Dissociation--October 2015
MINUSTAH Supplying Clinic with Clean Water–October 29, 2015 (Photo by John Carroll)
Years ago when I was a first year medical student, my dad was sick and was hospitalized. One day during a visit with my dad in his hospital room, I proudly explained to him where the fluid from his IV circulated. I described in great detail how the salt water went from his vein to to his capillaries and then on to his cells. I told him that after the cell received the fluid, the capillaries, and then the arteries carried the blood back to his heart and lungs to be recirculated.
My dad listened patiently to my lecture from his hospital bed and then asked me how this information was going to make him better. He wanted to know how to go from medical knowledge to effective treatment in order for him to be able to walk out of the hospital a healthy man. He seemed to be challenging me to “make him better” with the education that he was providing me.
As it turned out, I had no answer for him and the little medical knowledge I had at the time never ended up helping my dad. In fact nothing his “real doctors” ever did helped my dad. He never made it out of the hospital.
Now, almost forty years later, my wonderful dad’s question is still relevant. How do we take medical knowledge, which in my case has improved somewhat in forty years, and actually put it to use and help people get better?
Yesterday a Soleil mother brought in her four year old daughter to the pediatric clinic. The mother had an expression on her face that looked like at any second she was going to break down and cry. But she never did and the look on her face never changed. I finally realized during the visit that her face portrayed her daily struggle to stay alive here in the back part of Soleil.
Mother reported that her daughter had fever for a few days and the usual litany of other complaints.
The little daughter was brave and stood upright and let me examine her. The first thing I noted was that her pitch black skin was very very hot. I took her temperature under her right arm and it was 104.7 F.
But she didn’t really look sick. She looked like she didn’t feel well but she was lucid and didn’t look like death. I counted her pulse and it was unusually slow for the amount of fever that she had. This is called temperature-pulse dissociation. In other words, her pulse wasn’t near as fast as what her fever would have predicted.
Her exam revealed clear lungs but her abdomen was very tender to light palpation. And her liver and spleen were enlarged.
So this little girl was giving me clues to her diagnosis. With her very high fever and relatively slow pulse, along with a tender abdomen with a big spleen and liver, I wondered if she had typhoid fever. Other diseases such as dengue and malaria can present somewhat similarly but typhoid was at the top of my list.
She obviously needed to be worked up. Labs needed to be drawn. It doesn’t sound like it should be a big deal but it is here in Soleil. Everything is a big deal here.
Mother had no money of course. And the next three days everything in Soleil would be closed down. Saturday would be followed by Sunday which is November 1 and is a national holiday–All Saints Day/Day of the Dead. On Monday, November 2, the clinic would be closed as would everything else. And Tuesday, November 3, is the day that the recent Haitian presidential election results will be announced. So just announcing these results may mean the streets will become violent, blocked, or even worse. All 54 candidates want to win, and if they don’t, some of them will insist that the election was thrown and will make a fuss. And the entire country could close down.
And this means that this sad appearing mother will have no where to take her sick child– possibly for many days. So I knew I needed to do something then.
I presented the little girl to a Haitian pediatrician who works at the desk right next to me. She is a veteran and has worked in Soleil for 20 years and is a totally knowledgeable of situations like this that arise here every day. She suggested I send the girl to St. Catherine’s Hospital across the street from our clinic for some stat labs and admission. She even called the Haitian pediatrician working at St. Catherine’s and told her that we were sending the little girl over to be examined and for labs.
I wondered what could go wrong with this plan. But this is not my first circus either, and I knew probably everything could go wrong. Saint Catherine’s is a State run hospital and like other State run hospitals, is highly dysfunctional. However, I could see no other choice at this point. I slipped the mother 5 US dollars to begin her workup at St. Catherine’s and the mother agreed and left with her contorted face carrying her sick four year old who did not want to walk.
After our clinic had ended several hours later, I walked over to St. Catherine’s to check the labs and the fate of the little girl. I went to the office of the on-call pediatrician but she told me that she never saw the little girl or her mother and never saw any lab results either. The little girl and her mom were completely missing.
While I was speaking to this pediatrician in her office three young people, two guys and a girl, all about 20 years of age, were watching us through a tinted glass window and repeatedly told us (yelling through the semicircular opening in the bottom of the glass) that they were hungry, needed money, and that Fanmi Lavalas and its candidate would win the presidential election. The Haitian pediatrician just glanced at me as they continued to harangue us with their requests. However she continued to fill out her dossiers seemingly unconcerned about much of anything. When the most aggressive guy of the three suddenly opened our office door, the pediatrician screamed at him to close it and he did so right away.
I waited for another hour. The little girl and her mother never showed. In the pre-antibiotic days about 15% of untreated typhoid fever was lethal. I am not even sure that the little girl has typhoid, but whatever it is, she will go untreated now and maybe forever. Her immediate future depends on the shifting calculus that envelopes the dysfunction here in the slum and her innate immune system to fight whatever germ has attacked her.
What are the potential reasons the mother did not show? She could have walked home to check on her other kids and decided to spend the 5 dollars on food for everyone. Or maybe she has no one to watch her children because her presence in the hospital will be required 24/7 if her child was admitted to St. Catherine’s. The little girl’s father could have demanded the money from her mother. Or she may have been robbed by hungry and desperate people like the ones stalking the hallways at St. Catherine’s. There are many possible scenarios.
A huge gap exists (for many reasons) between what we CAN do in medicine and what actually gets done for the patient. Just as this little girl had the temperature-pulse dissociation, there is a dissociation between medical knowledge and delivery of care to the patient. The barriers that exist need to be identified and removed or all the medical knowledge in the world is useless if it can’t be used.
John A. Carroll, MD
www.haitianhearts.org
Thank you Dr Carroll
Your words touched my heart as I reflect on my week in Haiti. To see the need, to try and share the knowledge, to reach out a hand to help, but not knowing how it will end and yet continuing on to the next person, child. Thank you for continuing to help the children, the people of Haiti
Joanne
John
Let me know how I can help! Thank you and bless you and Maria for all
do!
Paulita (Pete)
Nicely written. Beautifully nuanced. Brilliantly understood.
Very true words. I struggle with that each time I visit. I am so glad you get to live your dream.
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