Wednesday, April 14, 2010

Haiti: Day 12

Back in Business

Today was a very good day on many levels. Firstly, our referrals picked up again. I'm sure the reason they slowed down was due to having a brand new set of medical professionals work with us. These practitioners come from many different settings, and I think often are not used to making psychiatric referrals. Also, as in so many instances, once we've both strengthened the interpersonal aspect of our relationships, the professional often follows.

More importantly, I had a number of good converstions with some key individuals today. I think I'm close to having a good overall feel for the dynamics of the hospital/nursing school/region, and may soon be able to synthesize a good plan of action to impart some significant change in the way that mental health care is delivered here. But I'm close...not there yet. More on that soon.

Today, I'd rather update you on the mother and baby we admitted to the hospital yesterday. In my opinion, their case highlights some of the clear weaknesses and potential strengths of mental health care in the region. This morning before clinic(after rounding on a woman in the ER with reported pseudoseizures) I checked in on mother and baby. All went well with them last night; the hospital staff of course had no need to use the tabs of haldol 2mg and lorazepam 1mg I set aside for them in case of agitation. From their neighbor's report, and from my assessment, we had no reason to suspect she would become agitated, but I like to be safe.
We planned to do a home visit this morning, but as was the problem with the mobile clinic yesterday, there is still a gasoline shortage in the area (someone working on a completely separate project was able to find some many miles away for almost $12/gallon). This afternoon, though, Cara from the nutrition program let me know they had found a truck (using diesel) to take us on the visit. So she, the neighbor and I hopped in the truck, and made our way to the home.

She lives not too far away from the compound, which is very increases the likelihood that someone can come and regularly pick up formula. It was far enough away for me, however, to get a feel for a more rural area. As we traveled, I began to see much fewer people on the side of the roads. We became more surrounded by trees and brush than by homes and rubble. We arrived at our destination, hopped out of the truck, and made our way down a winding narrow path, which opened into a hidden community of people off the roadway.

As we walked, as always, everyone was very friendly... the neighbor said hello to everyone, and we responded with "Bon Soir!" That's pretty much all I said, as the only non-Creole speaker in the group. (I gotta work on that) She introduced us to another lady, harvesting fruit in the middle of the clearing, who was "fou", or psychotic. When we got to the family's home, we found the patient's blind mother and her aunt sitting at the front of their very humble light wooden (heavy straw), tin roofed abode. They explained that yesterday, the daughter had gone to the hospital to get some help for the baby, but was supposed to be accompanied by her brother. Instead, she had wandered off alone, as she is prone to do, without an escort. They were very glad to hear that she and the baby were doing well. The aunt assured us that she would be responsible for coming to the hospital weekly to get help for the baby. And with that, we were off with a plan.

Many things strike me regarding this case. It speaks both to the abundance of resources available to individuals in this country (if they can find it) since the earthquake, and to the question of what happened before the earthquake when there weren't such great nutrition programs available? It speaks of course also to issues of competence, culture, paternalism and protection. But mostly I was struck by the fact that, although the community would kind of smile and say "Oh, she's 'fou'", their mentally ill were very much still a part of their community. I'm no longer even so sure that the patient needs an antipsychotic. I will continue to recommend it with the hope she will have some improvement in her thought organization, and maybe some associated improvement in mood with a decrease in her hallucinations. But as we know, our meds are much better with perceptual disturbances than they are with thought disorganization and mood. And the hallucinations themselves don't really bother me, or her community. They might bother her, we'll keep it. But if she were adequately breast-feeding, I probably would not.

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