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Canadian Paediatric Society

Don & Elizabeth Hillman International Child Health Grant

The Don & Elizabeth Hillman International Child Health Grant was created by the Global Child & Youth Health Section to promote international health opportunities for residents and fellows.  The section has established four $750 grants that are awarded annuallyto use toward completing a paediatric elective in developing countries.

To share this international experience with others, grant recipients are required to submit a brief written summary of their elective (1-2 pages) within one month of their return. The report will be published on the CPS website in the language of submission and may be included in a future CPS publication.

Submission deadline: March 31 or October 31

Nominations

Candidates will be assessed through a series of questions about the impact of the elective on their personal and professional futures. 

Candidates must:

  • Be registered as a resident or fellow in a Canadian paediatric postgraduate training program.
  • Be a member of the CPS Global Child & Youth Health Section.
  • Have support from a preceptor at the elective site and from the residency program director.
  • Have a preceptor at the elective site willing to formally evaluate the candidate while they are abroad.
  • Demonstrate appropriate preparation in advance of the elective as evidenced by a completed checklist of pre-travel arrangements.
  • Have support from a person who has experience in global health (international health and/or underserviced communities in Canada), and ideally is a current member of the GCYHS (the CPS can be contacted for a list of section members from each academic site if required)

The international elective must:

  • relate to child health,
  • be at least four weeks in length,
  • be in a low or middle income country, unless travel is intended for disaster relief or other work/research related to health in developing countries,
  • be a clinical or research elective.

Applications for courses or conferences will not be accepted.  Priority will be given to applicants who are not receiving funding or payment for their rotation in addition to their regular resident salary.

Unsuccessful applicants for Hillman support must submitted a new proposal for reconsideration.

Past Hillman award recipients are not eligible to re-apply.

Submissions

Applications must be submitted using the online application form and be received 2 months prior to travel and before the application deadline (March 31 or October 31). Incomplete or late applications will not be considered.

Submissions should include:

  • Confirmation by the elective supervisor at the elective host site, confirming their contact information and availability at the site during the elective. The letter should also indicate approval with regards to you practicing as a trainee during the planned elective, including information on medical licensure or malpractice insurance requirements (if applicable). NOTE: If site approval document not provided, fully explain.

  • Letter from your program director indicating support for your upcoming elective, emergency contact information and contingency plan, and return elective debriefing plan.

  • Letter from Canadian support coach indicating your coach’s experience in global health, including their ability and willingness to provide you with advice before, during and after your travels. Ideally, your Canadian support coach would be a member of the GCYH Section.

  • Travel and health insurance documentation. The GCYH Section strongly advises you to obtain full travel insurance. Your Department and University may help you to determine if you will be adequately covered for the following: evacuation benefits, referral services outside of Canada, emergency medical reimbursement expenses and recommend vaccinations for travel. If you do not have any of the above in place, please explain.

Past recipients

Robynn Geier - Paarl, South Africa - 2018

I recently had the opportunity to do a three-month Global Health Elective at Paarl Provincial Hospital in South Africa, and I am so grateful for the support I received from the Canadian Pediatric Society. I could not have envisioned a more enriching experience to round out my pediatric residency training. The team of doctors and nurses at Paarl Hospital face incredible challenges in diagnosing and managing complex, acutely unwell children, often within the context of difficult social situations. As an elective resident, I was not sheltered from these challenges, and had the opportunity to experience firsthand some of the ethical and medical dilemmas that walk through the doors of their hospital each day.

Paarl Provincial Hospital is a secondary-level hospital that receives patients and referrals from a catchment area of over 22,000 square kilometers. The population served by the hospital is approximately 600,000, with a large number of pediatric patients and an obstetrics department managing an average of 500 deliveries per month. Pediatric residents join the medical team on the inpatient service, caring for children and their families admitted to the medical ward or NICU. Paarl offered an amazing opportunity to develop more experience managing high acuity patients in the community. The hospital has a busy emergency department and pediatric service, with good exposure to medical problems we often do not see in Canada, such as tuberculosis, HIV/AIDS, and severe acute malnutrition.

International medical electives are innately designed to create a sense of discomfort and unfamiliarity in a new learning environment. My elective at Paarl Hospital was a humbling and rewarding experience, and gave me incredible insight into the challenges faced by patients, families and medical personnel living and working in South Africa. Managing resource allocation, adapting to differences in medical treatment and recognizing barriers to medical care were just a few of these challenges. On several occasions, our NICU ran out of CPAP machines and we were forced to decide which babies would remain on respiratory support and which ones might be able to cope off the machine. While in Canada we are relatively judicious in our antibiotic use, antibiotics were used much more freely in South Africa. I soon realized that this was correlated with the lack of follow-up that was anticipated at discharge and poor baseline health of the majority of children, whose comorbidities often included HIV, TB or malnutrition. In somewhat “over-treating”, they were in fact creating a safety net in the event that these children deteriorated in the community, had difficulty accessing transport back to hospital and/or were lost to follow-up. Unfortunately, some of the social barriers led to poor outcomes in our patients. During my final call shift, an infant was brought in to the emergency department in cardiac arrest. We had limited information on the patient, as no one in the emergency department spoke the mother’s dialect. The child had been vomiting for a few days, but the mother was unable to bring the child into hospital because they lived rurally, with difficulty accessing transportation. I worked alongside the emergency physician in the early hours of the morning, attempting to resuscitate the child. The mother was silent in the corner, it must have been terrifying. No one to help explain what was going on, endless beeping and humming from the monitors, her child barely hanging on to life. We tried to comfort her – I only wished she could have come in sooner.

When I first learned about social determinants of health, I was reading words on a page. Now, I see people. I see the 3 month old infant with severe developmental disability who recently lost her mother and has no extended family members willing or able to take over care. The grandparents are overwhelmed with other grandchildren. The aunt lives too far away. The child is too chronically ill. It will be too expensive. I see the twin girls with HIV, both recovering from serious infections in the intensive care unit. We have doubts that the family will be able to care for these children, it is too expensive to get transportation to clinic. They are on too many medications to remember. I see the teenage boy with TB, HIV and a serious bone infection, who has not been on treatment because of difficulty accessing the medical clinic. He has been here for months. There is no one with him in hospital because his mother is with her other child in ICU, at a different hospital. We give him colouring books and chat with him to keep him company. I see the countless numbers of children with severe acute malnutrition, whose parents are seasonal workers and have difficulty affording food. I see the infant in cardiac arrest, who likely had a simple stomach flu and could not make it to hospital in time.

Paarl Hospital, in many ways, was well equipped to deal with the challenges they face. The doctors and nurses have incredible training and are comfortable managing very ill children. They have a well-established Neonatal ICU, with good outcomes even for the most extreme premature babies. They have a comprehensive electronic medical record. Their dieticians and social workers are well-connected with community services. And, they make excellent use of the pediatric “Road-to-Health Booklet”, which has updated information on every child’s birth record, immunization status, growth chart and documented hospital/clinic visits. These mobile, patient-held “medical charts” have been used in South Africa since 1973, with many revised formats. Most recently, they have included 2 pages dedicated to HIV screening and management. While reliability and accuracy of these booklets still depends on social factors and access to care, the continuity and accessibility facilitates improved quality of care for these families, especially if there is a language barrier.

I learned so much from the patients, families and physicians at Paarl Hospital, and tried my best to share as much about Canadian medical practice during my time there. We had many interesting discussions on ward rounds about the differences in approach to medical management. The sheer volume of patients and severity of illness lended itself to plenty of opportunities to refine my procedural skills and neonatal resuscitation. These kinds of skills come easily to those who have trained in South Africa, but with improved access to health care services and fewer families living below the poverty line, we are often sheltered from these high acuity patients in Canada. As a future general pediatrician, these skills are critical in managing pediatric patients in the community setting, remote from the subspecialty services of a tertiary hospital, and I am so grateful for the confidence I have gained over the past few months. In return, I took every opportunity I could to do some bedside teaching with the medical students and interns. I managed to surprise even a few of the senior doctors by demonstrating a non-invasive method of obtaining “clean catch” urine samples in infants, removing the need for a painful, invasive catheter collection. The doctors would often excitedly report the success of this method to me the following day, and we would keep track of the number of catheters we had avoided using.

What inspired me most about working in South Africa was seeing how the dedicated staff at Paarl Hospital have ignited the compassion and generosity of the greater community and become true advocates for child health. During my time there, several of the doctors and nurses were working on transforming an empty room into a children’s library and playroom. They received donations from several organizations, families and staff members to revive the room into a playful, colourful space for the children and their families. One of the physicians also published a media release, asking for donations in-kind to help the newborns and infants waiting for adoption. Over the next 6 weeks, we were overwhelmed with donations – visitors would show up at the hospital with boxes of second hand clothes, toys, and hygiene products to donate to the children. We quickly ran out of space in our impromptu “donation room”. It was truly heartwarming to see the community response to some of the social challenges faced by our patients.

This experience will hopefully give me the strength and courage to ask the harder questions around social determinants of health, after seeing how strongly they can impact a child's health status. I hope to continue working in the global health field in some capacity, either through advocacy work, research or clinical practice. I am grateful to have had the opportunity to do this elective during my training and I will greatly miss the team at Paarl Hospital.

Sarah Johnson - Jinja, Uganda - 2018

Sarah Johnson, Jinja, Uganda -– 2018

It took me 40 hours to get from Edmonton to Uganda, and I felt as though I was entering another world as I first left the Entebbe airport in my sleep-deprived state. Having never been to a developing country before, I had done my best to prepare myself for my month long elective in Jinja, Uganda. Even so, despite the pre-departure workshops, the travel clinics, and all my reading, I was still shocked for much of my first few days in the country. The chaotic traffic, the clear disparities in standard of living, the groups of children pumping water from boreholes near their villages. It all was so incredibly different from my life back home. This difference extended to the hospital work. My elective was in pediatric infectious diseases with a focus on malaria. Before coming my Canadian preceptor had warned me- ‘it's not like here.. there are sick and dying children everywhere’. I quickly found out that he was entirely accurate in that statement. Malaria is incredibly endemic in that region, as are other infectious diseases including ones I had seen little of before - other parasitic infections, end-stage TB, measles, tetanus. Malnutrition and sickle cell were also commonplace. Fortunately the country had over the past several years seen a drastic decrease in pediatric HIV thanks to vigorous screening and treatment programs.

 
As I walked into the hospital on my first day I was not entirely sure what to expect. Jinja Regional Referral Hospital is a small government-owned hospital, which is frequently understaffed and undersupplied. Fortunately the staff there are among the friendliest and most welcoming people I had ever met. I quickly found my role in the hospital- spending the mornings rounding in the emergency room or the mother baby room. The afternoons were spent following up patients I had admitted, learning from the hospital staff with the rotating interns, or teaching the interns myself. Three of the weeks I spent there I also presented a teaching topic on the Thursday morning for all of the hospital staff (nurses, medical aides, staff pediatricians, and interns). These were very well attended and we had a great amount of discussion as we all learned from each other.


I gained so much respect for the people working in the Uganda healthcare system during this month. They managed to take seemingly impossible situations and find solutions. For example, the hospital frequently had power outages while I was there, often was out of the connecting pieces required to connect children to oxygen, and had only a select few options for investigations you could order. I couldn't help but think of all the conditions we were likely missing due to the lack of available investigations- the hospital had been requesting the reagents needed to run electrolytes, LFTs and RFTs for over a year. Despite all these challenges, thanks to cleverness and determined advocacy for their patients, the staff were able to make a huge difference for many of the children presenting there.

I am so grateful for having the opportunity to do this elective. I learned a great deal about not only the malaria that was my primary focus, but also about resource management in a limited setting, management of the acutely unwell child, the social and economic factors that impact health on a global scale, and what my patients from developing countries may have experienced at home. I definitely plan on returning to Jinja once I am a practicing pediatrician, and hope to keep global health as a focus in my career.

Thank you so much for the award that helped make this experience possible.

2018

Lauren Sham - Lusaka, Zambia

Arend Strikwerda - Gaborone, Botswana - 2018

For the months of June and July 2018, I went to Gaborone, Botswana for a global health elective at Princess Marina Hospital (PMH) and the Botswana-Baylor Children’s Clinical Centre of Excellence (COE). I pursued this elective to challenge myself professionally to learn and operate in an unfamiliar context, as I hope to prepare myself for a career in global health.

PMH was built in time for Botswana’s independence, which was celebrated 52 years before my arrival. It is the largest hospital in the country, and serves as the main referral centre for Botswana’s public health care system. I spent my first month working on the pediatric medical ward, where a fantastic team of pediatricians and pediatric residents took care of emergency room consults, recently discharged outpatients, and inpatients in around 35 beds - I say around because there was always room to squeeze in a few more beds, which was fortunate because the extra beds were often needed.

Our daily routines were similar to what I would experience on CTU at McMaster - a morning report followed by a teaching presentation started each day. We then had a short pre-rounding period to examine assigned patients and look up pending labs. By 10:30 every morning, 3 teams - consisting of a pediatrician, a resident, and several interns and medical students - would perform walk-around ward rounds (which inevitably always take longer than expected). We would grab a quick lunch followed by a variety of afternoon tasks; taking blood work, arranging scans, starting IVs and organizing discharges. While the framework was familiar, I encountered a variety of unique patients and situations. While many of the parents spoke English, I often had to modify my language and approach to interact with the pediatric patients that I was taking care of.

While I was at PMH, I was fortunate to be present at a grand rounds where the preliminary results of a national observational study were shown; a potential increase in neural tube defects in infants born to mothers taking Dolutegravir (an important new anti-retroviral) was approaching statistical significance. As I was sitting through the presentation, I realized that this was high level and internationally recognized research being done in Botswana - the findings are altering WHO recommendations. I am still amazed - I’ve met people who have done globally relevant research and am training at an institution that has a strong research reputation, but have never had the privilege to be in the room when brand new findings of this importance were announced.

I also worked at the COE; a partnership between the government of Botswana and the Baylor International Pediatric AIDS Initiative (BIPAI) which has been managing HIV+ pediatric patients in Gaborone since 2003. In a country with one of the highest rates of HIV in the adult population, effective management is extremely important. I learned that Botswana is the only African nation that is meeting the UNAIDS 90-90-90 goals for 2020 (90% of all people living with HIV will know their HIV status, 90% of all people with diagnosed HIV infection will receive sustained antiretroviral therapy, and 90% of all people receiving antiretroviral therapy will have viral suppression).

At the COE I participated in outpatient clinics following up patients who are HIV positive, from infants to young adults. I learned much about the care of HIV+ patients and about what their life can look like. I also got an inside look into how different areas of pediatrics overlap, and was surprised to find that I spent less time focussing on the infectious disease side of HIV management and more time thinking about my patients through an ‘adolescent medicine’ framework. Most of my patients’ disease management concerns stemmed from social difficulty. Whether there was an apathy towards their medication stemming from underlying depression, a fear of bullying or stigma, or a hectic home environment with poor parental support; I enjoyed figuring out what was at the root of medication non-adherence, and learning from my preceptors how best to figure this out. I especially enjoyed the seemingly daily conversations I would have with teenage patients about sexual health - including contraceptive options, HIV transmission between partners, and even explaining condom usage. My HIV+ patients are just regular teenagers, with regular teenage lives and questions.

Between my two months I had a wonderful clinical experience that will help me to be a better pediatrician here in Canada and anywhere else I go. While the “medical expert” aspect of learning on this elective was significant, I believe that the cultural and communication skills that I was able to hone will be invaluable to me. Thank you to the CPS and to the selection committee for helping to fund this unforgettable experience.

2017

Chloé Langlois-Pelletier - La Pointe, Haïti

Alexandra Rydz - Mbeya, Tanzania - 2017

Alexandra Rydz, Mbeya, Tanzania – 2017

Last October, I traveled to Mbeya, Tanzania, to participate in my first international medical elective. This experience was eye-opening and left me with a profound respect for the work my host organization was doing while also fostering a deeper appreciation for some of the resources available to me in Canada.

My elective was organized through the Baylor International Pediatric AIDS Initiative (BIPAI), an organization affiliated with the Texas Children’s Hospital. BIPAI operates in 13 countries outside of the USA to provide care primarily focused on HIV/AIDS, tuberculosis, malnutrition, and other conditions prevalent in those countries. While each site has at least two American-trained physicians, it is important to note that the clinic also employs locally-trained health care professionals in a deliberate effort to build capacity and local resources. During my rotation, I worked exclusively in an outpatient clinic with three American physicians; the remainder of the twenty-some multidisciplinary clinical staff were Tanzanian. Most mornings, I would arrive to a waiting room that was steadily filling. Most patients traveled by bus from rural areas that were hours away, and because appointments were not scheduled for specific times, they could wait hours to be seen. I would see patients in my office until the afternoon buses back to the rural villages departed, and then would take advantage of the late hours of the day to work on projects the clinic had assigned to me.

I am appreciative of the Mbeya clinic staff’s commitment to mitigating problems faced by patients, even if these problems are beyond the scope of direct medical care. During my elective, I witnessed this through the clinic’s handling of hospitalizations. Hospitalizations can precipitate financial and social crises, a reality that is less prominent in Canada. In the Mbeya region, where the median per capita monthly income is $5 CAD, paying for hospitalization is either an unaffordable luxury, or a burdensome expense with implications for the whole family. Hospitalization costs include not only admission fees, but also the cost of medical supplies. Recognizing this burden, the clinic strives to prevent hospitalizations in the first place: children in acute distress can be assessed and stabilized in the clinic, rather than in the emergency room. If a patient required intravenous antibiotics but is well enough to go home, the patient can return daily to complete their treatment course, with the clinic staff monitoring closely for signs of treatment failure. If admission is inevitable, the clinic sends medical supplies, such as intravenous tubing, bandages and catheters, to minimize the hospitalization cost for the patient and the family.

The clinic’s approach to malnutrition is another example of their dedication to patient well-being. Malnutrition is ubiquitous amongst their population, driven not only by the food insecurity that is highly prevalent in the region, but also by the increased metabolic demands that are secondary to HIV infection. By the end of my four week elective, I was still struggling to believe how stunted the growth of most of my patients was; strong adolescent males were a full head shorter than my midrange female height, and school-aged children weighed less than most of the toddlers I see in Canada. Acknowledging that malnutrition and disease exacerbate each other, the clinic deals with malnutrition not only by managing severe acute malnutrition, but also by conducting regular, well-attended sessions on basic nutrition. Furthermore, the clinic’s nutritionists have started a community garden which features and provides patients with burlap sack gardens, an innovative method of allowing even those with limited garden space an opportunity to grow some produce from home to diversify their nutritional intake.

The above-mentioned programs illustrate efforts made by the Mbeya clinic to meet the needs of their patients.  Despite these resourceful endeavours, there were still stark limitations to my practice in Mbeya compared to Canada.  One example is that we did not check electrolytes on patients at risk for refeeding syndrome, because the cost was prohibitive and the necessary machine only worked intermittently. The hardest reality for me to accept was how helpless we were in mediating difficult family dynamics. Several of my patients came from homes where they were witnessing marital spousal abuse or parental substance abuse. In one situation, a patient could not disclose his HIV-positive status because his mother, from whom he had acquired the disease, had kept it a secret from his father. If his status was disclosed, his father could become violent or abandon the family. Despite its prevalence, HIV still carries a heavy stigma. Through the clinic, we would offer to connect the patient to our counsellor, and the social worker would try to find ways to mediate the situation. Sometimes, the social worker would organize a family meeting during which parents would vow to improve their behaviour; on other rare occasions, the social worker could find an alternative caregiver for the child. More often than not, no major changes were made. There was no Child and Family Services department to investigate the situation more thoroughly and no social programs that would house and care for a child pending a permanent safe placement. It was these situations that made me long most for the resources available to me in Canada.

Overall, my experience was humbling and inspiring. Because I worked with a translator, I saw far fewer patients than any of my colleagues, and I certainly learned more from them than they did from me. The role I played in providing patient care at the clinic was small, which I thought might frustrate me. Instead, I am happy to have been able to participate in the work of an organization that is optimizing patient care through a thoughtful multi-pronged strategy.

Gilbert Lam - Siem Reap, Cambodia - 2017

Drip. Drip. Drip.

My sweat continues to fall, drop by drop. How am I the only one sweating on this ward? It cannot be humanly possible, even for these Cambodian people, not to be sweating! It’s 35 degrees Celsius and there isn’t even air conditioning. Am I nervous to make a good impression? Or rather, am I excited to see some interesting tropical infections?

Or perhaps am I uneasy because I stick out, the one dressed not in scrubs, but rather, a clean dress shirt and pants (which are now drenched in sweat)?

Worse, do I have a fever after just 48 hours here? Could it be possible to be showing symptoms of malaria, typhoid or dengue fever? What is the incubation time after being bitten by an Anopheles mosquito carrying Plasmodium falciparum?

I stand here on the inpatient ward, huddled among 10 other residents and interns, and Dr. Sing Heng, the senior doctor, what they call the attending pediatrician here. We are getting handover from the overnight resident - who is giving us the one-liner and the acute issues that have occurred over the last 12 hours. Though their English isn’t completely fluent, the language of medicine remains familiar. Words like: HIV, TB, malnutrition, abscess, poor family, “what is your diagnosis?”, DNR - these words mean the same as they do here as they do back home.

So many things are foreign to me: the food, the language, the political system, the hectic traffic. I grasp onto any semblance of familiarity, like hearing the language of medicine. This familiarity gives me solace.

This was one of my first journal entries in Siem Reap, Cambodia, where I spent a month-long elective at the Angkor Hospital for Children (AHC). The hospital opened in 1999, in the wake of recovering from the devastating Pol Pot genocide, and has now transformed into a truly incredible place. Not only dedicated to providing free healthcare for Cambodian children, the AHC is the only pediatric teaching hospital in Cambodia and provides a rich training program for local paediatric residents.

In line with my own career goals of practising general pediatrics, I spent my time on the inpatient ward, outpatient clinic and NICU. I also had the opportunity of making a rural ‘satellite’ visit to a peripheral hospital an hour away from Siem Reap; this experience allowed me to better contextualize the geographic and economic barriers of families I was meeting in Siem Reap.

Common illnesses that were familiar to me from my training in Canada included bronchiolitis, pneumonia, and gastroenteritis.  The part of me that loves infectious diseases was fascinated by the cases of dengue fever, typhoid fever and malaria. I even learned about illnesses I had never heard of before my arrival in Cambodia; “melioidosis” became a familiar diagnosis to me during my time there. Even more uncommon conditions that I did not expect to see were severe cases of lupus cerebritis, palliative Tetralogy of Fallot, and retinoblastomas. The clinical medicine was fascinating, and made me realize that, even though I am in my fourth and final year of residency, there is still lots I need to—and want to—learn.

Tap. Tap. Tap.

“That’s Castell's sign if you percuss here,” I explained to the medical students and residents during bedside rounds. I was pointing out splenomegaly in a patient with untreated thalassemia.

My role in Cambodia has been both learner and teacher.

As time passed, I realized role in Cambodia was vastly different from my previous global health experiences in India, South Africa and Nunavut. Here, my role involved a lot more teaching—offering educational support to the medical trainees. This is where I felt I could be of most use, rather than the direct clinical care that consumed most of my time in previous experiences.

Apart from giving teaching sessions on the ward, one unique example was working with the local residency program to deliver ‘journal club’. During my month, we worked on analyzing the original article appraising the Rochester Criteria, for febrile infants suspected of serious bacterial infection. Traditionally, journal club had been taught by the education director, but we had an idea that I could ‘teach the teacher’, so local residents could start to deliver journal club in the Khmer language. In this way, more physicians could understand and participate in discussions of epidemiology and critical analysis of a scholarly paper. Furthermore, as more residents from Ottawa go to AHC for elective experiences, we hope to develop a longitudinal partnership to contribute to the resident education at AHC. 

Akun.

That's “thank you” in Khmer. That's how we always finish rounding on one patient and move onto the next.

I don't know any other Khmer words. And the patients don’t understand much English. So here I stand beside the Cambodian doctors to interpret the conversation. In the meantime, my attention focuses not on the verbal communication, but everything else about the patient encounter.

Instead, I listen to the child and mother's tone of voice.

Instead of asking how the boy’s oral intake was last night, I notice he is now eating some rice porridge this morning.

Instead, I watch the interaction between mother and child. I watch her soothe her fussy child.

Instead, I watch the child's desire to play as a marker of clinical improvement.

It was during these moments of not understanding the literal words of patients, that I had my most profound realizations about global health and, really, medicine in general. I learned to listen to my patients even when I did not understand their verbal communication. I learned to truly observe and to listen. Global health became about understanding my own biases and perceptions, and being attuned to the sights, smells, and sounds that surrounded me.

I am thankful for the opportunity to have learnt and to have grown during my time at the Angkor Hospital for Children. As I finish residency this year and submerge into studying for Royal College exams, this experience was an inspiring reminder to practise pediatrics with compassion, and to listen to my patients in every way possible.

I am thankful for the CPS Global Child & Youth Health Section for the Don & Elizabeth Hillman International Child Health Grant.

Akun.

Gilbert Lam, PGY-4 Pediatrics Resident

Children’s Hospital of Eastern Ontario, University of Ottawa

For more information about the Angkor Hospital for Children and volunteer opportunities: www.angkorhospital.org

Elissa Champoux-Ouellette - Labrousse, Haiti - 2017

Au printemps dernier, j’ai eu la chance de partir pour Haïti suite à ma participation au microprogramme de santé internationale de l’Université de Sherbrooke. Après avoir été accompagnée dans la préparation de ce stage, j’étais fin prête à relever ce nouveau défi afin d’aller vivre cette nouvelle expérience et découvrir ces terres créoles dont j’avais tant entendu parler. J’ai fait la rencontre de mes coéquipiers à l’aéroport. Une brève escale à Miami nous séparait de notre destination, Port-au-Prince, où nous avons couché le premier soir avant de partir vers Labrousse. Après une bonne nuit de sommeil, nous avons fait la connaissance d’un homme exceptionnel : Figaro, notre chauffeur et guide touristique. Nous avons d’emblée été immergés dans un bain culturel lorsqu’il a commencé à nous donner des cours de créole en route vers Labrousse. Sa célèbre phrase « Koman nou ye? », significant « comment allez-vous? », restera à tout jamais gravée dans ma mémoire!

Notre trajet vers Miragoane, située vers l’ouest, s’échelonna sur plus de cinq heures.  Nous n’avions qu’une centaine de kilomètres à parcourir, lesquels peuvent se faire en deux heures lorsqu’il n’y a pas de trafic. C’est dans cette ville située au département de Nippes que commençait notre ascension vers Labrousse. Après une heure de route au rythme de la musique créole à travers des paysages à couper le souffle gorgés de précipices et de montagnes luxuriantes, nous sommes arrivés à Labrousse. Nous avons été accueillis chaleureusement par une dame qui s’occupa de nous tout au long du stage. Par la suite, nous avons rencontrés toute l’équipe médicale qui habitait dans une petite maison tout près du centre de santé. Dès le lendemain, nous commencions la clinique. Au début du stage, nous voyions les patients tous ensemble. L’équipe était composée d’un médecin haïtien, d’un résident haïtien en service social, de notre superviseur québécois et de mon collègue stagiaire également résident. Nous avons d’emblée été frappés par la barrière linguistique.  Bien que le français soit parlé en Haïti, la population de Labrousse ne parlait que le créole.  C’est grâce au médecin haïtien nouvellement arrivé que plusieurs changements avaient été instaurés, notamment des cours de créole. Sous forme de module et enseigné par une infirmière et le médecin haïtien, cela nous a permis d’apprendre l’essentiel pour questioner les patients. Tout cela était dans le but de s’initier à la culture haïtienne, mais aussi de nous préparer en vue de la mission de la dernière semaine de stage. 

À cet effet, cette dernière semaine appelée « mission » consistait à mobiliser une équipe d’infirmières du CEGEP Garneau qui venait en renfort pour offrir des soins de façon  intensive à la population du sud-ouest haïtien. Pendant ces sept jours de travail consécutifs,  nous avons vu en moyenne 70 à 90 patients par jour. Cependant, les premiers jours furent très tranquilles étant donné les pluies diluviennes qui tombaient sur les sols haïtiens. Les patients, venant majoritairement tous à la marche, ne pouvaient simplement pas se rendre au centre de santé. Une fois le soleil revenu, nous étions fin prêts et motivés à travailler! Nous étions divisés en trois équipes pour augmenter notre efficacité. Cela était donc loin de nos journées habituelles en clinique d’une vingtaine de patients. On sentait vraiment une dynamique différente au sein de laquelle rayonnaient une vitalité et un esprit de collaboration. Nous terminions nos journées avec le sentiment du devoir accompli. Deux journées dans la mission furent réservées aux cliniques mobiles. Le but de ces cliniques était d’offrir des soins à une population dans un milieu éloigné où l’accès à un centre de santé était difficile. Ainsi, les agents de santé dans la communauté étaient avisés au préalable de ces visites et mobilisaient la population à se présenter la dite journée. L’équipe se divisait en deux lors de ces journées. Pendant qu’une équipe se rendait dans le village à une heure de route, l’autre gardait le fort du centre de santé de Labrousse. Notre journée se terminait alors que nous avions vu tous les patients. Cela pouvait monter jusqu’à 75 patients.

À travers le mois, nous avons vu plusieurs cas très variés, dont plusieurs fièvres typhoïdes. La méthode diagnostique préconisée était surtout l’approche syndromique.  Compte tenu des tests diagnostics très limités, nous devions faire confiance à notre histoire et à notre examen physique pour poser un diagnostic. Par exemple, lors d’un après-midi, une matrone est arrivée avec un bébé de 24 heures de vie. Il était né à domicile la veille. La mere étant incapable de marcher trois heures dans les montagnes pour se rendre à la clinique, c’est plutôt sa matrone qui s’est présentée car elle était inquiète. Le nouveau-né semblait hypotonique et buvait moins depuis quelques heures. Effectivement, l’enfant était moche et fébrile. Il semblait en sepsis. Étant donné que les boires avaient diminués et que son état clinique s’était détérioré, nous voulions avoir une glycémie. Par contre, la dernière bandelette avait été utilisée le matin même, chez un patient comateux. Il n’y avait donc aucun moyen de connaître sa glycémie. Nous avons donc assumé qu’il était en hypoglycémie. Outre ce constat, un deuxième problème se présentait, en l’occurrence quell traitement allions-nous lui donner! L’enfant n’avait pas encore d’accès veineux, la mere était absente pour un allaitement et aucun lait de formule n’était disponible. Nous avons donc pris du D10% d’une poche par le biais d’une seringue et l’avons donné au bébé par la bouche. Les antibiotiques furent donnés par voie intramusculaire et nous l’avons transféré à l’hôpital le plus proche. Par chance, cette journée-là un chauffeur de FODES était sur place et a pu les reconduire. Plusieurs cas comme celui-ci nous ont incité à utiliser notre imagination afin de mieux soigner les patients. Les ressources étant limitées, nous n’avions pas accès à tout ce que nous aurions souhaité. Une fois cette réalité comprise, nous étions capables de changer notre mode de pensée et de passer à l’action. Ce fut un beau défi et une très grande leçon. J’ai eu la chance d’assister aux cliniques de vaccinations et de suivis de la malnutrition chez les nourrissons. Un programme est bien instauré et des agents de santé s’impliquent au sein du projet. Seuls les enfants en malnutrition sévère ont droit au plumpynut, une pâte à base d’arachides. Même si on veut en donner à tous, c’est impossible. Une réalité bien dure à accepter!

En conclusion, ce stage d’un mois m’a permis une immersion intensive mais brève dans la culture haïtienne. J’ai pu être mieux sensibilisée aux réalités économiques, religieuses et géographiques d’une petite communauté. Je compte bien recommencer cette expérience dans un avenir rapproché. Je tiens également à remercier l’organisme FODES, qui sans lui, cette expérience n’aurait pas été possible ainsi que toutes les équipes haïtiennes et québécoises qui ont rendu cette expérience inoubliable. Mèsi anpil ak tout ekip la!

Veronique Pépin - Port-de-Paix,Haiti - 2016

En octobre dernier, j’ai eu la chance de partir pour Haïti accompagnée de deux pédiatres du Québec.  Nous nous sommes jointes à l’équipe du Centre Médical Béraca situé à Lapointe-des-Psalmistes, une ville au nord d’Haïti.  Se rendre à ce village du nord par la route prend près d’une journée. C’est donc en survolant les montagnes que nous avons parcouru la distance qui séparait Port-au-Prince de notre destination finale. À mon arrivée, je pensais être happée par un tourbillon d’activités, d’odeurs, de bruits; ce ne fût pas le cas. Il y avait eu beaucoup de pluie et les rues étaient anormalement calmes. C’est après quelques jours de soleil que j’ai enfin pu découvrir leur effervescence. J’ai vite compris l’impact majeur de la météo sur le quotidien des gens. En l’absence de routes pavées, de réseaux d’aqueduc et trop souvent de maisons étanches, la vie devient rapidement compliquée par la pluie. Cette réalité a influencé grandement mon expérience de stage.

Arrivée à Lapointe, j’ai pu rencontrer plusieurs membres de l’équipe médicale et administrative. Nous étions visiblement attendus et nous avons eu droit à un accueil des plus chaleureux. Pour mes collègues, il s’agissait de retrouvailles avec l’équipe locale. J’étais la seule à y aller pour la première fois. Nous avons rejoint la pédiatre locale qui, j’allais le découvrir, fait preuve d’une polyvalence hors normes. En effet, elle porte également les chapeaux d’administratrice de l’hôpital, d’anesthésiste, de directrice d’école en plus de faire de la médecine interne adulte à ses heures et d’enseigner à ses collègues infirmières et médecins généralistes. Le dévouement des médecins haïtiens m’a frappée dès la première journée et n’a cessé de susciter mon admiration tout au long du stage.

Nos journées débutaient avec la tournée des enfants hospitalisés. Les lits de pédiatrie servaient à la fois pour les patients de pédiatrie générale, de néonatalogie, de soins intensifs et de chirurgie. Les maladies infectieuses, avec les pneumonies, diarrhées bactériennes ou parasitaires et autres fièvres sans foyer, occupaient la majeure partie de notre temps. Nous hospitalisions aussi, malheureusement trop souvent, des enfants souffrants de malnutrition sévère et de diverses blessures accidentelles (brûlures, fractures, etc.).

À l’instar des familles québécoises, les familles haïtiennes occupent une place centrale dans la prise en charge des enfants hospitalisés. Leur rôle est toutefois différent de celui auquel nous sommes habitués. Elles sont notamment moins impliquées dans la prise de décision qui revient quasi entièrement au médecin, mais le sont davantage dans les soins. Par exemple, elles étaient responsables de donner les médicaments, de faire les soins d’hygiène de fournir la nourriture durant l’hospitalisation. Les familles étaient également en charge de l’achat des médicaments et du matériel.

Une fois la tournée terminée, nous allions travailler à la clinique externe. Le débit était variable et rythmé par la météo. En effet, il est difficile, voire impossible, pour plusieurs familles de venir consulter lorsqu’il pleut. Ainsi après une journée de pluie, nous avions affaire à davantage d’enfants et ils étaient souvent beaucoup plus mal en point en raison du retard de consultation. L’exposition était variée allant de l’évaluation d’un nourrisson normal à la prise en charge d’un patient épileptique en passant par les cas de malnutrition légère, de maladies infectieuses plus ou moins bénignes et de l’évaluation de nombreux types d’éruption cutanée.

Haïti étant parmi les pays les plus pauvres, il va sans dire que les ressources étaient limitées. Nous avions accès à très peu de tests diagnostiques et bien souvent leur utilité était limitée par leur manque de fiabilité. De plus, les familles doivent payer pour les investigations et les traitements. L’utilisation judicieuse des ressources étaient donc un souci de tous les instants. Ainsi, l’histoire précise de la maladie et un examen physique minutieux étaient essentiels et souvent suffisant à la prise en charge adéquate des patients. Ce stage m’aura permis de découvrir qu’il est possible de faire des diagnostics assez précis uniquement sur une base clinique en plus d’apprendre à établir un plan de traitement malgré un certain degré d’incertitude diagnostique. Ces circonstances m’auront aussi permis d’améliorer la sensibilité de mon examen physique.

Finalement, mes quatre semaines de stage auront passé à la vitesse de l’éclair. J’ai eu la chance d’y faire de nombreux apprentissages médicaux mais surtout de vivre une expérience enrichissante humainement. J’aimerais remercier la bourse Don et Elizabeth Hillman, Dre Miriam Santschi et Dre Marie-Pier Grondin qui ont rendu ce stage possible. Je souhaite aussi remercier l’équipe du Centre Médical Béraca pour leur accueil et leurs enseignements.

Julie Hébert - Sokponta, Benin - 2016

Le Bénin aura marqué ma résidence de par cette expérience de stage inoubliable. Il m’a permis de confirmer que je souhaite poursuivre mon chemin en santé mondiale. Pour changer sa perspective, il est parfois nécessaire de prendre un pas de recul de ce que l’on connait. Au Bénin, j’ai fait des apprentissages sur la médecine, sur la culture et sur l’humain.

Nous étions surtout basés à l’Hôpital Abbraccio de Sokponta, un centre de référence pédiatrique pour la région. Cet hôpital est subventionné par une organisation religieuse italienne et le travail y est accompli par des médecins béninois compétents et motivés ainsi qu’une équipe infirmière dévouée. La coopération avec le personnel local a été précieuse pour la réussite de notre stage et l’atteinte de nos objectifs. Dans ce centre, il y avait plusieurs limitations diagnostiques lors de nos rencontres cliniques. Les bilans laboratoires doivent être payés à l’unité. Nous avons également rencontré plusieurs cas difficiles, souvent sur le plan médical, mais aussi sur le plan éthique. Un des petits patients, né dans un village situé à plusieurs heures de l’hôpital, souffrait d'asphyxie périnatale. Il éprouvait de la difficulté à respirer et était très pâle. Comme la mère avait subi une césarienne, elle n'avait pas pu se déplacer pour être avec son bébé. Lorsque nous avons senti que nous perdions le patient, le père et sa deuxième compagne ont choisi de le ramener auprès de la mère pour qu'elle le voie avant son décès. Cette pratique met surtout l’importance sur l’importance d’être auprès de la famille, même si cela implique de ne pas avoir accès à des soins médicaux dans les dernières heures. Lors de la dernière semaine de stage, nous avons la chance d’être accompagnés d’une néonatalogiste du CHEO, Dre Rouvinez-Bouali. Avec Dr Rached, pédiatre superviseur du groupe, nous avons complété une tournée formelle de la néonatalogie et de la pédiatrie avec l’équipe locale afin d’évaluer quelle est la prise en charge habituelle des patients. Nous avons renforcé l’importance de l’allaitement et des soins kangourous de même que la prise de la glycémie capillaire.

À vingt minutes à peine de l’Hôpital de Sokponta, au dispensaire des Sœurs du Christ-Roy, la médecine y était légèrement différente et il s’agissait de notre second milieu de stage. Les choix d’examens étaient quelque peu plus restreints, mais les infirmiers et le médecin étaient quant à eux très polyvalents. La variété des cas était impressionnante, puisque le seul médecin faisait tour à tour de la chirurgie, de la gynécologie, de la pédiatrie et bien plus. La sœur en charge avait aussi le rôle d’assistante-anesthésiste et de sage-femme. Nous avons eu un cas pédiatrique grave, un enfant de 13 mois est arrivé en détresse respiratoire, avec suspicion de malaria et surinfection bactérienne. Malheureusement, l'enfant a décompensé et il a nécessité une réanimation. De concert avec le médecin béninois, nous avons tout fait pour aider l'enfant, dans les limites adéquates culturellement, mais ce fut en vain. Perdre un enfant est toujours une tragédie pour une famille et sa communauté, mais ce décès aurait possiblement pu être prévenu si l’enfant avait eu accès à des soins plus tôt.

Pendant mon séjour à Gbaffo, le troisième milieu de stage, j'ai eu la chance de faire de la médecine de proximité. Nous avons été accueillis en grand par le village avec une célébration vaudoue. La chaleur était accablante, mais la semaine était mémorable. Des cas de paludisme, de malnutrition et d’infections diverses sont venus en grand nombre. Une petite fille de 6 mois que la mère a amenée pour une tachypnée depuis plusieurs mois s'est révélée avoir une coarctation de l'aorte, diagnostiquée avec tous les signes cliniques classiques. Les parents étaient aussi inquiets pour leurs enfants que ceux que je rencontre dans mon travail au Québec tous les jours. Avec l'aide de ma collègue résidente en pédiatrie, nous avons eu une conversation avec l'infirmière du village. Cela faisait maintenant plusieurs mois qu'elle y était et trouvait cela difficile. La chaleur, le manque de support et de ressources et l'isolement de sa famille étaient durs à supporter. Nous avons revu avec elle les étapes de réanimation néonatale Helping Babies Breathe, car c'est elle qui gère tous les accouchements du village. Les travailleurs de la santé de ces milieux reculés ont une large étendue de connaissances.

Pour la complétion du stage, chaque résident devait avoir un projet académique adapté aux besoins du milieu. Avec ma compère, Soha Rashed-D’Astous, nous avons choisi de présenter la formation Helping Babies Breathe à plusieurs reprises, soit aux trois milieux cliniques et à un grand groupe de sages-femmes de la région. Les séquelles de naissances difficiles sont un problème de santé publique important au Bénin. Enseigner cette formation fût une expérience que j’ai beaucoup appréciée, car les participants étaient très motivés.

Le stage a été riche en apprentissages et en découvertes, probablement le meilleur mois de ma résidence. Outre la médecine tropicale et l’apprentissage des différences culturelles, mes souvenirs du Bénin, c'est avant tout la gentillesse des Béninois et la cohésion que j'ai eue avec mes collègues résidents du stage qui vont me rester.  Ce sont les fous rires avec nos amis locaux, les sourires, les blagues, les chansons, Bac Bevi No Rowae. C’est les enfants qui sautaient à notre vue en chantant « Yovo, yovo, bonsoir. Ça va bien. Merci. » Ce sont les parties de soccer avec les jeunes du village. Ce sont nos tentatives de courses dans la plus grande chaleur. C'est la fois qu'on a tenté de voir des hippopotames après 5 heures d'excursion ! C'est notre soirée sur la plage en plein-air. C'est d'avoir confirmé que je retournerais sous peu en Afrique de l'Ouest.

Merci à l’équipe de l’Hôpital Abbraccio de Sokponta, à l’organisation des Sœurs du Christ-Roy et à tout le comité d’accueil de Gbaffo.

Merci à Mme Geneviève Alary, à Reine-Estelle et à tous nos superviseurs.

Merci à la SCP pour son support et pour le prix Don & Elizabeth Hillman.

Merci à tous mes collègues résidents, tout particulièrement à Soha Rashed-D’Astous, qui ont rendu ce séjour mémorable !

Jolène Breton - Kampala, Ouganda - 2016

C'est au printemps 2016 que j'ai eu le privilège de faire un stage de pédiatrie au Mulago National Referral Hospital de Kampala, en Ouganda. Pendant ce stage, j'ai travaillé en collaboration avec les résidents de pédiatrie locaux dans différents départements de l'hôpital, soit à l'unité de malnutrition, en néonatalogie, et à l'unité de soins aigus. Voici quelques instants marquants de cette aventure qui s'est avérée être l'une des plus enrichissantes de ma jeune carrière.

C'est notre premier jour de stage. Après avoir préparé ce stage pendant des mois, ma collègue Genevièvre et moi sommes enfin rendues à Kampala et nous arrivons peine à y croire. Nos sacs à dos à moitié ouverts dans le salon, on engouffre notre toast au beurre d'arachide et bananes, puis on amorce notre marche vers l'hôpital sous la chaleur matinale déjà accablante. On se fraie un chemin sur la rue à travers les travailleurs en complet, les populaires kiosques de journaux, et les boda-bodas qui zigzaguent dans le trafic : Premier rond-point, tout droit, deuxième rond-point, à gauche.

Les unités de pédiatrie de l'hôpital sont constituées de plusieurs petits bâtiments reliés les uns des autres par des trottoirs, ce qui donne davantage l'apparence d'un labyrinthe que d'un veritable chemin. Je me rends à l'unité de malnutrition, qui comporte une cinquantaine de patients, où je passerai plusieurs semaines. La journée commence par la tournée des patients les plus malades, séparés dans deux petites salles de acute care à l'entrée de l'unité. C'est en mettant les pieds pour la première fois dans cette salle, où les enfants se partagent à la fois les lits et la bonbonne d'oxygène, que j'ai été confrontée à la réalité des soins à Mulago. Ces patients, souffrant pour la plupart de complications infectieuses de leur malnutrition sévère, sont dans des états tellement dépassés qu'il est difficile de les prendre en charge adéquatement. La limitations des tests disponibles fait également en sorte que nous traitons souvent empiriquement les patients dont le diagnostic reste incertain. Une chose est sûre cependant : le VIH et la tuberculose sont surreprésentés chez ces enfants malnutris, et sont souvent la cause-même de leur malnutrition.  Heureusement, je partage la lourdeur des décisions de soins avec les médecins-résidents locaux qui m'ont accueillie chaleureusement dès mon premier jour de stage et m'ont rapidement intégrée dans leur équipe.

C'est dans l'unité de malnutrition que j'ai perdu mon premier patient ougandais. Ce matin-là, je me suis rappelé des pleurs de la mère lorsque j'ai emmené son enfant dans la petite salle de acute care quelques jours plus tôt : cela représentait pour elle, comme pour la majorité des parents, l'annonce du décès imminent de son garçon. Et elle avait raison, bien que j'aurais aimé lui prouver le contraire. Ce scénario s'est malheureusement reproduit maintes fois pendant mon court séjour (le taux de mortalité de l'unité étant estimé à 20%), et j'ai été surprise du détachement avec lequel mes collègues résidents vivaient ces situations. J'imagine qu'à force de perdre autant de patients, on n'a d'autre choix que de s'en détacher pour réussir à continuer sa journée. En contrepartie, j'ai été témoin de plusieurs belles réussites, d'enfants qui ont finalement repris du mieux, ce qui a su chasser le sentiment d'impuissance qui m'habitait souvent lors des premiers jours.

La deuxième partie de mon stage se déroule à l'unité de néonatalogie, où je travaille conjointement avec ma collègue Genevièvre. Nous prenons en charge les nouveau-nés à terme qui nous sont référés des salles de naissance ou des dispensaires voisins. Les bébés instables nous sont amenés sur une grande table, parfois même sur des chaises, et nous les transférons dans un petit berceau une fois leur condition stabilisée. Le manque de personnel et de ressources est criant dans cette unité comportant une trentaine de nouveau-nés à terme et autant de prématurés, et nous sommes heureuses de pouvoir, bien humblement, apporter notre aide. Mon passage en néonatalogie se décrirait comme une alternance de découragement face aux soins limités et de fierté face à nos bons coups. J'ai aussi été étonnée de voir à quel point le fonctionnement reposait sur la présence des mères qui doivent, mêmes quelques heures après l'accouchement, venir allaiter ou nourrir via tube naso-gastrique leur bébé. Ainsi, notre rôle improvisé de conseillères en allaitement est sans doute ce qui nous a valu le plus de reconnaissance auprès des mères ougandaises.

La dernière portion de mon stage se déroule à l'urgence, plus précisément dans une petite sale climatisée appelée soins intensifs au fond du corridor. Nous recevons les patients les plus malades, transférés de la salle de réanimation, sans toutefois avoir davantage de moyens pour les prendre en charge. Je suis confrontée aux ravages de la malaria, des méningites, et du VIH infantile. Je suis confrontée aux délais de traitements dans un milieu où les urgences sont ralenties par manque de ressources. Je suis finalement confrontée aux efforts des familles qui doivent trouver l'argent nécessaire pour les tests diagnostiques et les médicaments. Dans ce contexte, je réalise rapidement l'importance de faire des choix thérapeutiques judicieux, ceux-ci pouvant avoir un impact majeur sur les conditions de vie des familles qui souhaitent le meilleur pour leur enfant.

Après deux mois passés à Mulago, c'est maintenant le dernier jour du stage. Nous passons, Genevièvre et moi, par le local des résidents pour les remercier de leur accueil chaleureux et leur collaboration précieuse sur les unités de soins. Contre toute attente, ils nous avaient préparé un petit cadeau, de beaux foulards, qu'ils nous donnent en disant «Thank you for being our friends».

C'est donc le coeur léger que je rentre à Montréal, grandie par cette expérience empreinte de chaleur et d'humanité.  J'aimerais remercier en terminant le prix Don et Elizabeth Hillman ainsi que l'équipe du CHU Sainte-Justine, particulièrement Dr. Heather Hume, qui ont rendu ce stage possible.

Elizabeth de Klerk - Paarl, South Africa - 2016

My global health elective took me to a special part of the world - to my home country of South Africa. As part of a well-established partnership with UBC Pediatrics, I had the opportunity to spend 3-months working at Paarl Provincial Hospital. The hospital is located in one of the oldest towns in the Western Cape and is a secondary level state hospital that acts as a referral center for a number of neighboring townships and small cities.

Residents are immersed in general pediatrics, regularly working between the inpatient ward, neonatal intensive care unit, and post-natal unit. The patient demographic is young with ward patients typically between the ages of 2 months to 5 years. Pediatric care in South Africa only includes patients of up to 12 years, as compared to 17 years in Canada. Ethnically most patients are black Africans, primarily speaking Afrikaans or Xhosa. Afrikaans is my first language and I was very excited to speak it with my patients; however, having trained in Canada my Afrikaans medical terminology is limited. I initially thought this would be a barrier to communication but soon realized that patients and parents appreciated my lack of medical jargon!

As one of the publically funded state hospitals a large proportion of patients were underprivileged and impoverished. Many patients lived on the outskirts of cities in townships. During the apartheid era black Africans were displaced from their communities when specific neighborhoods were assigned as “white only”. These areas were segregated into townships and the housing in these areas was informal, with lack of access to essential services like clean water and electricity. Common medical conditions seen in the pediatric ward were a direct consequence of poverty and overcrowded living circumstances. These included infectious diseases (tuberculosis, gastroenteritis), food insecurity (severe acute malnutrition, preterm labour), and smoke inhalation from home fires (asthma exacerbations).

Limited resources were a key observation and presented in multiple ways.  Within the health region, resource scarcity was evident when we witnessed a pertussis outbreak due to immunizations at local community clinics being out of stock. Financial constraints at the state hospital led to daily discussions of how to work with fewer resources. This included judicious ordering of laboratory investigations and adapting to working with reduced staffing. Resident physicians completed many of the tasks commonly completed by ancillary services in Canada, such as phlebotomy and intravenous nursing teams. I had the opportunity to develop important procedural skills including obtaining intravenous access, phlebotomy, lumbar punctures, and surfactant administration. With these enhanced skills I became more confident to work independently. The ability to be autonomous in the hospital was important, as the patient volume and flow was far greater than what I was used to in Canada.

Clear differences between the children’s hospital in Vancouver and Paarl included open wards with multiple cribs and patients per room. Children were segregated into a gastroenteritis room and a respiratory/medical room. Isolation rooms and use of personal protective equipment for contagious illnesses was limited. In these close quarters mothers had a difficult time. If nasogastric feeds were required, mother’s hand expressed for hours as breast pumps were not available. They were required to sleep on the floor on thin mattresses during lights-out from 11pm and 5am. They also faced a lack of privacy and confidentiality, as fellow mothers often listened eagerly to what the medical team was saying about other patients during rounds. Despite these trying situations there was a clear sense of community between families. If a patient’s mother stepped out to shower or tend to a child at home, other mothers in the group would work together to look after the child.

During my time at the hospital I worked closely with the medical interns as we often shared call shifts. With a busy maternity ward we attended many newborn deliveries together. I noticed that interns quickly jumped to CPR in their treatment algorithm without going through all of our typical MR SOPA ventilation steps to correct low heart rate. Unfortunately interns do not receive formal training with neonatal resuscitation prior to starting their intense pediatric rotation, likely due to financial constraints and limited staffing. I was able to teach neonatal resuscitation with mannequins and simulation training, and feedback from the interns was positive. I also provided teaching on common pediatric topics including immune thrombocytopenia and asthma. Local interns reciprocated with specific teaching on HIV and tuberculosis; illnesses that we see less frequently in Canada.

Overall my pediatric experience at the Paarl Provincial Hospital was invaluable. While at times overwhelming, my experience is one that I would thoroughly recommend to my fellow residents. It provides a unique and impactful opportunity to gain practical skills and help provide care in a resource-limited area.

Last updated: Sep 21 2018