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| With the incredible nuns of Hospital San Carlos. |
The evening prior to my departure from Altamirano,
the Hospital San Carlos nuns invited me to join them for dinner in their
community. As I mentioned in my prior
entry, they are a truly incredible group of women. Each has unique and important
responsibilities in the daily functions of the hospital. Among them include: Sor Rosario, determined
hospital director and fearless leader; Sor Edith, wise clinical supervisor and
xray technician; Sor Genoveva, director of nursing and nursing education; Sor
Paz, pharmacist; Sor Consuelo, near to my heart, head pediatric nurse; Sor
Rosaura, head medicine nurse; and Sor Anita, the most senior of the group,
tireless nurse anesthetist. Though each
came to Catholic sisterhood through distinct paths, they all share a deeply religious and loving dedication to the poor and marginalized.
A story they shared that evening highlights the irreplaceable role that
they and the Hospital play in providing care to so many families throughout
Chiapas amidst a sea of barriers:
During a weekend when I had taken a respite to
visit the Mayan ruins in Palenque, a gravely ill five year old girl was carried
through the doors of the hospital by her parents in the middle of the
night. She was in severe respiratory
distress, with a fever, and a concerning murmur, likely decompensating from
pneumonia superimposed on a previously undiagnosed congenital heart
disease. Francisco, one of the several new
physicians spending his year of social service at the Hospital, immediately
called Carlos, an outstanding family medicine physician from Spain who has
served as the hospital pediatrician for several years. The patient was rapidly
stabilized and survived the 3-4 hour long journey to the pediatric subspecialty
hospital in Tuxtla Gutierrez, where she was intubated and placed on a
ventilator. Francisco formed a special
bond with the family, who, like him, spoke the indigenous language of
Tzotzil. Later the following week, he
received a phone call from the parents, informing him that their daughter had
died after several days of medical care. They had been profoundly impacted and
upset by a question that a Tuxtla provider had asked them, “Why did you take so
long to bring your daughter to the hospital?”
Perhaps a sign of a provider having trouble coping with the injustice of
losing a young life, or perhaps willful ignorance with regards to daily
injustices, including poverty and discrimination, faced by the indigenous
communities of Chiapas.
Hospital San Carlos serves as a safe, accessible,
and culturally sensitive and acceptable provider of inpatient, outpatient,
medical, surgical, pediatric, and OB/GYN care for indigenous as well as
autonomous communities throughout much of the state of Chiapas. Of course, resources are limited. Plain films and basic labs (which do not
include cultures) are available during the day as well as at night in the case
of emergencies. Bedside ultrasound skills are acquired by some of the
physicians over time. Outpatient
subspecialty referrals can be challenging, whether due to lack of patient
resources or long wait lists. Inpatient
transfers, such as for neonates who may need CPAP or intubation, are at times
refused by the referral hospital due to lack of beds.
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| One segment of the infant and toddler's unit. |
Caring for patients in both the inpatient and
outpatient pediatric units was truly an excellent clinical experience. In addition to a handful of newborns, we
typically had somewhere between 3 and 7 inpatient pediatric patients. Admission diagnosis were reflective of two the
top five killers of children under five globally, acute respiratory tract
infection and acute diarrheal illness. Probably
about a third of infants and toddlers were admitted with bronchiolitis,
pneumonia, and a surprisingly high proportion of bronchodilator-responsive
bronchospasm, perhaps secondary to indoor air pollution from firewood use. Another third were admitted with dehydration
in the setting of viral gastroenteritis, dysentery, and parasitosis. These diagnoses certainly have parallels with
those that most commonly lead to admission to MGHfC; however, the superimposed stunting and/or wasting among most of
the patients clearly demonstrated how chronic and acute malnutrition might
contribute to 50% of under-five mortality around the world.
I learned a number of infectious disease-related
clinical pearls during my month: one should assume that all children with
severe acute malnutrition have a severe bacterial infection whether or not they
have signs or symptoms such as fever; iron repletion for anemia should be
deferred until treatment of bacterial infections (e.g. infectious enteritis,
see: BMJ 2002;325:1142) has been completed, as there
is a theoretical risk of worsened infection; congenital tuberculosis exists (see:
N Engl J Med 1994; 330:1051-1054);
and the management of fever without a source in well-appearing newborns/infants
in the absence of culture data can rely significantly on clinical
suspicion.
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| Abnormal L5 |
The remaining one third of admissions encompassed an
interesting mix of subspecialty issues. These included: a 12 year old boy with anasarca,
ascities, pericardial effusion, and pleural effusions secondary to nephrotic syndrome;
a 3 year old girl with >50% partial and full thickness second degree scald burns,
one week out from injury, who was transferred AMA from government hospital; a 7
month old boy with tachypnea since birth and failure to thrive, without murmur,
but certainly with a yet undetermined congenital heart defect, admitted with
worsened respiratory distress; a 3 month old girl with severe stunting,
presenting with vomiting since birth, found to have hemoglobin of 4 and guaiac
positive stools; an 18 year old boy admitted after intentional ingestion of Gramaxone
(aka Paraquat), an almost universally fatal herbicide without effective treatment
nor antidote; and a full term, newborn boy with perinatal asphyxia, low apgars,
who developed clinical seizures on day two of life, requiring phenobarbital. I also encountered a good deal of developmental
delay, including a 2 year old boy who presented to clinical with a URI and who
apparently could not walk, stand, nor really sit appropriately. He had bilateral ankle clonus, lower
extremity spasticity, bilateral Babinski, and these apparent findings on
physical exam and plain film:
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| Violaceous mass over lower lumbar spine. |
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| Hospital de Especialidades Pediatricas - Tuxtla, Gutierrez |
I was frequently left with the desire to teleconsult
my MGHfC attendings and fellows and,
in fact, did speak with one of our wonderful cardiologists, Dr. Manuella
Lahoud-Rahme regarding one of our CHD patients. Wait times for consultations
with subspecialists at Hospital de Especialidades Pediatricas are often prolonged,
and the prospect of enduring the costs and opportunity costs of travel make the
trip all the way to Tuxtla Gutierrez prohibitively expensive for many families. Performing an echocardiogram while Dr.
Lahoud-Rahme watches via Skype, is just one example of the potential for
telemedicine to advance access to subspecialty pediatric care at Hospital San
Carlos.
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| Helping Babies Breathe - Workshop 1 |
In addition to the clinical and community-oriented aspects
to my trip, I spent some time working in the realm of formal medical education
and quality improvement. I gave a
chalk-talk on a variety of neonatal health issues for the physicians during one
of the biweekly morning conferences. This
was perhaps more of a learning experience for me, as my audience helped me grasp
the many adaptations necessary to take care of newborns in a low resource
setting. Continuing with the theme of neonatal health, Dr. Jennifer Kasper and
I prepared an abbreviated Helping Babies Breathe© training for
nurses, nursing students, and auxiliary staff at Hospital San Carlos, in collaboration
with Sor Genoveva.
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| Nursing students at their capping ceremony. |
There were 42 participants who attended one of two, two-hour
sessions that focused on the Golden Minute of life and practicing scenarios
with NeoNatalie newborn mannequins. About 3 weeks later, I was able to schedule
a follow-up refresher session, and while this landed at the tail end of vacation
week for the nursing students, 31 learners participated in the workshop,
including 10 new participants. While I
had intended to perform OSCEs to evaluate effectiveness of the first workshop
measuring retention of knowledge and skills, this was ultimately not feasible
in light of time and resource constraints.
Subjectively, the students expressed that they very much appreciated the
opportunity to reinforce and practice their skills. I could see that many were more prepared to
revive their mock newborn patients, and to do so within the first minute of
life. The second session also gave me
the opportunity to fine-tuning practices that I had observed in the delivery
room during my month, for example: not delaying bag mask ventilation to attach
oxygen to the self-inflating ambu bag and acting upon an emergency plan (i.e.
calling Carlos) at the first sign of trouble, whether fetal distress or
difficulty with ventilation.
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| Carlos (pediatrician in-charge) and I. |
Lastly, I worked with one of the hospital
administrators and Carlos to create a self-evaluation tool for the pediatrics
unit that could be used to highlight and select priority issues for quality
improvement. Drawing from hospital standards
from the WHO, the Mexican General Health Council, and other resources, the tool
asks doctors and nurses to respond to questions relating to seven themes using Likert
scales: professional communication, medications and errors, rights of the
hospitalized child, involvement and education of families, evaluation and
treatment of pain, hygiene and prevention of infection, personnel and
equipment, and trainees and continuing medical education.
I truly hope that I will have an opportunity to
return to Chiapas and to Hospital San Carlos.
My upcoming fellowship program in pediatric emergency medicine is affiliated
with two hospitals, UCSF and Highland, who send attendings and residents to San
Carlos. Now that I’ve had a chance to
reflect on my trip, it’s time to get busy thinking of next steps. Next steps in strengthening the Hospital’s
referral capabilities, perhaps via telemedicine … next steps in ongoing capacity-building
in skills such as neonatal resuscitation and pediatric ultrasound. I’m so grateful to all my new, amazing colleagues
in Chiapas, the sisters of Hospital San Carlos, Dr. Jennifer Kasper, Dr. Juan
Manuel Canales, and Doctors for Global Health, who together made this experience
as enriching as it was. Many thanks as
well to MGHfC Pediatric Residency
Program and the Partners Center of Expertise in Global and Humanitarian Health
without which this incredible experience would not have been possible.
Ashkon Shaahinfar, MD, MPH
MassGeneral Hospital for Children
Pediatrics, PGY3
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