Helping in Haiti – teamwork!

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Experience by Sweta Chawla, PharmD

Written by Monica Mehta, PharmD

An elderly gentleman presented to clinic with an elevated blood pressure of 160/90 mmHg.  The nurse shouted across the clinic to me inquiring about hypertension medications.   Sifting through my shelves, I pulled out a bottle with a foreign brand name. By chemical name, I recognized it to be a combination of amlodipine and telmisartan.   We figured out a dosage regimen and by way of an English to Creole interpreter, I counseled the patient.  Two days later, he returns with no change in blood pressure whatsoever.  The flustered nurse asked what else I had.  Before digging out the next bottle from my makeshift pharmacy, I decided to talk to the patient about how he took the medication.  After some time, the translator, nurse practioner and I discovered the problem.  Since I recommended that he take his pills with food, he never took the medication.  He has no food.

Sometimes it’s not about the drug.

The opportunity to go to Haiti presented itself.  If you were in my shoes, would you go?  Why not?  I’m a professor of pharmacy practice in at Long Island University in Brooklyn, New York with a specialization in community pharmacy.  Patients in my clinic have hepatitis C, hypertension, and diabetes, among other things.  More than just medication management of these diseases, I teach my students to provide care.  In whatever form they can.  During his rotation at my pharmacy in Brooklyn, a recent student measured a patient’s blood pressure with perfect technique and reported a normal reading.  However, he failed to acknowledge and comfort the patient, who was in tears because of a recent death in the family.  Sometimes caring for patients requires acknowledging their real problems – not just their objective parameters of disease.  With this attitude, I said yes to the trip to Haiti.

Our team consisted of other Long Island University folks, led by the Dean of Nursing and included nurse practitioner faculty and students, some of whom had trauma experience.  The six of us were to see patients in a family clinic in Haiti’s capital of just over 700,000 people, Port-au-Prince. Within the clinic, I set up my little pharmacy with the few medications that I brought.  I organized them by indication, with antibiotics in one corner, cardiovascular meds in another, and so on.  There was no pharmacist preceding me, as they are few and far between in this country.  A local Haitian nurse dispensed medications before I arrived and I learned that she often turned patients away if she didn’t have the exact medication that the doctor wrote down.  This is exactly why in this setting, organizing drugs by indication makes more sense.  If I didn’t happen to have one antibiotic, I could recommend another. The bottom line for me is that we used what we had to help the situations.  And resources were scarce.

An eight-year old boy, Franklin, who was much too thin for his age, arrived with fever and weakness.  After a physical examination, the nurse practioners suspected meningitis. With out access to diagnostic tests, our team came up with a plane to give a dose of IV and ceftriaxone. He also, desperately needed hydration, but we only had a single bag of fluids remaining, which went fast so we came up with the idea that, while the nursing student held the IV line, I drew up saline from 10 ml saline flush vials.  I withdrew fluid into a syringe and she injected it.  Twenty minutes and twenty vials later, Franklin seemed appreciably better and was able to eat.   Teamwork became our remedy for the extreme lack of resources.

Despite our rift in language, communication became key to providing health.  Taking a thorough patient history led to critical differences in patient management. And this was a tremendous challenge in a naturally introverted population who were too respectful to ask questions. Local physicians were giving Bactrim® and chloroquine to every patient for empiric management of gastrointestinal infection and malaria.  A young and thin woman in her mid-20’s arrived with severe suprapubic pain.  She had prescriptions for Bactrim® and chloroquine, wishing to have them filled.  After the nurse conducted a physical exam and found hepatosplenomegaly, we suspected that she needed more attention.  After vigorous questioning, we discovered that she recently had an abortion by taking misoprostol.  Could the misoprostol have contributed to the now enlarged liver?  I recommend to switch the Bactrim® to ciprofloxacin to treat her suspected urinary tract infection in order to avoid further hepatotoxicity.

The patient counseling skills that I teach my students back home meant more in Haiti than anywhere else.  These patients were so poor, that they came to us for management of every illness, not just those caused by trauma. There were many pediatric respiratory infections for which I had to use urine cups to administer oral antibiotic suspension when I ran out of the vials that I brought.  Luckily, I had a squeeze bottle with volume gradients so that I could measure water for reconstitution.  We simply couldn’t take for granted that they had a refrigerator to store the medication, so I taught them how to store medication bottles in chilled water.  One cannot assume that they are able to open the bottles and must be taught.  Even simple actions required physical strength beyond their means, as they were often malnourished and emaciated.  I will never forget spending over thirty minutes to teach a young and frail 12-year old girl how to use her albuterol inhaler.   The simple breath and hand coordination was a daunting task for her until we practiced together repeatedly.

The country was hot and humid with rainfall at night. We slept soundly in tents behind a damaged building.  People lived in dire poverty with a goal of survival by the day.  But they also danced and sang. Cooked wonderful meals for us. I held children so tightly, trying to give them strength.  And with their laughter, despite conditions in which they lived, I became inspired by human resilience.  On a trip downtown to gather more medications, I saw crumbled buildings.  There was a street vendor selling crutches, which were most likely donations from the states.  And next to him, a man was selling his family’s personal clothes.  Nearby, a man who was clearly more affluent was eating a meal while leaning on his motorcycle. In spite of the resource gap between these people, there was no stealing.  No fighting.  Haitian people are not violent by culture.  Back home, we hear about stories of explosive violence in the context of starvation in this country.  But I wasn’t scared for one single day in Haiti.  Not one moment.  The connectedness with the people obliterated any fear of them.

There are two main things I’d like to express to pharmacists.  First, if you want to help, there are opportunities if you seek them out.  Don’t allow your perceptions of limitations prevent you.  The first and last step of doing developmental work is the desire to.  Your skills and knowledge are ample.   And second, when working with a team, you can do anything.  We compensated for our deficiencies with each other.  I withdrew the saline and the nursing student pushed it.

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