (Safe Patient Advocacy Network) program. Our local shelters work closely with the hospitals so that through Bridge, with just a phone call from the nurse (or any staff member) a shelter counselor will be dispatched to the hospital 24/7 to offer shelter, police protection, orders of protection, counseling, case management, and child protection and other needed emergency services.
-Validation: "You do not deserve to be afraid, controlled, threatened, or hurt." The patient may need repetitive validation to understand that it was not her/his fault and that they do not deserve such treatment.
-Evaluate the severity: There are many tools available. In our area, agencies are encouraged to use the Lethality Assessment Program to determine the level of danger a patient might be in. This will help to determine the appropriate interventions.
-Education: often control has been establish by lies and deceit. Patients need to know the facts about their situation and what their rights really are.
-Referrals to ongoing community care and support such as legal services and support groups.
Recently, I met with a woman who has left an abusive relationship after many years. Her abuse was revealed to me during care provided for one of her pregnancies. When she felt it was safe to do so, she planned an escape that was two years in the making. When the opportunity came to flee safely, she took her children and left, with a well executed plan in place. They have remained safe from their abuser for a number of years. Talking with her about her situation reminded me, that there is hope for a life beyond the violence, if we are all willing to do our part.
Center for Disease Control: Intimate Partner Violence in Pregnancy. Retrieved 11/8/10. http://www.cdc.gov/reproductivehealth/violence/IntimatePartnerViolence/sld001.htm#10
Otemba, J. (2010). Complicated Pregnancies; implications and management. PESI healthcare. Workshop presented on 11/5/10 in Lenexa KS.
Kansas City Health Commission. Estimating the costs of domestic violence in the Kansas City area: a report on the 2009 domestic violence, point in time survey for the greater Kansas City area. Women's, Infant's, and Children's Health Committee, and the intimate Partner Violence Subcommittee. Approved and issued on 10/1/2010.
Saturday, November 6, 2010
A physician and staff writer by the name of Jerome Groopman published an article in 2006 in New Yorker magazine finally giving Ananth Karumanchi broad exposure to his work. Theories about preeclampsia abounded, but the true cause continued to allude the scientific community. For those who are unfamiliar, preeclampsia is a disease of pregnancy that manifests as high blood pressure (greater than 140/90) and proteinuria (protein in the urine). Edema (swelling) and neurological changes such as visual disturbances and hyperreflexia (brisk reflexes) can also occur. If left unabated, preeclampsia can lead to seizures (a condition called eclampsia) and liver damage caused by HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets). The only known cure is removal of the placenta (delivery of the infant), at which point, the symptoms quickly reverse, and the woman gets better (if no permanent organ damage has been done to the liver or kidneys). If preeclampsia manifests late in pregnancy (as it most often does), a preterm infant is delivered. If it manifests in early pregnancy, the fetus may have to be sacrificed for the mother's wellbeing.
It was known that the placenta was the crux of the problem, but how? Groopman details how Karumanchi's careful research isolated two anti-angiogenic proteins (they prevent blood vessel growth) made by the placenta. These proteins, serum fms-like tyrosine kinase 1 (sFlt1) and soluble endoglin (s-Eng) are made by the placenta to control placental growth, and counteract the effects of pro-angiogenic proteins, vascular endothelial growth factor (VEGF) and placental growth factor (PIGF). In preeclampsia the sFlt1 and s-Eng overwhelm the maternal blood stream and cause blood vessel damage throughout leading to widespread vascular permeability and increased vascular resistance. The sFlt1 ultimately causes the hypertension (high blood pressure) and the s-Eng is responsible for the decreased platelets and liver damage seen in the more severe forms of the disease. The amount of these substances increase over time which explains why this is mostly a disease of late pregnancy. It appears to come out of the blue, but in fact the placenta was damaged from the beginning.
Following conception when the fertilized ovum (egg) is a blastocyst (about 100 cells) and starting to imbed itself in the uterine wall (the decidua) small fingerlike protrusions called trophoblasts (precursors of the placenta) grow into the decidua and reorganize uterine spiral arteries in order to set up a good blood supply for the developing fetus. In preeclampsia, this invasive network of trophoblasts and spiral arteries is incomplete, and sets in motion the abnormal release of anti-angiogenic factors leading to ongoing placental insufficiency for the fetus, and vascular insufficiency for the mother, both of which manifest increasing damage as the pregnancy progresses.
Karumanchi after several attempts, was able to publish his findings (increased levels of sFlt1 and s-Eng in the blood stream of women with the disease) in scientific journals and now heads a prestigious lab at Beth Israel Deaconess Medical Center in Boston, complete with government funding. Dr. Karumanchi and his team are now hard at work on what seemed impossible 20 years ago, a treatment for preeclampsia. His research also has implications for cancer treatment interestingly enough, since tumors, like fetuses are dependent on diverting and establishing rich vascular networks.
Preeclampsia and eclampsia continue to plague African-American women at higher rates along with diabetic women and women with preexisting hypertension, obesity, or previous preeclampsia. Those older than 35 and younger than 18 (of all races) are also at a higher risk. No one is sure why, but theories abound. There is still much about this disease that is a mystery.
Last week, my friend Dotty's daughter-in-law delivered a baby boy at 36 weeks due to induction for preeclampsia. She was not in any of the high risk categories. I assured my friend that for preeclampsia, induction is often indicated. Dotty remarked on the small placenta, and the feeding difficulties that are typical for late preterm gestation (more on that in a later post). I am delighted to see inroads being made. They are looking not only at methods of treatment, but early diagnostic tools as well (though the discovery was made 10 years ago and there are still no medications or biologic markers on the market, but I understand that these things take time). I suppose we are all still waiting for the happy ending to this story.
Narrative Report of Research Activities in the Karumanchi Laboratory
Role of angiogenesis in the pathogenesis of preeclampsia (PE) (currently the major focus of the laboratory): Our laboratory has identified sFlt-1, an antagonist of circulating vascular endothelial growth factor (VEGF) and placental growth factor (PlGF), from preeclamptic placentas and has confirmed that it is released into the blood stream in vast excess in patients with preeclampsia. Exogenous administration of sFlt-1 into pregnant rats reproduces the phenotype of preeclampsia, namely proteinuria, hypertension and glomerular endotheliosis, the classic lesion of preeclampsia. These observations suggest that excess circulating sFlt-1 contributes to the pathogenesis of preeclampsia. We have also demonstrated that circulating sFlt-1 and PlGF levels can be used for the clinical diagnosis and the prediction of preeclampsia. Work is in progress to understand the regulation of sFlt-1 production by the cytotrophoblasts of the placenta. We are also testing the effects of antagonizing excess sFlt-1 with growth factors and small molecule compounds in our animal model of preeclampsia with the goal of finding novel treatment options for this disease. Additionally, we are currently characterizing other gene products that are elevated in preeclampsia and which may be synergistic to sFlt-1 in the pathogenesis of preeclampsia and may serve as biomarkers for the early diagnosis of preeclampsia. This project is part of our interest in studying the contribution of endothelium in the pathogenesis of proteinuria and other vascular diseases.
Groopman, J. (2006). The preeclampsia puzzle: making sense of a mysterious pregnancy disorder. The New Yorker.
Karumanchi, S.A., et el. (2008). A longitudinal study of angiogenic and anti-angiogenic factors in normal pregnancy and patients destined to develop preeclampsia and deliver a small )for gestational age neonate. The Journal of Maternal-Fetal and Neonatal Medicine. 21(1). 9-23.
Levine, R.J., Qian, C., Maynard, S.E., Yu, K.F., Epstein, F.H., Karumanchi, S.A. (2006). Serum sFlt1 concentration during preeclampsia and mid trimester blood pressure in healthy nulliparous women. American Journal of Obstetrics and Gynecology. 194(4). 1034-41.
Silasi, M., Cohen, B., Karumanchi, S.A., Rana, S. (2010). Abnormal placentation, angiogenic factors, and the pathogenesis of preeclampsia. Obstetrics and Gynecology Clinics of North America. 37(2): 239-53.
Staff, A.C., Braekke, K., Johnsen G.M., Karumanchi, S.A. (2007). Circulating concentrations of soluble endoglin in fetal and maternal serum and in amniotic fluid in preeclampsia. American Journal of Obstetrics and Gynecology. 197(2). 176-8.
Friday, November 5, 2010
Monday, October 4, 2010
Today we all got up early and headed off to the Bel Aire Clinic in Port au Prince. I have gotten a better look around the neighborhood here in Petionville and it actually is full of gorgeous mansions. The neighborhood is nicer (ie cleaner) and I see more businesses that are transnational chains, more restaurants, more nightclubs, more grocery stores etc. Here is evidence of the class distinction. So far I had only seen poor and poorer and poorer still. I still don't know any Haitians who live in these mansions. However I have met far too many Haitians who are intelligent, and civic minded who are unsure of what the future holds for them. Many of or interpreters such as George, Innocent, Mose, Reginald and many others are bright and energetic young men with unlimited potential, but very limited opportunities. Their is no clear cut route for them to attend college (especially now when many schools were lost in the earthquake). Haiti seems poised to lose its best hope for the future if there are no educational opportunities for these young men (and women). I cannot say what will become of them. If the potential of this generation is not fully exploited, that will be the true tragedy.
The Bel Aire Clinic is housed on the second floor of a church. We had four physicians this morning seeing patients. My students, Rebecca and Sr. Marie did triage, I worked with two nurses in the treatment room (patients came into us to get shots, private exams, wound care, or other special treatments. We had a constant flow of patients. Three other nurses worked the pharmacy including Chris who teaches pharmacology. He really worked hard during the week and got the Bel Aire pharmacy organized and cleaned. I helped, remove a rock from a child's ear, cleaned and redressed some pressure ulcers, dressed a burn, did some bandage changes, assisted with a GYN exam, and cleaned and organized the treatment room, labeling and organizing supplies. I should not use the term room since there are no walls on the second floor and room divisions are by function or walled off petitions. As usual, you make do with what you have. My work to day in the the clinic was my most enjoyable clinical experience. After we finished we went shopping for souveniers. We stopped at two separate market places and purchased paintings, boxes, wall hangings, and Haitian flags. Some of the more adventurous (ie younger) folks then went out to eat at a restaurant while the rest of us came home. I had a nap and got back to the business of blogging. Its been a busy week, We take the plane out in the morning and will take 12 hours to reach home. I wish I had down time to 'recover' but first thing Monday morning, I start teaching again and I have a test to take, and a second draft of my thesis due. No rest for the wicked I suppose.
Today, my four colleagues went out to do a community clinic, while I stayed at the clinic in the can, just down the road a few feet. It was a routine, uneventful clinic with the Haitian doctor. We saw about 30 patients, mostly sick babies, and elderly with chronic conditions. There is so little we can to about the chronic conditions, but because the clinic in a can (a trailer building, built in China and 'mailed' here to it's current location), is more/less permanent, folks can come back to get refills on their high blood pressure medication (lots of hypertension and heart disease). Today was a very eventful day, however, not because of the clinic. We finished up around 1:00 and I headed home to the maternity clinic for lunch. Soon after, my peers returned from their clinic as well, and we also decided to take a walk with our interpreters, George and Mose. George and Mose are 21/22 years old, the typical age of interpreters, young, strong, handsome, and outgoing. As we walked, nurse Linda told me about her most challenging case of the day:
Linda saw a pretty, petite Haitian young woman of about 20 years of age. She administered a pregnancy test to the girl and it was positive. When she found out she was pregnant, she became upset because her parepnts would be angry with her. She said that she would seek an abortion. When Linda tried to talk to her about it, she would not be dissuaded. Even the interpreter told her the girl was determined to do it. Linda gave her birth control information and discussed other options, but in the end gave her a course of antibiotics and made her promise to take them after the procedure was done. Hearing this story was heartbreaking, and Linda was obviously still shaken by the encounter. I'm so glad Linda thought to give her antibiotics. The greatests risks with abortion are hemorrhage (which will kill you quickly) and infection (which will kill you slowly). In a country like Haiti that is very undeveloped and very Catholic, I think she will have a hard time finding a safe practitioner to give her an abortion. Most hospitals are owned by religious organizations which won't offer them. She told Linda she would do it herself if she had to, by pills or by 'other means'. I teach about abortion as a part of my OB lecture so depending on how far along in her pregnancy, pills won't do the job after between 9-12 weeks gestation. If she uses an instrument on herself she is at very high risk of hemorrhage or infection or both. In other words, there are no good forseeable outcomes for this young woman. Attempting an abortion could very well be a death sentence for her. A very sobering thought indeed. Tomorrow I'll ask Dr. Denton (our host) about this. I'd like to know the frequency of abortion here and what options she has to get it done safely.
As our walk continued,we wound our way around the 'neighborhood'. It was quite unlike the view from the road in a tap tap. As we walked we saw up close and personal how people lived. Even after a previous trip to Haiti, I found it shocking. People living in tents and shacks along side their cattle, goats, and pigs. How they lived this way was inconceivable to me. No electricity, no running water. I felt as if I were seeing the real Haiti for the first time. All the people came out of their houses to see the 'Blancs' walking by. No doubt very few whites/westerners ever see what we saw. George and Mose greated all their neighbors graciously and if I smiled and said "Bonsua" they smiled and said it right back, We passed lots of new wooden small shacks that various organizations had come in and built, they were tiny little houses but far superior to a pieced together tent. George took us to his home to meet his family which included a grandmother, a cousin and her three children and another cousin, sister to the first. George's mother died when he was young, and he lost his father in the earthquake. George and his cousins and grandmother lived in a tent outside their home which had sustained lots of earthquake damage and was being repaired by several men walking around and hammering on the roof. 'The men climbed into the trees to get us coconuts, which George's cousin slashed open with a machete and we all drank fresh coconut milk and ate the coconut out with spoons. We stayed about an hour and George and I talked a long time. He wants to go to school in the US and study law and then return to 'do something great for Haiti'. I believe that someday, George will do just that.
We had other adventures on the walk, including seeing an abandoned sugar cane factory, that George says will open in October and employ 2,000 Haitians (may it be so). I lost a flip flop during the walk, and could not continue, so George hired a motorcycle to drive me the rest of the way back to the clinic. I was very nervous, (folks use motorcycles for taxies here, and it was not unusually to see four or five people on a bike zooming by in one direction or another) but as I was the only rider on a privately rented bike, and Mose did the driving (the driver stayed behind with our group) and he headed my admonishments to 'GO SLOWLY MOES" it went pretty well. Remember there were no paved roads where we were, only dirt and rock streets (that's why my flip flop didn't hold up) and of course full of huge holes! So there was Mose driving slowly with me on the back, while he weaved in and out of traffic and gigantic pot holes. That was my adventure for the day. I got back in time to wolf down dinner (a potato, carrot, and greens stew, flavored with meet of an unknown origin, and served with (you'll never guess) beans and rice. All delicious. Then I accompanied Dr. Denton to the hospital to visit a post op patient, which I will write about tomorrow.
Today saw another early start, as four of our small group took a short tap-tap ride to the beach and set up a clinic under the palm trees. We saw about 50-60 patients, some we could help and as always, some we could not. After we had seen every patient, my colleagues took a dip in the ocean while I enjoyed the scenery (I'm not a swimmer). We rode back 'home' to our little maternity hospital and I took a nap until dinner. Tonight we were served a potato, yam and beef stew and white rice with a pureed bean sauce. I've since spent 3-4 hours reading homework (I have a pathophysiology test when I return home) and am finishing a long day with my journal. I'm short on detail because I'm tired and in need of sleep, but it has been another amazing and thought provoking day. We had great discussion over dinner processing what we are seeing: the nature of health and wellness, the geopolitial and socio-economic basis for health, the upheaval of Haiti, the nature of family, the meaning of hope and happiness. Sometimes it is all too much to take in at once. Thank goodness for interludes of blessed sleep.
Addendum: Now with some sleep, I'm ready to reflect upon a couple of events yesterday.
Most interesting case: We saw a boy of 12 years yesterday with severe cahexia (not just lack of fat, but lack of muscle- literally skin and bones.) He was with his mother and younger brother and sister all of whom were well nurished and looked fine. His mother stated that he had been sick for two weeks and had no appetite and diarrhea, but his severe state looked like it took a lot longer to produce than two weeks. He was flaccid and lethargic (not surprising- we produce our energy (ATP) in our muscle fiber and he had very little) and had a very flat affect. He was given a referral to the hospital for follow up care. He was heartbreaking to behold, and difficult to even look at. I felt this child might be dying and there was so little we could do. We talked about him long after clinic. We have no diagnostic equipment to diagnose so we can only guess at what the problems are based on clinical manifestations. Did he have severe and prolonged intestinal worms? Was it neonatal transmission of HIV/AIDs? Did some combination of opportunistic infections tax his immune system to the point it wasn't fighting back? Sadly, there is no way to tell. Worse still, no way to tell if his mother took him to the hospital. You need money to pay for healthcare up front. Without money, they'll be turned away, no matter how dire the situation. The hospitals here do turn people away for all kinds of reasons. I can only hope that emaciated boy with the haunting eyes gets the medical attention he so desperately needs.
Thursday, September 30, 2010
Saturday, September 18, 2010
Saturday, July 31, 2010
Tuesday, July 20, 2010
Monday, July 19, 2010
Friday, May 14, 2010
Wednesday, May 12, 2010
Wednesday, May 5, 2010
Here are photos from the luncheon yesterday. Midwife Cathy (white hair, pink shirt) was honored as one of the 25 Shining Stars (always been a star in my book!) next to Rachel (another midwife) determined to open the next birth center here in town. There's a shot of my table and all my guests. Dr. Palmer a dentist who has done some kick ass research on the relationship between breastfeeding and good dental health (brianpalmerdds.com), Pat, my partner in crime who teaches pediatric nursing, Airick West, president of the KCMO school board, Pakou, local birth activist writing a book of birth stories of women of color, Liz, mom extraordinaire and fellow nursing educator, Mariah (my mini-me) all around birth and breastfeeding advocate and professional volunteer. The final photo is of Liz and I. Another nicely done luncheon, honoring folks who deserve the recognition.
Sunday, May 2, 2010
Saturday, April 24, 2010
Tuesday, April 13, 2010
Sunday, April 11, 2010
Friday, April 9, 2010
Thursday, April 8, 2010
All these images were taken at our clinic held in a church. We didn't know at the time how luxurious our accommodations were. We were sheltered in a building out of the heat with private areas to talk to patients and give exams. Our entire team is pictured along with our interpreters. YaVonne in pink is a cardiac nurse, Emma ran our pharmacy, the other woman in green is a neurologist from New York, and my interpreter Kicki. We all worked well together and saw about 100 patients that day.
Sunday, April 4, 2010
While at the Haitian Family Mission on the fourth day, we were in the midst of our outdoor clinic, under the almond tree. A man arrives carrying his crying little boy. Being in acute distress, they are ushered to the front of the line. The little boy has lacerated his finger while playing atop a building debris pile. (Remember, the piles of rubble are everywhere. Most of the buildings appear to be built of concrete, and it is piled mountain high with wires and metal pipes shooting out all over. They must be very tempting for a little boy.) It is a very severe cut requiring three or four stitches. There is no doctor with us on this particular day. I am on a team with a pharmacy tech, a couple of medics, an EMT, and a non-medical. The doctor working with the mission is on vacation. I am selected to do the stitches. Now I have only done stitches on uncooked chicken breasts. But thats more experience than anyone else on the team. We could send him to a hospital, but he might wait hours (even days). He's at the top of our clinic list, but he would be at the bottom at a hospital. So I resign myself to doing my first stitches on a real person. I draw up the lidocaine after locating a suitable needle and syringe and am about to administer it when I hear, "Here comes so and so, she can do stitches. She does them all the time." Talk about saved by the bell. I happily hand my syringe off to so and so and proceed to assist her as she administers four neat and tidy little stitches into the tiny finger. After she's done I wrap the finger in guaze and with the help of an interpreter, give Dad instructions on care and returning to have them removed. This shouldn't be a problem since the stitcher lives at the mission. Later in the day, when I ask the stitcher what specialty of nursing she practices, she stated matter of factly that she wasn't a nurse at all. Taken somewhat aback, I asked her what her training was in. She told me her formal training was something akin to a medic (I'm not sure what that training is.) I ask her where she learned to do stitches. She told me that even though she has very little formal training, she learned her skills from various doctors and nurses that pass through the mission. They let her observe and try skills out as they guide her. She got her training informally, hence, the "Haitian MD." She wore a white lab coat and had a stethoscope around her neck. It's true that even I was diagnosing and treating in the tent cities. I was treating diseases I had never even seen or heard of before. Does this sort of thing result in subpar care? I'm sure it must. Twice, my interpreter KiKi diagnosed my patients when I had no idea what I was looking at. A child came with a hard white plaque on her tongue and upper palate. I thought it was yeast until I palpated it and found it hard and unmoveable. I had never seen anything like it. I asked the other healthcare providers. They didn't know either. Then KiKi spoke up. "I don't know what the name is in English, but in Kreyol, we call it 'shunk' and they treat it by rubbing it with lemon and salt until it is rubbed off. It comes from kids putting all kinds of dirty things they find into their mouths." Well that was good enough for me. "Kiki, tell the Dad what you just told me, and tell him the treatment." I was horrified to think what that pretty little girl had put in her mouth to cause that awful looking fungal growth. She could no longer eat, and could barely talk. I shuddered even more to think of her Dad scrubbing her tongue with lemon and salt until it bled. But hey, I couldn't come up with anything better. The home grown cure seemed reasonable to me. We didn't have any antifungals except those to treat a yeast infection, and this was no yeast infection. In that moment I didn't think of KiKi as overstepping his bounds as an interpreter. I was very grateful to him for giving guidance on something I had never seen the likes of. My trip had been filled with many moments when I was looking around thinking, 'should I be doing this?' (things I would never be allowed to do 'back home.' But I wasn't at home. There was no one else to do it and I was knowledgeable (sometimes) and willing (everytime). In those moments, I know I too was getting my "Haitian MD."