Addendum: Preparing oneself for multiple choices

In my recent entry, I contrasted the working definitions of child health promotion in resource-rich versus resource-restrained settings. I implied that there is little that can be done in Swaziland to resuscitate struggling newborns.

While this is unfortunately the case, we are constantly engaged in capacity-building that is resource appropriate. When we participate in clinical training and mentorship, we use only what is available at the local clinic. All that I bring is a stethoscope, written reference materials and hand sanitizer. (Sometimes it is difficult to find soap.)

If you are new to the blog, you can check out a few of these clinics in previous posts (Links: St. Phillips , Shewula , Matsanjeni)

A couple of weeks back, thanks to the generosity of Operation Smile, our entire clinic staff spent the day receiving basic life support training. These skills are applicable to all clinical settings on all continents, and can certainly be used for neonatal resuscitation. To do it, all you need is you.

Here are some selected photos of our clinic staff from that day:







KT doing chest compressions.


Sipho and Eunice helping an infant who is choking.


Mlungisi, also performing the infant heimlich.

Today’s photo(s) from the Cape: Wine country– 5 of 10

Mountains near Stellenbosch.


Cape Dutch architecture, circa 1700.


'Fair trade' in 1936,

Today’s photo(s) from the Cape: Wildflowers – 4 of 10

It is wildflower season on the Cape Province's "West Coast".


Flowers.


Flower (2).


Flowers (3)



Helping a turtle across road. (Peculiar-looking creatures.)


Picnic on dunes (Nutella, olive paste, pastrami, cheese, bread, and Coke.)

Today’s photo(s) from the Cape: Kayaking – 3 of 10

Not a bad way to spend an hour. There were whales that could be seen from the balcony of the beach cottage, but I could not find them. They are elusive, fast creatures.

Preparing oneself for multiple choices - Study break musings

I have my "pediatrics board exam" coming up in mid-October.

Here is one of the practice items, an example of the type of question that appears on the exam:

“During the resuscitation of a 1.5-kg preterm infant who has apnea, you notice that inflation pressures of 15-10cm H2O for the first three breaths do not result in chest wall excursion, and the infants color remains poor. The heart rate is 90 beats/min. Of the following, the BEST next course of action is:
(A) administration of intravenous epinephrine
(B) administraion of intravenous naloxone
(C) chest compression
(D) endotrachael intubation
(E) Increase inflation pressure”

In most all of Swaziland, births occur at home, certainly premature ones. Even if they occur in the hospital, there are no newborn (much less preemie) face-masks to resuscitate. Except for a finger on the femoral pulse of the baby, there are no heart rate monitors.

IV meds, ET tubes, and mechanical ventilators there are none. Of course, there are no neonatologists.

So, why am I telling you all this on a blog that aspires to be upbeat?

Well, I have done several hundred of these pediatric boards "prep" questions over the last month, and there is not even a whimper about practicing pediatrics in resource-limited settings.

Here is the problem: almost all of the world's pediatrics is practiced in resource-limited settings.

There is certainly plenty of vile childhood illness here in Africa on which to base multiple choice questions. Most of these illnesses have inexpensive, relatively simple treatments...i.e. answers.

So, why doesn’t the American Board of Pediatrics test me on how to address the world’s most common illnesses in the plain, impoverished context in which most of the world’s illnesses are addressed?

Why not give me one question that asks me to help a child with limited resources at my disposal?

Now, I am assuming that you, the reader, are eager to point out that we are not tested about African children because US-trained pediatricians are almost all US-based pediatricians. We are, after all, talking about certification in the USA.

Good points. Now consider the following:

· In the USA, there are 28-165 pediatricians per 100,000 children, and the states with higher per capita income have more pediatricians.
· Before I came to Swaziland, a nation of about 500,000 under 18 year-olds, I was told that there was one in-country pediatrician. (I met her. She is great and works hard.)
· Baylor currently employs nine Swazi-based, US-trained pediatricians, as well as a family practitioner and two adult internists. This gives Swaziland around 2 pediatricians per 100,000 children.
· Meanwhile, 153 of every 1,000 children in Swaziland die before age five. In the US, the under-five mortality rate is 8 per 1,000.

I understand that it is a good thing that US-based pediatricians are able to spend thousands of dollars to help save the life of a child. It is not a surprise that our credentialing process reflects that.

But, does our credentialing body not agree with me that child health is global by definition, that a healthy, sick or dead child is still a child, regardless of nationhood?

The American Academy of Pediatrics’ states that it is “Dedicated to the health of all children.”

Great.

The American Board of Pediatrics, who administers my certification exam, strives to promote “high quality health care for infants, children and adolescents.”

Admirable.

My point is this:

Either these mission statements need to end with the words “in the USA” or the AAP and ABP must strive to encourage American pediatricians to reflect on child health promotion in resource limited settings.

At least one question.

Gotta go. Off to study.

Refs:
PEDIATRICS Vol. 116 No. 1 July 2005, pp. 263-269
PEDIATRICS Vol. 100 No. 2 August 1997, pp. 172-179

Happy birthday Dad and Sis!

Today is my father's (Charles Ray Phelps II's) and sister's (Sarah Jayne Hathcock's) birthday.

Please see this short video to mark the occasion.

(Oh, I am also afraid that I was allocated little on-screen, uh, "star quality", so do not expect anything Oscar-worthy. I thought about trying a second take, or maybe something scripted, but my beloved family traditionally prefers informality and imperfection when it comes to this sort of thing. We reserve our 'A game' for horseshoes, trout fishing, and Texas Hold-em poker, among a short list of other things.)

Today’s photo(s) from the Cape: Kite-surfing 101 – 2 of 10

Learning to fly the kite (1).


Learning to fly the kite (2).


James, my instructor, who knows how to fly the kite quite well (1).


James (2).

Today’s photo(s) from the Cape: Sundown studying – 1 of 10

This week, I am in Cape Town, South Africa. I am here to do some studying for the “pediatrics board exam” (which I will be taking in October) and to wander around a bit.


Not-so-candid me running through some exam prep questions on my computer.


An Atlantic-Sun rendezvous, marking another day's end.


My generous terpsichorean hosts, Catherine and James.

ANSWER: Swazi 'cultural competency' pop quiz (Question 7 of 10)

ANSWER= (d) Enema instrument.

Well, I finally bought one of these. (My dad's birthday is coming up on the 28th of the month. Happy birthday, dad!)

The one pictured cost USD$4.50 and was purchased at the roadside shop pictured in the previous "pop quiz" post.

I am not sure of the exact statistics, but these are very commonly used for "cleansing", especially on Sundays, and are often found hanging in private latrines here in Swaziland.

Now you know.

Burdened hunters – Cultural encounter series (1 of 10)

On my way to work yesterday, (like the day before, a 2 hour drive each way), I looked out the window. I had tried reading during the drive and found myself little smarter and much sicker. (Something about the UNICEF truck, the vehicle we use for rural site visits, disagrees with my inner ear, stomach, and all of those other body parts that are afflicted when car sickness sets in.)

On my protracted commute, I saw crowd of people, mostly women, with wheelbarrows. They were awaiting the delivery of powdered maize to sustain their families. Children used the wheeled vehicles for cots, seats, or shade, depending on their size and age.

I saw a child laying across three empty twenty-some-odd liter water jugs in the morning sun at the minibus stop, likely awaiting pubic transport to the muddy river down the valley. Despite the magnitude and seeming impossibility of his errand, and despite the dirt devils that sprung to life in the wake of passing trucks and powdered his clothes and jugs, wore a relaxed, reflective expression.

I saw women with bundles of wood balanced carefully on their heads, each bundle longer and by all appearances heavier than the body shuffling beneath. They were for building or burning, I know not which.

I saw a semicircle of people bent at the waist around the newest deposit of municipal garbage at the landfill outside of Manzini, Swaziland’s largest city. They picked through colorful plastic bags for something worth more than trash, something that could be eaten or sold.

I saw a grazing wildebeest, one of the few respites my eyes found between these and other incessant high-speed snapshots of impoverished human beings.

Human beings sitting hungry, thirsty and dusty atop the food chain.

Why I love my job - Quote 11 of 20

“I have got a little doctor behind me.”

– Vusi (a proud father) commenting on Siphesihle (his 6 year-old daughter) playfully listening to his back with an imaginary stethoscope, shortly after I did so with an actual one.

Siphesihle is thriving on ARVs.

For quotes 1-10, click here.

Addendum: One hundred and one Swaziland destinations- #13: Matsanjeni

Rita at her desk, which is home to several dozen of today's patient files, an appointment roster, an ARV roster, female condoms, male condoms, and plenty more.

Today was another one of those long there-and-back days. Matsanjeni was the there.

Total travel time 4.5hrs. Total mentoring time: 4.5 hours. Total patients seen: 35.

For those of you who have not read about Swazi destination #13 (and Rita), click here.

Swazi 'cultural competency' pop quiz (Question 7 of 10)

The photo below is of poor quality. I work hard not to rubberneck, and so did not dwell long when shooting. I searched diligently for online images of this device and found none. Basically, they are coffee cans with a clear plastic tube attached. My question for you is this: What are the things hanging up?





(a) Dispensers for cattle dip (i.e. for livestock deparasitization, esp ticks)
(b) Tubes for siphoning or filling gas and oil tanks
(c) Maize mealie meal storage/dispensing canisters
(d) Instruments for self-administered enemas
(e) Feeding tubes for parentless or disabled baby domestic animals

Today's patient encounter

This is Bayanda. He is 8 months old. He started ARVs today. More on him soon.

ANSWER: Swazi 'cultural competency' pop quiz (Question 5 and 6 of 10)

The answers and explanations correspond to questions 5 and 6 below. The questions relate to Swazi destinations #14-15 (also below).

#5 Answer: (a)
#6 Answer: (c)

If any of you Swaziland aficionados know the explanation for these seemingly disparate correct answers, please let me know. I have asked around, so far to no avail.

Reparations in La Mancha - A patient encounter

www.wikipedia.com

She wore a deep ink-blue head scarf with little white windmills on it. I wondered where she had purchased the fabric, for I have yet to see a windmill in Swaziland.

She appeared tired, and it was not because of immunocompromise or illness, for her CD4 was quite high and her body showed no clinical evidence of HIV infection.

I told her this. She responded indifferently with the subtlest nod of recognition, her eyes never rising from her folded hands.

On her previous visit, she had been fast-tracked because her infant child was admitted in the local government hospital, and she had to return to the ward quickly to ensure her child was fed, medicated, and all of those hospital-specific activities that are handled by actual nurses when they are not overworked and under-trained.

This visit, the mother had waited in the queue with the rest.

While I wanted to believe that the child was playing happily and healthy at home, I knew the answer to the question I was about to ask.

“How is your baby?”

“He died,” she said, still looking down into her hands, which suddenly appeared quite empty.

The confirmation gave me that hellish feeling that one has when temporarily unable to convince himself or herself that the world is a good and fair place.

I said something to the empty-armed mother, something entirely inadequate. The well-intentioned words left my mouth with a pretense of grace and immediately fell to the floor with a clumsy thud.

They fixed nothing.

“What happened to the child?” I asked.

While she spoke in SiSwati, a swoop of her hand over her lap told me that the child’s belly had grown very large in the final days. She then held her hands out as if holding her child by the head and trunk, and brought them together, pantomiming the weight loss that preceded the child’s demise.

When she finished speaking, as a tear escaped the mother’s dulled, icy, otherwise indifferent eyes, the translator to me that “the stomach grew very big and the baby was losing weight. The baby died Saturday.”

The hellish feeling returned. I manufactured a few more well-intentioned, sympathetic words trying to inject something besides sadness into the sorrowful, hardened woman. I then wrapped up the visit, unable to repair the irreparable.

For an instant, I sat alone in my exam room wondering if addressing global pediatric HIV was somehow hopeless, absurd, quixotic.

Then, after the briefest instant, I decided it was not.

Ashamed that the thought even crossed my mind, I stood up to call the next patient.

He was a happy, healthy child, thriving on ARVs.

Monday - A minute-long patient encounter

Several events conspired to make this Monday a challenging one.

After a difficult day, I sometimes pull up the two photos below and look 'em over for a minute or so.

Happy Monday.

Severely malnourished, immunocompromised child.

The same child after ARVs.

--

"Monday's child is fair of face.

Tuesday's child is full of grace.

Wednesday's child is full of woe.

Thursday's child has far to go.

Friday's child is loving and giving.

Saturday's child works hard for a living,

But the child who is born on the Sabbath Day

Is bonny and blithe and good and gay."

- Monday's Child (a nursery rhyme)*

*Actually, it seems that I should be most weary of Wednesdays and Thursdays.

One hundred and one Swaziland destinations - #16: The Ngwenya Glass Factory

The Ngwenya Glass Factory is one of the more often cited tourist stops here in Swaziland.

I included it because, well, bright orange glowing molten glass is quite a sight.

It flows like cold molasses and luminesces like lava.

The photos below depict the the activity on the glass factory floor and a few of the products.


The factory floor. An occupational hazard mine field.


Glass blower.


Kiln and sweating artist.


Vase.


Vase 2.


Elephant 1-5. They also make hippos, lions, etc. etc. etc.

Swazi 'cultural competency' pop quiz (Question 5 and 6 of 10)

The following questions will test your knowledge of Swazi destinations #14-15 below:

#5. Both homesteads pictured have a round hut on them. This is traditionally called:
(a) The granny house (or “Kagogo” in SiSwati)
(b) Young men house ("Lilawu” in SiSwati)
(c) Married man’s house (SiSwati name not retrievable)

#6. This round hut is the place where:
(a) The dancing occurs
(b) The marital bed is situated
(c) The children sleep and the food is prepared
(d) The grandmother, or gogo, sits to give advice in the evenings

One hundred and one Swaziland destinations- #14 & #15: Two Swazi homesteads

Dallas is a city. Mbabane (where I live here in Swaziland) is almost a city. Well, let’s just call it a town. It is big for Swaziland, but it is a town. 80K inhabitants or so.

In any case, most of Swaziland, just like most of Texas, is rural.

The quintessential Texan is not a Dallas real estate agent or a Houston banker. He is a cowboy, a farmer.

Well, so it is in Swaziland. Folks live and make their living out on the countryside. They live in homesteads like these.

A traditional homestead, on the way to Matsanjeni Health Centre (see below for more on Matsanjeni)

A more modern homestead along the same road (note the electrical wires).

Counting to three – three patient encounters

The summary page of the Baylor clinic’s electronic medical record contains most all of the information one needs to guide a patient visit, including an “issues for follow-up” box.

One morning last week, I saw three patients with the following issues for follow-up.

Patient #1, age 3 years: “Cough; mother died.”
Patient #2, age 8 months “On TB treatment; mom died 7/7/07; thrush”
Patient #3, age 4 months: “Mother deceased (need to clarify TB status of mom); pneumonia, HIV DNA PCR pending”

A year ago I would hear a word like “body count” and think of crime dramas or war documentaries.

Now that I have done the counting myself, I just think of people my age or younger who have died, many of them leaving parentless children.

These are too many parentless children here.

Still, the counting continues.

--

I hope that I continue to get better at what I am doing.

I hope that we continue to do more and more.

I hope that some day there is more counting down and less counting up.

I hope this dearly.

One hundred and one Swaziland destinations- #13: Matsanjeni

Matsanjeni is one of the health referral centers in the Shiselwini region of Swaziland, essentially making up the bottom third of the country. It is a dry hilly part of the world. If I were to do a watercolor of the landscape this time of year, water and an earthy brown color would suffice. In late winter, the only exceptions to this are the colorful woolen clothing of the inhabitants and the bright orange flowers that adorn the area’s large and ubiquitous aloe plants.

Otherwise, it is a dry land of diluted browns.

Of course, the pied spring will come soon enough. Then, the toaster-oven-summer.

During this time, it is my hope that Nurse Rita and I will be able to entice the children of surrounding Shiselwini to come in for HIV testing and treatment. As of now, they only have thirty something children on ARVs, and this represents but a small fraction of the catchment area’s infected children.

For this reason, every 2 weeks, I make the two-hour drive to Matsanjeni to mentor Nurse Rita, who is very comfortable with ART in adults but timid when it comes to pediatric HIV care.

Over the past two months, Rita has begun to schedule children on the day that I am scheduled to visit. On my first day at the health center, there was one child. Last week, there were six. Next time Rita expects to double that.

When the rains have come and gone and the colorful but punishing summer replaces the cool dusty earthtones of wintertime Matsanjeni, I am confident that we will be sweating alongside several dozen newly-discovered pediatric patients.

When the weather again begins to cool, I will have taught Rita all that I know, and she will be ready to manage HIV+ children herself.

--

Matsanjeni is one of three outreach sites where I have worked.See the following links for the other two:

One hundred and one Swaziland destinations #9: St. Phillips
One hundred and one Swaziland destinations #10: Shewula

Baby skin - A patient encounter

It was not the kind of rash you have to lean in to see, but I wanted to get a better look.

When I approached Mluleki to look at his skin, he started giggling.

Soon he was guffawing.

Seven month-olds are usually a little more tepid when I approach them, but Mluleki was not. He was convinced that I was playing with him, and he found our game simply hilarious. His eyes followed me, waiting for the next subtle excuse to burst into gleeful laughter.

He is what I will call precocious socializer.

I am what I will call a clinical opportunist.

Since he was having so much fun, I pretended to play along while actually leaning in further to scrutinize the irregularities on the child’s face and neck.

As I did this, there was little hilarity to be found.

The red bumps were everywhere. In places the bumps were covered with thick golden scabs resembling corn flakes. In the areas that the child could reach and scratch, there were bloody scabs of deep purple. In the middle of his forehead, there was an area where his skin pigment had eroded away from the crusting and scratching. The exposed blush-white tissue beneath contrasted sharply with the skin around it.

Areas that were not crusted or depigmented were raw-steak-like.

Mluleki's face was a mosaic of skin pathology.

But, oh my, how this child did laugh as I examined his pathological, bleeding, dichromatic, caked-over, raw-steak-like skin.

Mluleki may or may not have HIV. His skin tells me that he probably does but final diagnostics are still not back, and, in addition to being opportunistic, I try to be optimistic as well.

With effervescent children like Mluleki in the exam room, this comes easier, no matter how pathetic and sad their inherited afflictions.

Of course, regardless of his HIV status, Mluleki’s skin should get better. It should someday be smooth, scabless, and evenly pigmented. It should someday cease to resemble uncooked beef.

I don’t care how many medicines it takes to make this happen.

A baby deserves to wear baby skin.

Mluleki deserves to laugh beneath a humane complexion.

No birthday suit should be allowed to succumb to such badness before it has seen a birthday.