Thursday, April 27, 2017

Morning Report in Mirebalais, Haiti

Oren Johnson, MD 
Resident in Diagnostic Radiology at Brigham and Women’s Hospital

Morning Report in Mirebalais, Haiti 

“Education then, beyond all other devices of human origin, is the great equalizer of the conditions of men, the balance-wheel of the social machinery.” -Horace Mann

I went to Mirebalais, Haiti to work at Hôpital Universitaire de Mirebalais (HUM), primarily to teach the Internal Medicine and Emergency Medicine residents basic image interpretation. The hospital has imaging capabilities, but no radiologists on-site to interpret the studies in real time. The clinical teams are often the primary read/interpretation while they wait for a remote radiology interpretation to be completed.  Our plan was to teach as much as possible, consult on cases, and really understand the clinical landscape at HUM.

I interpret studies for HUM, while in Boston, but honestly had no context or understanding of what then happens with that information or under what clinical constraints my colleagues had in country. The Internal Medicine and Emergency Medicine programs welcomed and invited us to the Internal Medicine morning report and Emergency Medicine morning rounds.  I knew this would be my greatest opportunity to understand how medicine was practiced at HUM.

 Internal Medicine Morning Report Hopital Universitaire de Mirebalais, Haiti
Today was our first Morning Report. I sat in the resident library, more of conference/computer room, at a table that was surrounded by 30 people (residents, medical students, and attendings). My program director and I sat in anticipation of how the morning report would be run and what our role would be. I hadn’t been to a medicine morning report since my intern year, 4 years ago. The room was quiet, except for the drone of spinning fans, and the occasional goat or cow you could hear in the fields adjacent to the hospital.

Then, rather abruptly, one of the residents started to address the group with a certain degree of forced confidence in Haitian creole.  I don’t speak a word of Haitian creole, but the tone of her voice, universal signs of concealed nervousness, and the stack of patient charts that lie before her, made it clear. She was the Admitting Resident overnight, and she was tasked with presenting the newly admitted patients and their overnight management. There was a welcomed familiarity with this construct and dynamic.

This country and hospital were foreign, but I strangely felt at home in the midst of these patient discussions. The resident presented the first case, a patient with HIV that had stopped their anti-retroviral medications, and was quickly interrupted and corrected when she said the patient was “non-compliant”.  The chief of medicine opened a discussion about the difference between adherence and compliance. A topic I remember distinctly discussing as an intern at my own morning report.

Outside of Hopital Universitaire de Mirebalais, Haiti
The resident continued with the case, often getting no more than three words out before more questions were asked. What are the stages of chronic kidney disease? Do you really think this is right heart failure?  Can you interpret this EKG?  At each juncture, residents sitting at the table would pull up various articles on their devices, quoting the most recent literature. I was amazed by the intellectual curiosity, engagement, and command of this knowledge. Residents at different levels were contributing to the discussion, providing insight from articles they had recently read or were accessing at that very moment. I saw how powerful access and knowledge can be.

These discussions were spirited, and I was fortunate to have one of the residents translating the details of the conversation. I felt the attendings were challenging the residents, and the residents were rising to the occasion. It was inspiring that this level of discourse was taking place, and it was only the first patient admission being presented.

I was brought back to reality when after the first patient presentation, there was a final question posed by the chief of medicine. “So now how are you going to manage the”  Each patient presentation boiled down to this question. These amazing residents had the entire body of medical literature at their fingertips. They knew or learning how to optimally manage their patients based on the latest evidence, and they couldn’t fully implement what they were learning. No access to a cath lab, limited access to hemodialysis, a limited formulary and lab, and patients with no financial resources to adhere to prescribed treatment, the challenges are many. It was disheartening at first to see this process.

Upon reflection, I realized how much more I was impressed by the residents and attendings. They faced the limitations of their environment head on with unwavering dedication to learn and practice medicine to the best of their ability. I would come to learn and appreciate this first-hand in my daily radiology teaching sessions.

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