It’s Go Time in Cite Soleil!--July 2020

 

Eight-year-old Jonka in Boston/Cite Soleil with Sickle Cell Anemia. (Photo by John Carroll–July 25, 2020)

I have had the opportunity to work in the only clinic which is still (partially) functioning in Cite Soleil. It is the Hands Together Clinic in the Soleil neighborhood known as Boston.

The two Haitian doctors who normally staff the clinic have not been coming to work for several months due to the gang violence in Soleil. However, the nurse and community health workers still do come to the clinic each day.

Yesterday I had the opportunity to give a talk on the history and physical exam for the 10 community health agents who came in on their day off for “continuing medical education”. Most of them live in the neighborhoods nearby.

I asked the chief health agent if I could use his 8-year-old son, Jonka, as a model for the talk. He said of course and went and got his son across the street in Beleko. Jonka has sickle cell anemia and has had multiple sickle cell crises in his life that have required hospitalizations and blood transfusions.

I tried to keep things as simple and relevant as possible in my presentation. There is no reason to lecture on blood gas analysis, the anion gap, or electrolyte imbalance here in Boston. The health agents don’t have access to these tests in the first place because their cost is prohibitive for their patients who all live in the slum.

I stressed that listening to the patient’s history is so very important. Patients will tell us what is wrong with them if we just listen. Mothers know their children very well and it always behooves us to take the mother’s complaints very seriously. As a rule, no one listens to the poor when they have something to say. But the poor have a lot to tell us if we give them a chance.

The population density in Soleil is very high. And it is very hard to find a quiet secluded place anywhere in the slum. But I have told the health workers it is important to find as quiet a place as possible to make the patient comfortable during the history and the physical exam. Haiti is one of the most important places in the world where the basics such as the history and physical need to be stressed because that might be all we have to make a diagnosis.

So we started with little Jonka as our model. I placed him on a wooden bench in the middle of us and he seemed good with it.

I showed them how to take the vital signs including pulse oximetry. I stressed that one must follow the same steps on each patient every time unless one is doing a targeted exam in an emergent situation.

Jonka’s pulse ox was 93% which may be a tad low due to his pulmonary disease from sickle cell anemia.

We moved to the examination of Jonka’s ears. I went over the three areas of the ear but stressed the middle ear and otitis media which is so common here. I showed them how to hold an otoscope and gently place it in the external canal so as not to hurt the patient. None of the community health workers have an otoscope and the clinic does not have one either which will make it very hard for them to practice this simple maneuver.

We then moved to the examination of Jonka’s mouth and throat.  I told the students to look at the color of Jonka’s buccal mucosa as it was light-colored indicative of his chronic anemia. And I showed them the back of his throat and his tonsils.

At the blackboard (which actually had chalk) I wrote down the main bacteria that cause ear infections and tonsillitis and how to treat with high dose amoxicillin.  I stressed that tonsillitis needed to be treated for 10 days to avoid Rheumatic Heart Disease which is rampant in Haiti. My students asked good questions, took notes, and one took a picture of what I had written on the chalkboard with his smartphone.

I then went over Jonka’s lungs and described normal lung sounds versus abnormal sounds such as wheezing and rales and explained their clinical significance. For example, I gave a made-up case of Jonka presenting with a fever, cough, and rales, which would most likely mean that he had pneumonia (or acute chest syndrome) rather than congestive heart failure with rales. I think they understood the importance of making this distinction and that these two problems would be treated much differently (antibiotics vs. diuretics and nitroglycerin).

We then reviewed the basics of Jonka’s heart exam. I showed them where to place the stethoscope on the chest over the base and apex of the heart and told them what valve was located in each area. We went over Sound One (Lub) and Sound Two (Dub). Lub-Dub, Lub-Dub, Lub-Dub, etc. I taught them when systole occurred and when diastole occurred and what was happening in the heart during both of these phases. Like the otoscope, only one of the health agents has a stethoscope, so they will have to share it to improve with their heart exams.)

Little Jonka couldn’t have been a better model patient. Like most Haitian kids in the slum, he sat still, asked for nothing, and cooperated for almost two hours.

I went over different situations where they needed to stabilize the patient quickly (e.g. putting in an IV and giving a bolus of fluids) before sending the patient on his or her way. They do get a lot of bullet wounds and obstetric emergencies and they need to know when to keep the patient and when to refer the patient.

I ended the talk by putting the Medscape French Edition App on one of their smartphones. This is an excellent free app that has diseases and medications and much more.

I told these students to read this app for 30 minutes per day and discuss one medical topic each day as a group and teach each other.

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The slum is filled with so much pathology. So much sickness. So much tragedy.

I am sad every day when I finish hanging out with “my students”–the community health agents in Boston/Cite Soleil.

They are facing the impossible. Most of them are from the slum and they know how things work.

And they don’t seem sad with the challenges.

I shouldn’t be either.

 

John A. Carroll, MD

www.haitianhearts.org