Numbers and Diseases

Kriye

2019-09-26T13:13:00.002-05:00

I don’t always sleep well when I’m in Haiti. I don’t say that to complain, but as a mere statement of fact. The beds are not luxurious, but they are a thousand times better than what most of the Haitians we are serving sleep on. It is difficult to control the temperature; the city can smother you with heat and humidity while the thin mountain air can leave you chilled. As I’m older I feel more aches and pains, which seem to be magnified with poor quality sleep. And then there are the noises.

Typical noises in Haiti can be Kampa music from a distant discotheque (Club Affeksyon is one of the best named ones I’ve visited). The bar could be empty, but that won’t stop the owner from dropping dope beats through the aux cord ALL NIGHT LONG. If it isn’t the beats, then sometimes it’s the ‘baaaas’. I laugh at the customs form when re-entering the states as is asks if you’ve been on a farm or handling livestock. Have you been to Haiti? Anywhere but the city is agriculture and livestock. Roosters, goats, pigs and dogs all like to make their presence known at all hours of the night. Sunrise be damned.

On the morning of 9/17, though, there was different sound… a ‘kriye’. We had had some deliveries the day prior, but none of the newborns had been noisy up to that point. There were two pediatric patients in the hospital. But, again, they had not made much noise in the days up to this point.

I couldn’t sleep. It was LOUD. And it had been going on for over an hour straight. So, I got up.

She was outside the hospital… sitting in a chair… and she couldn’t have been older than nine months. Her hair was in braids. She had a dress on. I looked around and there were several adults using the outdoor water supply to wash off their feet as they changed their clothes. It was, maybe, four in the morning… maybe. #EverythingBeforeSunriseIsFourAM I picked her up and I think the sheer shock of my whiteness plucking her off the metal folding chair stole her voice. She stared. I bounced. Silence. Perfect.

Her mother finished cleaning up and came and grabbed her. About that time, she started crying again, but I at least satisfied in my mind the source of the screams. I was up for good at that point, so I went into the post-partum suite to check on the moms and babies we had delivered. When I passed back through the lobby of the clinic, I saw the little girl, her mom and her brother laying down on the bench to hold their spots for the day’s clinic appointments.

I don’t personally see as many patients in the clinic as I used to. I mostly go to observe clinic flow, provide resource support, trouble shoot and offer an occasional “this is how we would approach x/y/z in America”. On this day I was observing in clinic when the mom brought her young boy and girl in to see Dr. Leo. Once again, my pale skin must’ve scared the little girl, or she was tired, or she was cold, or she was hungry because she immediately started screaming… no…crying – scryming?!? I tried to hold her, but that was unsuccessful. John, however, is the child whisperer and was able to bounce her around the clinic enough to keep her content.

She wasn’t the patient. Her brother was. His body was skin and bones and his face looked beleaguered. He was, himself, a child, but you could tell that he carried so much responsibility at his young age. The little girl looked nine months. She was fifteen months. The mom’s concern was that the young boy had been coughing for over two months. He was timid and often parroted what his mom said when Dr. Leo would ask a question. Suddenly, Leo recognized the mother. He confirms her name and turns to me, “we diagnosed her with TB last April.” Yes, Tuberculosis.

She had gone to “the city” as a 16 year old. According to Dr. Leo, she met a man and got pregnant. As is all too common a tale, the man left her without concern for the well-being of his child or the child’s mother. She moved back to Gran Bwa this past March. She lives with her mom and tries to work as a seller in whatever market she can create an opportunity. Even in better economic times, there are not a lot of opportunities in rural Haiti.

I can’t say that I’ve seen a high volume of TB patients during my time in Haiti. It isn’t the easiest thing to test for, so I may have started the work-up on some patients with breathing/coughing complaints that would eventually lead to a TB diagnosis. However, we have a 20 year old mom of two with a known TB diagnosis. The older child is here for a cough lasting two months and looks emaciated. The 15-month-old has powerful lungs but is clinically malnourished. Everyone needs treatment and fortunately there is a State sponsored clinic in the area with a TB program. Yay!

Jocelyne had been in treatment since her diagnosis in April. One might think the system would take care to ensure close contacts did not contract this deadly bacterium, but alas here we are. All we need do now is send our young man down to the clinic on a TB day to undergo sputum testing and enroll in the treatment program. And fortunately, September 17^th was a TB day! We tell the mom to hurry, pack a quick sack with a little food for the trip, and grab a moto to take her to the clinic building.

This would’ve been too easy. The protests, or #Manifestations, had started in Port au Prince and somehow had found their way up our peaceful mountain. Crowds flooded the city streets to burn tires and generally disrupt commerce. Not with plans of violence, this time, but to cause a scene and be heard. The same was true in the mountains. Young men, and possibly women, set up “road blocks” along the one road that went up and down the mountain. Jocelyne was stuck. She couldn’t reach the clinic to get her son started on his life saving medication. She returned to the clinic and they had to wait.

This is one of many “road blocks” this poor, young family is going to have to deal with just to treat this disease. I mentioned earlier that when I found them originally, they were cleaning up in the water supply outside the clinic. They had hiked several hours in the mud just to get to our clinic. They had brought a change of clothes to ensure that they were clean and dressed well to see the doctor. If I’m sick, you can bet that I’m rolling up to my doctor’s office wearing sweatpants and bags under my eyes.

Several days go by and finally the mountain road opens. They were stuck at our clinic the whole time. I have difficulty with the clinic being treated like a soup kitchen, but in this situation even Scrooge would show compassion. Charity is, to me, a very delicate and difficult act in Haiti. With nearly every trip I have people offer to personally give me cash so that I can deliver “whatever they [Haitians] need.” I always go into a trip not knowing what I will encounter. Where will the money be best used? This time, it was clear. I spoke briefly with our Haitian social worker - who had already recorded as much information about this family as he could - and I told him that I had money to support this young mother and her two children. I felt that we should buoy them as they tried to fight through poverty to treat tuberculosis. The clinic will always do what is necessary to take care of patients, but I wanted Jean Louis to not have to worry about the funds coming from somewhere else.

Their story isn’t finished. Unfortunately, it is one lasting several months with frequent long trips to refill their anti-TB medication. It is one lasting several years to fight through the cycle of poverty to have a sustainable income. But I do think we offered this family a new chance at life. For those that gave this trip, thank you. Jocelyne and her young family have an opportunity to pursue life they would not have had without your gifts. I cannot thank you enough.

Akouchement Lakay

2019-07-18T00:08:00.000-05:00

Since the @ServeHaiti Instagram post caught a fair amount of attention I thought I'd give the writing thing another shot.

I had returned to Haiti after being whisked away in a helicopter just two months earlier #Manifestations. I'm still getting the feel for this whole Medical Director thing, but if it gets me into the beautiful country more then I support it. ServeHaiti is piloting a new data collection program that will (hopefully) allow for near real-time information to be easily organized and analyzed. We do (I say 'we', but it's definitely got nothing to do with my actions) amazing work in Grand Bois, but it's really hard to say those things without objective information.

That's why I'm here though. Help introduce the program. See it in action. Troubleshoot early problems. And obviously to work on my tan. #BeachSeason.

The first day was great! Abby and I were able to get the selected #CommunityHealthWorkers to the clinic and give them their "new" device. And by "new" I mean four-year-old, generously donated, tablets running Android platforms. But that's definitely #HaitiNew. Even Dr. Leo and Jean-Louis (JL), our hospital social worker, were in on the fun. The plans are to have our childhood malnutrition program data recorded, our pharmacy inventory, and then track the work of our community workers. Abby was able to walk everyone through the sample templates so they could familiarize themselves with #Collect.

The following day we were off! John, Abby, JL and myself hopped on motos and headed East! Or North! Or... I really don't know my directions when I'm down there and often feel like I'm going in circles. Probably explains why my "short jogs" end up with me getting totally lost. Riding on a little moto is exhilarating. If you're able to pry your eyes away from the fractured, mud-gravel-dirt road directly beneath you and look outward over the sharp cliff to the beautiful mountains and valleys you'll wonder why more people don't tourist here. Then you hit a rock, fishtail, and think WTF WHY AM I NOT WEARING A HELMET.

An hour into our ride we stopped at a crossroads to pick up another of the CHWs. It was around 1030 but already the Caribbean sun was putting in work. Silianette was out handling some local community meetings. The plan was to pick her up and head to the far reaches of the Grand-Bois territory to see data collection in action. I was pumped. I was promised some good hiking. The sun was out so the guns were out. Fixing to be a great day.

Until

We're walking back to our motos Silianette tells me, quite plainly, "there's a woman in labor over there'". They wanted "the doctor" to check on her. When I get to the house I see this young woman laying on the floor, holding her pregnant belly, and another young woman sitting behind her so that she has somewhere to lean. She was term. First baby. She had been seen in the clinic for her prenatal visits and had not had any known complications. Her contractions started at 0400 that day. WHAT? G1P0 contracting for only 6 hours. Give me a break, take two Tylenol and sleep it off. I tell John that I'll make sure she isn't too far dilated, but that I think it'd be safest for her to take one of our motos back to the clinic and deliver the baby there. 6 hours. G1. #Laughable. Silianette was able to grab some gloves from her house out of her CHW supplies.

"Okay, I'm going to need to help you up into this bed so I can check your cervix" doesn't really have great direct translation into Haitian Creole. I think John basically said, "Get in the bed he's going to check your uterus." Message delivered. We help her climb off the floor and up onto the elevated mattress. "A little pressure annndd…." Oh boy. My body language said it all. Completely dilated. Bulging and tense amniotic sac. Still 0 station, but at this point I can't send her on a moto. "We're going to be having this baby here".

I look at my surroundings. Slabs of tin peppered with holes are over my head. Around me is a network of sticks and branches held together with dirt. The floor is dirt, tamped and swept smooth. A straw mat and blanket are still on the ground from where mom-to-be had been sitting. A child walks in carrying a plastic chair offering me a place to sit. A neighbor picks up my backpack and sets it on a table in the adjoining room. Clear off the schedule, we're gonna be here a while.

I step outside to discuss the plans with Abby and Jean-Louis. I have hand sanitizer, my stethoscope, and Silianette's meager supply of nonsterile gloves. Abby is quick to snap me out of my thoughts and keep me to task. "Yes, we need a razor blade, two pieces of string, and boiling water." Sure enough, within an hour Abby had sourced an unused razor blade and two eight-inch pieces of string, boiled them, and scooped them up each with a fork so that they could be kept sterile...ish.

Photos courtesy of @servehaiti on the gram

For anyone who has not had a baby it's a lot of misery and waiting. I didn't know when my training might be helpful, but basically I was sitting around talking and thinking. JL and Abby did take one of the CHWs to head off and start the data collection. Silianette stayed close, but took the opportunity to survey some of the nearby houses. John and I stayed in the house and learned about our 20 year old patient and her soon to be 0 day old son. The father of the baby had left shortly after they learned of the pregnancy. She had a strong support system including a sister whose toddler was absolutely petrified of me and a grandmoun who has had several of her own children. A midwife may or may not have been notified, but was not nearby.

Her contractions started before the sun came up that morning. Apparently, 4am is generic for "before the sun comes up". It could have been 8pm the night before for all we know, but we know it wasn't light out. I'm so used to having my patients walk in saying, "I started timing my contractions last night at 715 pm but they were only 12 minutes 32 seconds apart then, so I didn't come in, but then this morning at 2am I felt one that was extra strong, and I thought my water broke, but maybe I peed a little, anyways the contractions are 10 minutes apart and my doctor told me to come in if my contractions are less than 10 minutes apart. *breath* So, how far am I dilated?" #FirstWorldProblems

I encouraged walking, but she didn't have the strength for that. She tried to eat, but got sick. We treated some water and flavored it with Mio. That went down okay. She was breathing through her contractions and cycling every 2-4 minutes. Noon comes and goes. I have a few breakfast bars in my backpack, so John and I each eat one. A few of the kids running around outside share another one. I ask to check if she's made any progress, but she really hasn't.

I manage to break her water. Clear fluid. Hopefully this show can get on the road.

And this is where the panic and worry start settling in.

I set my phone out and play some music. At one point I had a "Push a Baby Out" playlist with Salt-n-Peppa, TLC, and Bieber, but I had to settle on whatever my Spotify favorites were. I look at my patient and the emptiness in her eyes. I look at my arms and my whiteness just glows in the dark hut. If this delivery does not go well I worry what this might due to the trust and relationship our clinic has with the community. Will I be blamed? Will the clinic be blamed? Such little control with so much pressure.

Another hour passes with her pushing with every contraction. I try to tell her not to push, conserve her energy. But you tell that to an unblocked pregnant woman and see what happens to you. I check again and get a sense of position. The baby is LOP and asynclitic. We try the floor again on all fours to see if that's more comfortable for her. Yes, the dirt floor. Her prayers start flowing. It's all rapid Creole, but I've heard them enough times to get a sense of what's being said.

She gets back into the bed. I check and we haven't made much progress. With her next contraction she pushes and I try my damndest to turn the baby's head using just my fingers. I have no way to assess fetal heart tones so every moment she's still pregnant is just taking years off my life. And yes, I know they aren't sound science, but when you've trained having that information most of the time then not having it is anxiety-invoking. Back to the floor.

Progress! We've delivered hair! I get to make the joke that all his hair slowed him up! It gets about as many laughs as you would expect. She's tired and over it. She makes slow and steady progress with each contraction now. The baby's crowning. Her pushes are near continuous, but she's running out of steam. I have her family help support her legs as I kneel on the dirt floor heart pounding. "Please God, healthy baby. Please God, healthy baby."

The head delivers and he's facing left. Shit. Tight nuchal cord. I grab for it and try to tell her not to push. I can't clamp and cut. It's tense. I don't think it would allow us to deliver through. With my second quick sweep with my left hand the cord slingshots from around his neck. Oh thank God. Head down. Shoulder. Back up. Grab the legs. POOF! Baby boy followed by a pile of poop. No screams. No tone. I grab the string and fumble through tying my long-forgotten surgical knots near the boy's umbilicus. Then another knot a few centimeters away. No time for theatrics. Grab the razor blade and put the business end against the cord. Saw away.

Separated, I turn to the bed behind me. My internal clock is both at zero seconds and a thousand seconds right now. Towels. Dry. Stimulate. I throw my stethoscope down... *bump * bump *bump * bump... right about the rate of a catchy pop song, so probably 120 BPM. That's good. Still don't see a lot of chest rise. I tell John to continue to vigorously dry the baby with a fresh towel as I tilt his head. No suction bulb, of course. Stethoscope back to the chest... same pace. No movement.

Seconds. Minutes. Who knows. I don't know about NICU attendings, but anytime I find myself in this situation I feel like I'm all alone and I have zero concept of time. Stimulate the body. Support the airway. Pump the legs. I'm almost about to lift him by his heel and slap his but when suddenly he sputters out series of coughs. Quite possibly the most beautiful sounds I've ever heard. I let out an audible sigh.

He's breathing. His skin slowly pinks up. And here comes the crying. I swaddle him and try to bring him to mom. She's not having it. Sister grabs him up and the rest of the family swarms her. I kneel back at mom, still on the ground, and twirl the umbilical cord around my right index finger. It comes easily. Seems to be intact as I inspect it on the straw mat. I'm not sure why but I do brief exam for lacerations or brisk bleedings. For real tho, what am I going to do? She has a small side wall laceration, but no deep perineal laceration. I apply a piece of gauze and hold pressure.

It's done. We have a crying baby. We have a mom who is standing up to put on underwear. We have an excited family rushing into the "delivery room". As I walk out the sun still hits my eyes. It's 4pm. I have John give Silianette instructions so the mom and baby will follow-up in the clinic tomorrow. Instructions if she has any further bleeding. Encourage her to breast feed as much as her body will let her. We say our goodbyes. Eat a small amount of the food they offer us. But the rain is coming and our moto driver wants us to get back.

Near perfect timing, Jean-Louis and Abby arrive at the crossroads at the same time we do. We course back across the Haitian landscape as storm clouds gather overhead. Back at the clinic we pay the drivers and find our food waiting for us on the dinner table. The rain falls as the sun fades away. The raindrops echoing off our tin roof with authority. The rain is welcome to the drought-stricken area, but I can't help but think of that tin roof sheltering that brand new baby.

Love in the time of Cholera

2018-06-19T09:14:00.000-05:00

Do you remember the SNL bit commercial for "Oops! I crapped my pants!"? Well, I do and it was hilarious. When it first came out I was in 7th grade (back when SNL was still entertaining). I thought I was long past the time of worrying about crapping my pants - or at least until I caught up to my dad in age. Turns out, that wasn't the case.

When it comes to my travels in Haiti, I'm not the most careful. I've eaten my fair share of "street food". And... tbh... I don't see much different between the street vendors in Haiti and food trucks in the U.S. Well, other than a health code I suppose. I buy fruit and veggies from the market, and then eat them after a quick rinse. I'll utilize the available filtration systems and water delivery relied upon by the locals instead of purchasing purified water. And I tell myself I do this because "if it's 'good enough' for the Haitian locals, then it's good enough for me." My GI tract must not have gotten the memo, or perhaps it did.

It was the spring of 2013 and I had just received my diploma from medical school. I co-piloted a clinic team that hiked up to a church building in rural Haiti to deliver medical care. The trip had plenty of ups and downs. If we're talking about the hike, then I would say we went up and down three mountains (but who's counting) in each trek of the hike. If we're talking about my relationship at the time... then probably more. But we survived (the medical team and my relationship) the mentally and physically exhausting trip.

An amazingly rewarding experience to deliver medical care to this rural community. I won't sit here and defend the merits of delivering healthcare to a community for four days and not return, because there really is no defense. However, the trip was more of an exercise in logistics and feasibility if I'm being honest. The sustainability part was to follow, but plans and priorities change (and vulnerable populations suffer).

But we were back in our cozy, Coralville apartment. The trip was complete. Unpacking had yet to start, but there'd be time for that. We had a big weekend coming up, after all. What had originally been planned as a Haiti fundraiser ended up being downgraded to just family and friends coming up for sand volleyball and a few beers. There may have even been a planned "table-topping" into "You Lost that Loving Feeling" into a proposal, but something happened.

The trips to the bathroom woke me up in the morning. And I couldn't stop. I was having more than four stools an hour and by the time noon hit I had gone to the bathroom nearly a dozen times. If you want to google "rice water stool" you can get a sense for what it looked like... An infectious disease doctor I work with now and have a tremendous amount of respect for remains skeptical of my self-diagnosis of cholera. But, had I seen a patient in Haiti with my history, knowing that it had reached epidemic proportions with the rainy season, I would have arrived at the same clinical diagnosis.

I tried to keep up with my oral intake. I was chugging Gatorade and water and Pedialyte and truthfully anything I could to keep up with my ongoing losses. I tried Immodium to slow down the process, which worked a little. I thought, "Hey, maybe I can go join in on the fun with my GF and her friends playing volleyball." I even changed to head that way. But then I started walking down the steps... and I wasn't as ready as I had thought. Sooooo, it happened and I had to bail on our plans for the day. And it was a sore subject. Another fracture in the foundation of love that led to the demise of a promising relationship. But how do you tell someone you had an accident like that? You don't. You keep it locked up deep inside of you until you finally have to write a blog post about ongoing issues with cholera in Haiti.

Unfortunately a new outbreak has surfaced starting this past weekend. The clinic I've served at (aptly named ServeHaiti) has been forced to put its cholera treatment tent back into use. It also has converted a newly built "waiting pavilion" into a cholera treatment center to house the patients surviving the hike to the clinic. We've already had two deaths at the clinic, and reports of several more that could not make it.

Worth noting that the clinic is a car ride followed by a 4-5 hour donkey ride from the source of the outbreak, so how many patients are stuck in rural-er Haiti unable to receive medical treatment?

By day two of my illness I was dehydrated. I was having fevers and chills. I had cramps so bad I couldn't eat and I'd vomit anything I tried to drink. I gave up trying to do it the "Haitian" way. I took full advantage of my white American privilege and my mentor at the time brought two bags of IV fluid to my apartment. My body was like a vacuum. The bags were empty in less than 30 minutes. No pressure needed. I took antibiotics, Zofran and a steady dose of AC to keep cool from the Iowa heat. I didn't even have to face the embarrassment of going to the world class institution that is the University of Iowa Hospitals and Clinics to receive treatment. I didn't have to admit to having an illness that literally made me crap when I walked.

The people of Ma Georges face the harsh reality that help is not nearby. No girlfriends and mentors with IV catheters and sterile tubing. No Walgreen's with shelves upon shelves of prepackaged rehydration therapies. No toilets to flush away the evil and send it to a processing center. They're at the mercy of the elements for their water supply and sanitation. And it's probably the privilege in me that causes me to say that I'm not sure who feels more powerless.

I encourage anyone interested to follow @ServeHaiti on social media platforms for updates on the #Cholera #Outbreak. That's where these photos are from.

Konten

2018-02-09T23:57:00.000-06:00

This last trip a volunteer asked me how many times I’ve traveled to Haiti. I couldn’t answer them. I ballparked the answer as somewhere between eight and twelve. Some trips longer than others. My comfort with Creole also variable. My destinations change. I’ve visited during my various stages of education. There have been trips where I’m so far removed from my faith I might’ve spontaneously combusted walking into a church. More recently, that has flipped to where I lean on my faith because I have learned that so much healing is beyond my control. You know how frustrating that is for someone with as big of an ego as me?!?!?! No matter the settings or situations I’ve felt like Haiti “helped me” much more than I helped the people I went to “serve”.

I typically use this blog space to discuss clinical care for a patient encounter, but truthfully this most recent trip had very little of that. And it may have been my most rewarding trip yet. And I don’t say that to discount my other experiences, but my mentality was so different this time. First, I was leading a bunch of other blan for the first time. Second, I really separated myself (some) from the clinical and focused on the people. And I was filled with joy.

One of the unique aspects of the St. Vincent de Paul clinic in Gran Bois where I was working is that it is basically one game of “Red Light… Green Light” away from the Dominican border. No passport needed. If anyone follows my other social media efforts you may have seen pictures of the stone marker denoting where Haiti transitions into the D.R., or even the photo of my phone getting confused and welcoming me to Vietnam. #TrueStory #GoHomeSiriYoureDrunk

Naturally, it’s a neat group activity to take a team of newbies on a hike and go to the “border”. Then we get to take the standard photos of people “straddling the border” or waiving to each other from “different countries”. Yes, everyone who travels to Haiti is a nerd, or at least they must pretend to be one when they travel with me. #DealWithIt

It was Sunday and we had a pretty eventful day - a two-hour church service (more on that experience on a later date), a walk through a bustling market, a sampling of fresh sugar cane, a soccer game, and so on and so on. But, later in the afternoon and after our 3 pm “dinner” was settled I rounded up the crew to “hike to Dominica”. Everyone put on their Dri-Fit tops, athletic shorts or gore-tex hiking pants, and Merrill hiking footwear to get ready for the trek. Needless to stay, our (my) pasty-white skin and fresh, name-brand threads stood in stark contrast to the collection of kiddos that decided to follow us on our hike. #ThisIsNotACallToDonateClothing

It was going great. We had one good incline that made you kind of feel like Rocky when you got to the top. But of course the kids dominated it like it was nothing. #AltitudeTraining #HaitiFit The climb was early in the hike, at least, so the rest of the time we could enjoy the amazing views from a relative highpoint.

Some stumbles. No falls. Some poop dodging. “Oooh’s” and “Ahhhh’s”. And arrived at the marker. There’s a peace at the top of a mountain in Haiti that is impossible to put into words, even when you’re surrounded by a thunderous herd of little boys. Come with me some time and I’ll prove it. Then you can try and put pen to paper. Photo after photo after photo snapped trying to capture the majesty of the setting sun over mountain tops with lakes in the valleys. Bob Ross would stay and paint for days. But, days we did not have.

Haiti is on the CDC travel advisory warning list. Recommendations are not to be out after dark for safety reasons. Security in the country is sparse. As a foreigner you are warned that you could be targeted. Well, objective numero uno for this boss was to keep everyone on the trip safe (unless you count letting them ride on motos). So, as I could see the sun was setting I had to break up the four hundredth photo “straddling” the border to encourage us to head back.

We took a slightly longer way back, but one without as many steep climbs or descents. Still copious amount of fecal material on the trails though, don’t worry #NameThatPoop #FunGame. As the sun sank further several of the community boys ran ahead of us heading back home. And then it struck me, they probably had a curfew. How silly is that of a “eureka” moment? Oh yeah, these little children are probably not supposed to be out after dark - especially with a bunch of foreigners. I wonder if their parents are gonna ground them for being home late. Is it weird that I, for some reason, figured those cultural things were exclusive to our over-protective suburban, “Wonder Years” families?

As we sauntered on we all became engrossed in our steps. It was dark. The paths were made of rocks and dirt and poop, so no step was to be taken for granted. The moon was coming up but by this time we were between peaks. We were passing people, likely on their way home from a day of work or even a late Sunday church service. The path narrowed and was flanked on either side by tall, thick bushes. And my worst fear became a reality.

The screams were reminiscent of a ferocious charge during a military battle and they seemed to surround our little party. Panic was immediate as eyes quickly darted and tried to adjust. Fight or flight causes your pupils to dilate so more light gets to the retina. And what did we discover? That those little shits had set up an ambush! They hadn’t run home to beat curfew! They just wanted to scare us! And scare us they did!!! I think one of the volunteers might’ve peed a little. Terror turned to pure hilarity as they laughed and laughed and laughed at the jumpy blan.

They were so proud. And so much like little boys in the states. Ornery little devils that were just up to mischief. Oh, and they weren’t done. They performed the same trick TWO MORE TIMES to us as we finished up our hike. But, I wasn’t about to let them have the last laugh. I caught a glimpse of a rock sliding and then a shirt trying to hide behind a mound of dirt. They had laid their next trip… I made my move. I swung around to the left to try and outflank them. My long strides were lucky that they found true footing as I quickly ascended the large dirt and rock pile.

I went for it. “Ahhhhhhhhhhhhhhhhhhhh” as I wildly swung my arms in the air and closed the remaining steps to their secret location. And they erupted in shrieking giggles as they scattered. They scurried every which way, their smiles nearly glowing in the waning daylight.

But the final word would not belong to the blan… A few of the boys set up one final trap for us as we were getting ready to turn back towards the clinic. It was a fantastic cap for an eventful day. A day disengaged from the clinic. A day where we just went into the community to be among the people. We attended church. We participated in commerce. We played Sunday futbol. And we were the source of entertainment for a gang of mischievous boys. I felt a sense of contentment and belonging that I can’t say I had ever felt just working in the clinic.

Grief (The Story of Mirlande)

2018-02-02T22:14:00.001-06:00

On an earlier visit to Haiti, I was fortunate enough to be invited to an “English Club”. No, it was not an elitist club created for and by the blan, but rather a group of Haitians that would meet and practice their English. It was fun! They’d propose a topic and have philosophical discussion, in English, about it. I quickly found that I wasn’t necessarily there to participate in the conversation, but more to help their pronunciations #StillAnOutsider

One such meeting took a turn I would have never predicted. The topic was depression or, more specifically, “Who was more depressed – Haitians or Americans?” Wow. Let that sink in. It seems so trivial, but then it starts hitting on so many different levels. To me, at first, it was a no brainer. I offered than in my brief (especially at that time) medical service in Haiti I very rarely came across patients whom I thought would meet criteria for depression using any sort of scoring system. However, in the U.S. I feel like MDD is one of the more common diagnosis codes that end up in my notes. Diabetes Mellitus Type II. Morbid Obesity. Major Depressive Disorder #TrendMuch? I was hooked to the conversation.

In the group, the overwhelming response was that Haitians were more depressed. I mean, they would HAVE to be, right? Half of the morning in rural Haiti is spent getting water. Most don’t have steady employment. Food insecurity is common. Infectious disease and trauma are daily occurrences. This conversation was just two years removed from the Earthquake that claimed hundreds of thousands of lives and unquestionably impacted every single person in Haiti. Plus, it was hot as hell where I was and there were no AC units to be found #FirstWorldProblems. How could you disagree with their argument?!?

It stuck with me. Mental health is a wholly under-represented field in low-resource countries. Somehow, my friends at Respire are accomplishing the impossible by offering mental health counseling to their students. The results and stories are both sad and amazing. But it wasn’t until I was on this most recent trip to Gran Bois with ServeHaiti that I realized how vital this service is to community wellness. (I hyperlinked to both organizations' websites if you want to see more about the awesome work each are doing or are interested in donating time / money / goods).

The story was sad. A 6-month-old was brought in by her father because he couldn’t get her to eat anything. She was laying in our hospital crib covered by a tattered blanky. The kind of tattered you’d expect next to a toddler that just didn’t want to let go of their baby blanky. Her brown eyes wide open and just piercing through me. No smile. No tears.

The dad didn’t offer much for nonverbal cues as I began my infant exam. That’s when we went from sad to tragic… “The mother had been working in the garden when a rock fell and hit her head and she died.” Hold up. Imagine, real quick, that you’re hunched over a 6-month-old auscultating her heart and trying to get any kind of reaction out of her with silly faces. Then your interpreter drops this bombshell on you. A monotone, run-on sentence that punches you right in the gut.

“Wait…. What??” “That’s what he said. The mother was working in the garden when a rock fell and hit her head.” “When did it happen?” “Last Friday.” It was Wednesday. The girl hadn’t eaten anything in six days. The staff at the clinic had started her on Plumpy Nut RUTF and Oral Rehydration Syrup as well as a vitamin regimen and some antibiotics for kicks.

Powerless is seeing a problem and not being able to provide a solution to it. And boy did I ever feel powerless. Her problem extended well beyond any physical ailment. She was grieving. I imagine she was confused. She needed to be nurtured. Held. Breastfed by her mom because that’s all she knew. The father needed counseling. How the hell does he deal with this? Single parenthood is tough in the states (speaking not with personal experience), but I can’t even try and relate it to rural Haiti.

It was a heavy reminder to me that mental health is more than just depression and “feeling the weight of sadness” as it was once characterized in a Zoloft commercial. It’s about grieving. It’s about coping. Addressing PTSD. It’s about the mind working through problems that modern medicine struggles to define let alone treat. It’s about a community that doesn’t isolate a patient struggling with bipolar disorder or schizophrenia like they’re a crazy demon. It’s about a healthcare provider who realizes that alcoholism and addiction can’t be treated with a pill or incarceration. These treatments often require deep, interpersonal relationships, trust and a spiritual healing.

The first photo is her on admission and the Facebook image gives a little more background into some family dynamics from a couple of other volunteers. This picture is her after ten days in the clinic. Thank you to Liz McDermott and Sarah Stafford for the updates.

I don’t yet have a conclusion for the little girl’s story. I hope the ending is far away and happy, but I fear the worst. Even in the U.S. a tragedy like this would be very difficult to recover from. They were the last patients I said goodbye to on my way out. Her eyes still wide and vacant. His eyes confused and full of fear. I think I speak for the whole team that saw them when I say their faces will never leave my mind.

Blan

2017-02-27T21:35:00.000-06:00

Have you ever seen the show, “The Whitest Kids You Know”? It may have been inspired by me. I seem to typify every “white” thing in both appearance and activities. I listen to Kanye and can rap several of his songs at the drop of a dime, but secretly enjoy T-Swizzle and definitely had her back when the two of them were beefin’. I use the word “beefin’”. I pretentiously drink microbrews when I go to the bar. I think it is our moral obligation as a nation and as individuals to support those less fortunate.

Probably the one “white” thing that doesn’t resonate with me is running. White people love jogging, or maybe it’s ‘yogging’ #WithASoftJ. My dad was an avid runner participating in marathons through most of my childhood. I suspect if I were to take it up I might be decent at it, but it’s not my thing. Hell, I should probably give my menisci to my dad as he’ll get more out of them than I will.

Except of course, when I’m in Haiti. I have no idea why but I enjoy running the foot trails along and up the mountains in Gran Bois. Maybe I just really like stepping in shit. Maybe I like tumbling down a mountainside while all the Haitian children laugh. I definitely like the scenery. I’m not sure God has created more beautiful and scenic views than in Haiti #SorryNotSorryTwinPeaks. I try and take pictures, but I give up because there is no way they can match the en vivo experience.

My first full day in Gran Bois, after a long clinic day and after a large “supper” I opted to throw on the tennies and head off on the trails. Again, pretentious white person, I was jogging in an Under Armour dri-fit t-shirt. Bright red. Hard to miss. I took off on the paths up the nearest mountain. Familiar trails turned unfamiliar quickly, but “deciding where to go” was just a break in disguise. And I’ll cop to it, the rice and beans tasted way better the first time than the second…

I made it back to the clinic and then headed off in the other direction. I had hoped to catch a group headed on a hike to the Dominican border, but just ended up wandering down new paths and scoping out new mountain top views. My story nearly took a sharp twist as I was passing a man guiding a bull down one of the footpaths. Standard procedure is to speak some salutation to anyone you pass. Even if you don’t stop to engage in conversation, they’ll be much more pleased with you having heard you wish them a “Bon swa”. So I take to the left edge of the path as I pass the man and his beast and I finish my greeting I catch the bull lowering his head and taking aim at the gorgeous, red shirt adorning my chest. I about face planted in a pile of donkey shit jumping out of the way, but the man was equally quick with his switch and got his bull in line. A friend of mine always said, “If you mess with the bull, you’ll get the horn.” I pert near got both of them.

Undaunted, today I took off in another direction. So as not to become a target for any livestock, and obviously to work on my tan, I ran sans shirt. With my headphones on I can block most of the calls from off of the side of the road. A quarter of a mile from the clinic I ran by a cock fighting ring. If I had had any cash moneys on me I would have stopped to gamble a little, but alas I kept running. I found an incline with stairs carved and molded into the side. And this led me to more and more steep hills that led up to one of the higher mountain tops around us. Again, several “deciding where to go breaks” were had. When I arrived at the summit of the trails I stopped to take it all in. Gorgeous. Amazing view of the entire country side including a speck in the distance that was the medical clinic.

Suddenly I was approached by three school children. One actually had his language book out and was practicing his speech. I wasn’t running, so I took out the headphones and did my best to engage them in conversation. I knew I wasn’t the first white person they had seen, but I may have been the first “red neck”. I could already feel the slight burning sensation on my skin that likely meant my color was already changing. We went through the basics. Name. Age. Grade in school. No I’m not German. Yes I was staying at the clinic. No I didn’t know where I was going. No they didn’t know who lived in the small hut at the very top of the mountain we were standing on. The back and forth continued with several pauses and “M pa konpren’s”. But my stomach was telling me it was time to get back, so I offered my parting words. They smiled and laughed and said several things back and forth that I could not catch. However, looking around as the sun was fading I can imagine only one thing. “We are disappointed. We thought you would stand at the top of this mountain and give the valley ‘daylight’ for a few extra hours tonight.” #ThatWhite

Death Summary

2017-02-22T18:01:00.000-06:00

The patient was a pleasant 72 yo f with a PMHx significant for HTN. She had initially presented to the clinic for follow-up after several months of being without her anti-hypertensive medication. She was started on oral medication and dismissed home. As she was leaving the clinic she began experiencing unilateral weakness on her R side and an inability to talk. Her family quickly realized something was wrong and brought her back into the hospital. Her exam was consistent with a dense L sided MCA stroke. tPA was not given as it has at best questionable science behind it. Also we have no CT scan or the actual drug itself. Aspirin was administered rectally and the patient was left to recover in the hospital. Unfortunately, the patient’s blood pressure became increasingly difficult to control and the patient went on to have a generalized tonic-clonic seizure. IV Diazepam was given and she had no further seizure-like activity. Plan of care and prognosis were discussed with family. Without aggressive treatment of her blood pressure (250/120 and up) with IV medication, imaging to truly identify the magnitude of the lesion and eventually a feeding tube to help with nutrition, then the scope of her disability and chances of her recovery were both grim. The family elected to keep the patient in the hospital. While the patient showed no outward evidence of discomfort she continued to decline until she passed away on 17/2/17 at 1700. She was surrounded by a large cohort of her friends and family.

This is a death summary. Every individual who passes away in a hospital setting receives one of these. They are cold and “factual”. And honestly, the one above has more detail than any others I’ve read or written. Covering an inpatient hospice service, I’ve gotten kind of used to writing a death summary. Covering an inpatient stroke service also means I have seen those sorts of devastating strokes before. They’re horrible, awful, terrible things. We have little treatment for them. Our main hope is to prevent them.

And that’s the kicker in Haiti. Primary prevention of medical illness (i.e. preventing the first stroke or the first heart attack) is incredibly difficult. In speaking with Dr. Leo after this woman’s passing he was quick to point out that her case should be a beacon to the community for why it is so important to treat tansyon oh. However, he said that the people will say, “Oh she shouldn’t have crossed *that road today” or blame it on other superstitious things. Maybe her family was “cursed”. Maybe she crushed the wrong plant as she was hiking up the mountain to clinic. Seriously, this will be how they explain her death. Sidenote, having walked from the road to this poor woman’s house I’m surprised she didn’t have her stroke en route. It was a very steep climb.

Death means so many things in Haiti. I’ve seen new moms stare blankly or even with some semblance of relief when I’ve told them their newborn passed away. This woman had “eaten a lot of salt” and there was nearly a riot in the hospital there were so many people clamoring to display their distress over her passing. Also, how ironic is the “eaten a lot of salt” metaphor for a person being in their older age? Especially when diseases related to hypertension are likely one of the, if not the most, common cause of death in that population.

A small contingent of blan from the clinic attended her funeral. Her daughter has actually been on staff at the clinic for several years, so the family was part of the clinic family. I didn’t know what to expect. I figured there would be a fair amount of wailing and shouting, which there was. I figured there would be a lot of singing, which there was less than I would have guessed. I figured there would be a collection passed, which there was not. And I figured it would be at a church, and this was at her home. Her grave was dug behind her house. Apparently you have to be a member of the church in order to have your funeral at the church and to be buried in the cemetery. I remember from before; death in Haiti is big business.

We stayed in the back so as not to generate a large distraction from the proceedings. Soon I was surrounded by a puffs of smoke. A group of older men had gathered behind a wall of her house to smoke cigarettes and drink moonshine. They were laughing in conversation with each other, and I can only imagine that they were sharing loving stories about the recently departed. Everyone handles death and grief differently, so I’m not going to question their actions.

As the ceremony closed, the procession was led by two small children carrying a beautiful wreath. Pall bearers took their place and the casket was carried past us and they began the descent down the steep, slick path leading to the grave site. They struggled. It was narrow and the embankment was steeper still. Thankfully the casket never fell, but there was a steady rotation of men jumping in to help out. My interpreter, John, was quick to lend a hand. He had revealed to me days earlier that his father had passed away in the week before my arrival to the states. He too had had a stroke. I can’t even imagine how difficult the entire course of events was for him, but his focus was entirely on the family of this decedent.

The casket was lowered and covered. The family returned to sit and receive those who came to pay their respects. Mwen desole pou ou. Hugs and tears and hugs and tears. But there was beauty in the grief that I can’t explain. And as we began our long hike up the steep mountainside to the road we were able to reflect on just how intimate the event was that we had just attended. This was a deeply loved woman from the community and we were welcomed as family because they knew we had loved her too. While she passed under our care, we had shown compassion and had offered all of the treatments available to us.

It goes to show, even when you can’t fix, even when there is a potential for fix but maybe not immediately available, even when you’re delivering a message as grim as the one I had to, if you do the small things with great love then people will find comfort.

Her body was released to her family for burial at home. This is Dr. Matt Downen dictating death summary on ……. Thank you. End dictation.

2016

2017-02-20T05:45:00.000-06:00

What a year. It took several celebrities from us, but fortunately the great Betty White is still with us. The Cubs ended their drought. It was the year of the "epic" sports collapses. It finally found me with a real job. It was my first calendar year without a trip to Haiti. And speaking of epic collapses, 2016 gave us Donald Trump. #NoComment. #EndParagraph

Judging by my social media pages and WhatsApp threads people were ready for 2016 to end and 2017 to return. Every time the calendar turns over a sense of renewal breathes life where there may have been stagnation, anger or frustration. For me it saw a return to Haiti! #Overdue It also saw me take on a larger role in one of the NGOs I’ve been fortunate enough to Serve with in Haiti #ServeHaiti #SeeWhatIDidThere But, in my new role, I was quickly made aware that the transition to 2017 also meant one other thing: countless medications in the clinic’s pharmacy were now obviously expired and would likely have to be discarded.

I get it, no one wants to take ‘expired’ anything. No one wants to feel like they are second class, or worse. Can you imagine what would happen if you peeped your prescription from Walgreens - the same one that just cost $300 - and it was past the expiration date? If your answer wasn’t #FlipShit then you’re lying. Unfortunately, that’s more the norm in Haiti than I’d care to admit. Personally, I’ll pitch my milk a day or so after the expiration passes, but pert near anything else it’s gotta be obviously rancid before I’ll waste it. I think I have some leftover Augmentin from before I moved to Wichita that I wouldn’t be opposed to taking if I thought it was indicated #EveryPharmacistJustShuddered #AntibioticStewardshipAtItsFinest

In Haiti, these men, women and children hike for hours, pay cash that they’ve saved up for God knows how long, and then they are often handed medication that is past its expiration date or close. So, as the new U.S. based Medical Director I get to decide what’s ethical regarding dispensing policies. On the one hand, I hate to see what are probably perfectly good medications burned. On the other, how can you say you value a population if you constantly treat them like a second class citizen?

Donated meds also make for a very difficult ethical dilemma. The best part about donated meds? They are often the cutting edge treatments because they come out of sample closets. The downside? Their so novel that most physicians don't really know how to utilize them. They are often used infrequently. And they aren't sustainable because once that small supply runs out, we certainly can't afford to pay the premium price for a new medication. Meds from pharmacies and hospitals are awesome. They are a marker that people are willing to give what they can for a cause. However, these are often short dated, so must be used shortly after delivery. Ideally, we develop a semi-structured formulary and purchase from wholesaling companies on a regular basis and use donations to fill in certain gaps. The first step to that is identifying what is on the shelves, what you need and then what needs to go.

Fortunately, some amazing people have been working in the pharmacy to help with the purge #TrueOfAllPharmaciesReally. Old doesn’t begin to describe some of the medications they found. I’m talking meds that expired before I became a doctor. This also meant several bottles of very practical medications barely beyond their expiration date found the flames. I don’t remember the last time I cared for a patient in Wichita that wasn’t on atorvastatin, clopidogrel and pantoprazole. That’s slight hyperbole… but anyone that prescribes in a hospital knows it isn’t far from truth. Anyways… #FireEmoji

In some instances, we valued availability over “quality” in some cases. If we only have 10 vials of a particular IV antibiotic but they are all “expired” should we really discard them? Again, if it were me as a patient I would take an expired medication over no medication in a heartbeat. As an American, I doubt that I will ever have to make that choice. #LandOfTheFreeHomeOfTheWellMedicated.

So 2017 is here and the old meds are out. I suppose the purge is symbolic of the renewal of the pharmacy and clinical practice in Gran Bois as much as a New Year’s resolution is for most people. It’s a promise going forward to be better stewards and distributors of effective medication. Fortunately, it's not like someone is going to come back to this post in five years and check our inventory in the pharmacy.

Spectrum

2017-02-17T18:20:00.000-06:00

I like my bubble. Not talking treasure chest carrying an oxygenator like in Finding Nemo, but rather my personal space. I expect a three foot radius of air around me in all directions. I have to mentally talk myself through hugs. In fact, it wasn’t until I lived with a particularly ‘huggy’ group in medical school that I really hugged at all. (Shoutout to PRS: DK Fox, Kaplan, Gid, Kale and Dawn). The anxiety I felt then, and often still do, when someone gives you the nonverbal sign that says, “hey, hug me” is nauseating. I’m also a counter. Steps. Chews. It’s natural for me to count and ‘balance’ antything I can control. I literally change my stride length based on the surface and any “cracks”. Sunflower seeds have to alternate between sides of my mouth. Obviously, I'm pretty weird, and truthfully these idiosyncrasies are just the tip of the iceberg.

I think people exist on a spectrum of “neuro atypical”. Most can either hide or disguise their idiosyncrasies that don't "fit in". After all, behavior is all relative and cultural. What one person sees as abnormal another culture may revere. Sometimes I feel like the U.S. culture is quick to label something a disorder when it is just who someone is. I’m by no means trying to diminish the difficulty children with autism or even ADHD have in our culture. But as a physician I can say that I’ve seen the spectrum of behavior that can fall under these diagnoses. Some children have extreme difficulty integrating into the typical U.S. culture and often end up in behavioral camps or group homes. While others integrate well, become professionals, raise families, and live the “American Dream.”

But how does that work in Haiti? It was another morning clinic working in Gran Bois with John and a mom brought in her undersized 18-month old boy. Chief complaint: “Malnourishmant”. He was recently seen and diagnosed with malnutrition and told to return to the clinic when he could be enrolled in the Medika Mamba program. So, surprisingly enough, here they are for follow-up.

It didn’t take long to see that there might be something else at play here. His eyes were very focused as they examined the room. He did not make eye contact with me, likely the “strangest” thing he’s seen in his life. His mother placed him in a seated position on the exam table and there he sat. No excess movement. No attempts to climb down. No cries. Nothing. No fear. Unquestioning. He spent another few moments looking around the room and as I started with my normal questions, I caught a behavior I have never seen in Haiti. He started rocking. Rhythmically. Forwards and backwards.

“Madame, eske li pale?” I ask her if her child speaks. “No, li pa pale.” No, he doesn’t. Never? No words? At 18 months? Admittedly I do not have the child development scales memorized. I never did and likely never will. And how applicable are the U.S. scales to Haiti? I have no idea. I certainly have never seen independent research verifying it. But generally, humans develop biologically. Independent of their surroundings barring chronic stress or malnutrition. And even then most children meet other milestones at roughly the same pace.

No social smile. No fear of strangers. He let me pick him up, but his eyes continued to dart around. Dr. Leo tried to use a tuning fork to get a reaction out of him. Nothing. Maybe he has a congenital deafness? That would explain the speech delay, but after setting him down he immediately set back into the rocking motion… That one is tough to explain.

Poor kid. I feel for him. I feel for his mom. I can’t imagine how it would be to raise a child if they do not reciprocate emotions or love in the “typical” way. I think that is a large part of the frustration with raising a child with autism. I also can’t fathom a person aversive to physical contact and connectedness living in Haiti. This culture is nothing but in your personal space. Granted, I’m a 6’4” white dude, but you can’t take a walk down the road without several kids following you and walking with you. Shared transportation. Hugs. Physical touch. Holding hands amongst friends. It’s a culture that seems to feed off connectedness. It’s a daily struggle for me not to be overwhelmed.

I think the hardest thing in this culture will be trying to “explain” the difference. I can just see friends asking the mom, “Why is he ‘different’?” I suspect demons and curses may be blamed. There certainly aren’t vaccines to attribute the difference to. Will the family pursue “traditional healers” to try and “fix” their son? I’ve certainly been wrong many times in my life, but I have a hard time picturing how some of the ‘treatments’ employed by the traditional healers would help.

This kid needs therapy. He needs specialists to help him with his speech. He may need specialists to help him understand what his particular “differences” are and then methods of coping with societal expectations of him. He needs patience and understanding. Comfort. Encouragement. And I honestly don’t know that he will receive those in Haiti. For a brief moment, as Dr. Leo was explaining to the mom that she needed to eventually take the child to a specialist in Port-au-Prince, I thought about the adoption process and how to get this child to the States. But this special child deserves more than to be whisked away. He deserves to be with his loving family, amongst his people, and for us to figure out how to serve him.

Promise

2017-02-16T16:15:00.000-06:00

It had been an amazing week in the mountains. We had successfully planned, recruited, supplied, hiked and hosted a truly mobile medical clinic hiding among the clouds near the Dominican border. We saw nearly 300 patients and had to unfortunately turn many away due to resources. To say the Haitian pastor who hosted us was ecstatic would be an understatement. I would say he is still grinning, but that was two and a half years ago. And I haven't been back.

The plan was to make the trip every 6 months. Recruit a dozen or so medical volunteers of various backgrounds willing to make the half day hike to sleep on a concrete floor in the Haitian mountains, backpack all of our food/meds/clothes up and down the two mountains, and provide medical care where no others do. The 'team' walked back to Gran Bois with that understanding...And I wonder at what point the pastor realized that he would likely never see us again.

Here come the excuses. We didn't have the support and infrastructure to continue the clinics. Our Haitian connection to the location soured his relationship with Dr. Leo. It gets expensive to fly to Haiti multiple times per year, hire interpreters, buy meds, etc. And needless to say you'd need a large population of potential volunteers to recruit from. And the time to recruit them. When we are pulling 80 hour weeks in Wesley Medical Center it's tough to find the time to do these things.

This situation isn't unique. Unfortunately the empty promise to return is often the norm rather than the exception in Haiti. At this point I'm sure the Haitians are more surprised if someone does return than they are disappointed that they didn't. Voluntourists are nothing if not genuine in their words - often filled with a new found sense of purpose and the joy and peace that brings. As they walk into the Haitian airport their only thoughts are on a return trip. Sadly many never set foot in the country again. Life happens. Other commitments, financial and time commitments, happen. Kids. Family. Work. Soccer. Fantasy football. And their "promise" is broken.

As a physician, I've learned not to make promises. Speak in generalities. Vagueness is your friend. Speak with confidence but without commitment. When you break a "promise" as a physician it's the same as being wrong. And if you know me, then you know I hate being wrong. All physicians hate being wrong. It extends beyond risk of litigation. It shakes your confidence. If you're wrong now, you could be wrong with your next patient. In sports they always talk about having a "short term memory". I've found, in medicine one tends to remember every single time they've been wrong, forever. Every promise made. They all have faces. Each failure has a face. The families have faces. The parents of the sick child have faces filled with fear. And then you tell them their baby will be fine, and pray that you're not wrong. Every picture sticks with you.

I broke my rule recently. I haven't made a promise to a patient or their parents since Bedica. And promised myself I wouldn't again. I hate being wrong and I hate hate hate breaking promises. As a physician, a promise is an unnecessary commitment to an unpredictable outcome. And I can't 'break' what I don't make. The case was a 30 year old male with what we thought was an odd fungal infection in his lungs. I started providing his care a couple days into his admission. My checkout was "young guy with what we think has histoplasmosis". "Dr. Moore is consulted." You may not know this but Dr. Moore is quite possibly the smartest doctor in Wichita. So hearing this, I mentally check the patient into the back of my brain. I've got plenty of other patients to keep my brain power occupied. This one is what we call #ConsultedOut. That's when you have enough specialists on the case addressing the critical and active needs that as the primary hospitalist you can just be like #Whatevs.

He wasn't getting better. Every day I'd round on him and and his spirit was strong, but his body more worn. Breathing a little heavier. Sweating a little more. But always smiling. Room air. Then 1 liter O2 per minute by nasal cannula... Then 2-3 L by NC. In retrospect my notes really foretold the impending decomposition of my patient. People on the right treatment tend to get better, not worse.

He asked me, "How am I doing." "You're doing great. Keep up your strength. Work on deep breaths. Keep eating. You have one of the smartest doctors in the state on your case." No. I wasn't referring to myself. "Is this cancer?" he asked. "No. It's an infection." #Confidence

We bonded. We saw each other daily. We were at very different places in our lives, but we were the same age. Every day he asked me how he was doing and every day I offered reassurance. Every day he asked me if it was cancer. Of course not. How would a 30 year old without any risk factors get cancer? It didn't fit. His history didn't fit. His imaging didn't fit. "We are just waiting on these tests to come back to confirm which infection it is."

He was moved to the ICU in the early evening. "Am I going to get better?" "We think so." He could no longer speak with any strength, so he had to write his questions. "Survive?" "We think so..." He immediately called me out. "Think?" he wrote on his paper. My confidence must've checked itself at the door. He saw the concern in my eyes. "Cancer?" he asked again. "No."

Biopsies would prove me wrong. He was subsequently intubated. And even while intubated, and on heavy sedation he would ask me the same questions. "Survive?" "I hope." He wouldn't stand for it. His watering eyes told me he needed confidence from his doctor. He had a wife and several children. He needed confidence from his doctor so that he could have the hope. Yes. Me. The least important "doctor" involved in his care. The resident of his hospitalist team. By this time he had accumulated a cardiologist, a pulmonologist, a nephrologist, an infectious disease specialist, and a hematology/oncologist. My notes had detailed problem lists, but if I'm being honest the "problems" my team and I were managing were nutrition through a tube in his nose, preventing blood clots, and a making sure he pooped. #VeryImportantStuff

I did it.

"Yes, you're going to survive. Our goal is cure... I promise we are going to take care of you."

I've been sick ever since because I didn't believe my own words. I walked into his room filled with a sense of guilt, failure and shame. His mother must've hated me. She suggested early in his course going to a different hospital. I'm sure my incompetence has done nothing but reinforce those doubts.

It wasn't long until he couldn't ask me any further questions. His body finally relaxed into the sedation. Of course, I wasn't my usual, upbeat self heading into his room. I timed it during nurse shift change when visitors were asked to leave. I didn't tap on his chest to see if he would wake up and follow commands. I used an inside voice to "ask him" how he was doing. No response. But I knew how he was doing. And I knew I wasn't strong enough to stand in front of him and ask him about it.

His family elected to try a dose of chemotherapy. Chemotherapy is an acute toxin to try and address a problem for long-term gain. My patient wasn't able to tolerate the acute toxin. His breathing worsened. He went into arrest. He's young. This isn't supposed to happen. And I wasn't supposed to feel. He's a patient. I'm a doctor. I assess his problems and I prescribe medication to fix him...or find smarter doctors to prescribe medicine to fix him #MostOftenTheCase

Chemotherapy was off the table. Steroids weren't making any improvement. We had "exhausted all available options". There is nothing more humbling as a physician than walking into a patient's room - surrounded by the same family who witnessed Mr. Smooth and Confident throughout their loved-one's stay - and having to deliver the message that the dozens of doctors involved cannot fix what is going on. It's crushing. It's devastating to the family and it's miserable to the doctor delivering the message.

He passed away shortly after that conversation. A thirty-year-old life taken away by an aggressive form of cancer he neither earned nor deserved. A thirty-year-old physician again humbled by how limited "modern" medicine truly is. And another reminder of the power of a promise.

Koupe

2017-02-16T15:45:00.000-06:00

There was no easing into the situation. I arrived to the hospital mid afternoon and before I could drop off my bags I was ushered to the procedure room. I was greeted in the lobby by familiar stares from the Haitian patients. The blan operating the power tools were all foreign. It was a whirlwind of sights and sounds. But it still felt like I was coming home.

Sitting on the exam table was a young man with his foot hanging over a trash can. "You must be Dr. Matt!" exclaimed an unfamiliar voice. I would come to know the two young ladies as Liz and Casey, one an OB nurse and the other a Med/Surg nurse, and both from Iowa. But for now they were doing wound care on the young Haitian man. My eyes fell to his foot and the large, gaping, clean wound. "We were just getting ready to stitch this up. Do you want to look at it?"

I hadn't event had the chance to take my post-road-trip-poop. The foot and wound itself had been thoroughly cleaned when I compared it to the rest of his skin. "Jean, can you ask him what happened." "He was struck with a machete." Casey quickly interjects. #Standard "Has he ever gotten a tetanus shot?" "What's that?" Jean asks... "Yeah that's probably a silly question."

I explore the base of the wound. Yikes. This sucker is deep. Hmmm, this hard white thing is probably his bone. That would mean that his tendon was severed and since I can't see it, then I bet it retracted proximally. "Jean, clean you ask him to wiggle his toes?" His right foot fires into action. "Et, lot pyes?" "Li pa capab." comes from behind me as the patient exchanges a distressed look with my interpreter. What are our options here? My last trip I brought the hard drive of the broken x-ray machine into the states, so I couldn't image his foot to detect foreign objects or assess the status of his cuneiform bones. Liz and Casey had cleaned all of the visible grime and grit out of the wound. There was no way we were going to be doing tendon repair. We don't have crutches or a walking boot. "Alright then, let's close it up."

His foot had probably a 50/50 shot of getting a serious infection. Maybe higher. We put him on the broadest oral antibiotics we had, augmentin. Yes, the same antibiotic crappy U.S. doctors give for colds and flus. Fortunately, I don't think there is the same problem with antibiotic resistance that we face in the states. I "made" him non-weightbearing. Which meant he hopped with the aid of his companion until he was out of my sight when he likely started hobbling and limping.

I was back. And Haiti seemed to be primed to throw what it could at me.

Bon Bagay

2015-11-13T09:01:00.001-06:00

She sauntered into the exam room like the twenty or so patients before her. At first shocked to see white skin, but, let's be honest, she had already heard about the blan at the clinic from the community. Her dossier was limited and very much in Kreyol. Name. Date of birth (she actually knew hers). Her place of residence. And whom was responsible for her. Probably not as applicable to this twenty six year old, but obviously important for the "timoun" (children) we see in clinic.

"Sa gen?" John starts off, knowing me well enough that he can go ahead and get the encounter started without me saying anything. "Oh tet fe mal... vant fe mal... la gripe..." She went on. John knows he doesn't have to interpret the basic stuff for me, but does so out of professional courtesy. I begin in with my exam. Head looks pretty normal. Eyes are normal and her conjunctiva are pink. Teeth are rough, but better than most. Ears are clear. Neck is supple with a few smallish lymph nodes, likely from her teeth. Her heart is regular and her lungs are clear. Hmmmm, her abdomen is a little more plump than normal. Like, American plump. "Ou ansent?" She smiles sheepishly. "Wi." "When was your last period?" John rattles off the Kreyol version. You'd think after all this time I would know that phrase. "Nine months ago." I pull out my iPhone and when she offers the actual date I plug it into my OB wheel app. She's 32 weeks and 2 days. "Are you feeling baby move?" She says yes. #FunFact I've had women in Haiti tell me they've felt movement at 12 weeks. #JustGas

"Konbyen fwa ou ansent?" "Twa fwa." I feel around on her abdomen trying to locate the uterus. I look through her patient chart and find two other visits documented during this pregnancy. One in June and one in September. Interestingly enough neither documented heart tones. She's on the chubby side even for an American woman, so I'm struggling to find a defined uterine fundus. Hmmm... I grab the doppler and flip it on. Nothing. I smack it. There's the static. I place it on her abdomen and start searching. Mom's... Mom's... Mom's... Nothing over 80 beats per minute. She's still smiling. Dr. Ulysse is sitting at the desk behind me and I call her over for assistance. I ask the patient if she's had any bleeding this pregnancy. "Wi." At five months along she had two days of bleeding but it stopped and hasn't recurred.

Dr. Ulysse palpates the patient's abdomen aggressively and looks over at me. "Li pa ansent." And she laughs. She rattles off a lot of Kreyol to the patient that leaves me completely lost. The patient's demeanor never waivers. I finish my clinic note as the patient exits.

There are a number of things I would be doing right now if this situation were happening in the states. First, we just told this patient that she likely miscarried. That is relatively devastating news to some young women. But in Haiti it's just, "You have a cold." or "You lost your pregnancy." and the world keeps turning. From a medical standpoint I would order both a urine and a serum hCG test. I would order a transvaginal ultrasound if either of those were positive. And I would check the patient's blood type and antibody status. Typically we have a sono in the clinic room with transabdominal probes, but not this trip. It's getting repaired and/or replaced in Port-au-Prince. Also, turns out, we don't have any urine pregnancy tests available. This was the fifth patient who came in reporting a missed period that I couldn't tell was pregnant or not. Generally it's okay to write for a month's worth of prenatal vitamins and have them come back to the clinic for either the pregnancy test, a sono, or both. However, in this particular case the test was relevant as she could have retained fetal parts.

Dr. Ulysse and I settled on making a referral for ultrasound in Port-au-Prince. But this brings to light a much larger issue - needed supplies. I had no clue that we were out of such a basic test or else I would have been freaking out every walgreenns clerk in Wichita because some random dude would be buying handfuls of urine pregnancy tests. Instead, I brought several vials of local anesthesia and a few IV start kits that I had accumulated during my shifts at Wesley hospital. Turns out the clinic is loaded up with both of those things, and my contributions will likely expire on a shelf.

I've had several people send me supplies to take down on my trip and they are absolutely wonderful. I couldn't thank them enough for their generosity. And I've never had this sort of instance come across, but several stories of #AidGoneWrong exist in our world of nationally broadcasted disasters. Whether we are talking about Hurricane Sandy devastating the U.S. Eastern seaboard or a giant tsunami striking the coast of India, people are aware of the devastation immediately (thanks Twitter #Hashtag) and feel compelled to contribute. But when people are sending Hurricane Sandy collection centers their tattered clothes that they've been meaning to throw out for years then something is amiss. Old Halloween costumes and half used scented candles have also made the list of less-than-helpful donations.

WTF were people thinking? I know it's easy to get swept up in the desire to "help" but at some point you gotta ask yourself, "How is my gift going to be used? Is there an active need for this donation? Would it be more efficient to contribute cash? What larger implications could my gift have (i.e. am I going to impair a local business or economy with a donation)?" #CashIsKing in most places. Haiti, not so much all the time. But certainly I've learned that I can buy school supplies down here for cheaper than the states. I can buy toothbrushes and toothpaste for very reasonable prices, even with the "blan tax". Medical supplies are so hit and miss that I would hesitate to rely on buying those specialty items in country.

But it's no secret that countries like Haiti are heavily reliant on foreign assistance. This could be direct aid to the government as well as NGOs operating with donations from generous civilians. Certainly both ServeHaiti and CHI couldn't operate without the generous contributions of donors and volunteers. This entry isn't to request donations, but it is to encourage you to choose wisely how you donate. Although it is probably inefficient, I always suggest personal travel. The experiences you glean have the potential to change you. But for some travel isn't feasible. So I encourage anyone interested in "helping" to pray on their decision and ask themselves the questions above. If I had asked the right people the right questions I could have provided better care to the patient instead of dropping off more clutter.

Gratèl

2015-11-09T10:17:00.000-06:00

Gratèl. Gratèl. If yesterday was the day for obstetrics in clinic then today was the day for rashes. One after another. Moms bringing in their little boys and girls with various skin conditions. Pitiriasis versicolor. Scabies. Impetigo. Eczema. It was enough to make me an unofficial dermatologist. Although I am horrible at trying to identify rashes. Especially the erythematous rashes on dark skin. There's no erythema! If you're lucky you can see a faint purple hue to the skin, but that's the extent of the color change.

The first patient was actually an adult male. He was 24. But he was here with his mom. #SeparationAnxiety #PeopleProllySameTheSameThingAboutMe His main complaint was dizziness and what I perceived to be near syncope when changing his position. Near syncope is that feeling where you get a little tunnel vision, your legs get wobbly (wobble baby wobble baby wobble baby wobble), and you feel like you might pass out. It's a super common complaint both in Haiti and the U.S. #FunFact people don't bwe enough d'lo. If you're dehydrated, it's tougher on your pipes to keep that blood flow and maintain the pressure of the blood feeding your brain. No brain flow and obviously you're gonna pass out. Kinda protective in a way if you think about it. If you pass out because your body can't get blood to flow to your brain, then by being on the floor you eliminate the force of gravity. So cool. But he was fine. It was 1 pm and he hadn't peed all day. #SignPost I obviously did the mature thing in my counseling... I told him mom to make him drink more water. I tossed in a script for iron pills because he seemed a little anemic, but that was more to keep them coming back. His story is only relevant because he had such an impressive display of tinea versicolor on his trunk. I just happened to catch it, but it was diffuse hypopigmented coalescing patches with annular borders and slight scale. It's a harmless rash, but from a nerd standpoint it's really cool to see under a fluorescent light (No clubbing for this guy).

Then came the scabies patients. You can just see them scratching themselves in the waiting room. Digging their nails all over their trunk, axillae, arms, legs... basically anywhere they can reach. You just have to wonder what the patients next to them are thinking as they share the bench. No, "share" offers a poor mental picture of the reality of the clinic waiting bench. It's like when you have four friends for two seats at the football game, but everyone's standing, so you think you can get away with it. Well, imagine if everyone in the row did that. And now think about that first TV timeout when people go to sit down and suddenly it's getting really cosy. That's what the clinic bent is like. Nothing is off limits either. Breastfeeding. Coughing. Contracting. Bleeding. Vomiting. Eating. All in the comfort of your neighbor's lap.

I really tried to talk myself into thinking one was pityriasis rosea, but just to make sure I consulted with Dr. Ulysse and she just looked at me like, "Are you stupid? This is scabies for sure." Fine. #CommonThingsAreCommon #DiagnoseWhatYouCanTreat so he got a topical agent to try and eliminate this parasite from his skin. One problems. It's a really complicated set of patient instructions. And it's one of my biggest frustrations with Haiti. Compliance in the U.S. is like 10%. That's right. Those of you out there thinking, "Well, he's certainly not talking about me!" How many times has your doctor prescribed you dietary changes and exercise? Stretches instead of pain pills for muscle aches? Rest for sore joints? Avoidance of stress and meditation for anxiety and depression? Avoidance of caffeine and screen time before bed for insomnia? And have you ever missed a dose of your meds? If people did everything doctors said at 100% then we'd have no patients.

But to sit and try and instruct a mom, who prolly has to take care of like four other people in the household (conservative estimate) and just hiked two hours with an itchy, infested toddler on her hip, on how to make wash the patient, cover them in this medication, and then repeat it for two more days, and then wait a week and repeat it once again, and oh by the way boil any sheets, toys or clothes that could have come in contact with the kid.... Ugh #RunonSentencesAreFun Speaking of fun... Mom, you should probably repeat the process with everyone who has shared a bed, or been in close contact, with the patient. She literally laughed at John when he finished the instructions. And God bless John. He's give "my" instructions on scabies so many times he doesn't even need my prompt. He does it all on his own and I can trust what he's saying. #GivesMeMoreTimeToDocument #ThatsKindofAJoke We even tried the Ebberwein "Teachback" method (I'm sure he has a patent on it), but it was an epic fail. Oh well, it was our last patient in a rather tumultuous clinic day and I had to go to the bathroom. #WellHydrated

With such a large team here I never know which restroom is gonna be open, but I found the one in the guys' bedroom vacant. Now, if you've ever cared for a patient with an itchy rash, especially if you suspect some sort of infection as the etiology, you get just a little itchy yourself. And sure enough, I had held this boy with scabies in an effort to build some rapport and by now... My shoulder blades were squeezing together a little... I was swinging my head down to rub my neck and shoulder together... Just feeling a little creepy crawly. Even as I type this the same crawling sensations are running over my skin. It's expected. You know it's going to happen. And even though you know you didn't contract whatever infectious rash afflicted the patient you just can't help it. But as I stood to use the restroom I couldn't help notice a new sensation. No, it wasn't burning when I was peeing. It was on the outside of my left arm... in several places. My hands were a little occupied, but I tried to shake the sensation out of my left arm and dismissed it as paranoia. And then I looked down. And sure enough, three little mites, or bugs, or something were crawling all over the amazingly well-defined tricep area of my left arm #HaitiFit #SarcasmAgain.

WHAT DO I DO?! I can't swat at them because I'd lose control and spray the floor. I tried to hold the stream, but I couldn't. WHY DO I HAVE TO BE SO DAMN HYDRATED?!!? It was torture. Seconds felt like hours as I just knew those things were making their way to what they saw as a permanent home. Burrowing under my skin and building a mantle place to hang all of their family photos. "Quickly... Quickly... Quickly..." I thought, as my stream started easing up. Kegels, ENGAGED!! And as soon as I felt control, my right arm went flying around and smashed my new hitchhikers. #CrisisAverted #StillMightTakeAScriptForIvermectin... #IStillFeelItchy

Kurrant Part 2

2015-05-17T10:57:00.000-05:00

At ServeHaiti I've been incredibly spoiled with a touch of the U.S. luxuries I'm very accustomed to. They are outfitted with solar panels that charge a battery throughout the day, a wind-powered generator and then the traditional fossil fuel powered generator. Most of the time I have wi-fi access while I'm in the clinic, which is helpful. It's one thing to not be able to communicate with the patients, but then factor on the fact that I can't even access my medical resources to help with treatments and I would be basically worthless down there.

But the ServeHaiti clinic is the exception, not the rule. When I was doing my surveys a common request was for "kurrant". If you want electricity in Haiti you have to buy a generator and then the fuel to run it. Needless to say, most people just do without. So, if you have one you can be big dog on the block, charging people a day's wage just to charge their cell phone. Can you imagine what it would be like for there to be zero power #WalkingDeadStyle? Complete darkness. No street lights, just the occasional stray moto headlight zooming down the gravel road. It just seems unfathomable for anyone to expect a country to develop, or rebuild after a series of major natural disasters, when there is no water security or electricity for the people to use. #RantOver

Puerto Rico to the East, Domincan Republic, and then Haiti.

I think I fall asleep around 10 pm. I had an alarm set for 1030 just to get the jump on my hourly checkups. Fortunately, or unfortunately, the neonatal resuscitation table has a sensor that will detect the surface temperature of whatever is underneath it. And anyone who has worked with these darn things can tell you, they’re a fickle lot. Even if the baby is there and is at a normal temperature the alarm may still sound. Well our baby isn’t quite back to normal temperature, so sure enough the alarm sounds. 1015. Almost. Guess I can cancel my hourly alarms. I get up, hit the reset button and take a quick listen to her heart and lungs. Stable.

Suddenly the room is filled in darkness. The oxygen machine begins alarming. The resuscitation machine lets out an awful howl. There is a faint beeping heard in a far off room. The power went out. This is new. Since my time in Gran Bois I’m not sure I ever dealt with a power outage. I swaddle her with the blankets and begin some breathing assistance with the ambu bag. Dad and grandma come back in to check on her. “Fils cop bay tete?” “No, pa capab.” She just wasn’t breathing comfortably enough for me to suggest her to try and breastfeed. Maybe when we get power and she can get her oxygen back. Yeah, I didn’t try and tell him my thinking cause that would have been a communication nightmare.

I hear Prophet’s name called out and then about five minutes later the power kicks back on. Hallelujah, I’m not sure how much more of the mindless bagging I could take. I turn the table and oxygen back on. While I’m awake I give her a little more IV fluid PO. She actually does a great job with it. Breathing? Labored but stable. HR? 110s. Back to bed.

Thirty minutes later the resuscitation table alarm sounds. No problem. Check on her, things are looking good. I lay back down on the bed and just as I’m falling back asleep, the power goes off again. I turn off the oxygen machine and the resuscitation table, cover her back up in blankets, and watch. She’s breathing okay. This time the power is back up in short order. Machines on. Still stable. Back to bed.

Another table alarm comes and goes without incident. And then the power goes off. Three times for those keeping track at home. I turn off the machines and lay back down. I don’t really know what else to do. This is the time when you start to question whether your effort is misplaced. Is it really worth me staying up all night for this patient? No one else certainly seems like it's worth it. I must’ve drifted off because I was startled awake ten minutes later when dad and grandma came back to check on her. I get up. She’s blue again. Her body is limp. Her respirations are infrequent and irregular. And her HR is 15.

I take off the nasal cannula to ensure that the mask gets a good seal and deliver two rescue breaths before starting CPR, pumping my thumbs where there already is significant bruising. 30:2. 30:2. Five cycles and a pulse check. Still 15. No respirations. The flashlight in my mouth offers the only light in the room. My skin glows in the dark down here, but to watch her chest for movement I have to have the light. What am I missing? Neonatal sepsis? Is she so early that her lungs aren't developed? Did I give her a pneumothorax with my first rounds of CPR? What's her blood sugar? Medicine is much more fatiguing when your questions outnumber your answers.

My jaw is sore. My mind is tired. My spirit is exhausted. And then I feel the vibration in my pocket from my phone. I’m sure everyone has had the phantom vibration syndrome, where you constantly feel like your phone is going off. Well, I’ve had that too, but I was certain this was legit. Not sure how though. I haven’t had service or Wi-Fi since I’ve been here. I mean, I’ve been connected to the router, but the connection to the internet has been down since before I arrived. Maybe, just maybe, in some strange twist of fate, my phone is connected to the internet and I can look up a formal flow sheet for neonatal resuscitation. Maybe Youtube how to intubate a neonate with a tongue blade and a straw. Anything to change the impending outcome. I pull out my phone.

Calendar notification. Two days until “Bedica’s birthday.” I fumble as I try to quickly resume compressions. My hopes dashed and what a crushing blow. Her lips and eyelids are a faint blue hue. Grandma has already left the room and only dad is standing there to watch this white man beat up his newborn baby girl. Ten minutes past the hour and I’m done. I look at the father and can’t imagine that I would want to keep seeing the same trauma inflicted on my baby girl. The outcome isn’t going to change. Not without epinephrine, atropine, IVFs, an incubator, and a real NICU team. A family medicine resident in his second year that is terrified of sick neonates cannot win this battle with a flashlight. I stop. I swaddle her in her blankets and carry her to her father. I don’t even know what I would say if he spoke English. “I’m sorry.”

Kurrant Part 1

2015-05-16T19:40:00.000-05:00

The silent vibration against my thigh was an unfamiliar sensation over the past few days. I have been without 4G, 3G, 1G and wireless since I arrived in Haiti. So even while the mindless banter in my group texts is likely ongoing, I have been completely removed from it. Leaving my phone truly silent. So naturally, I checked to see what may have gotten through. The message was simple, but the timing could not have been worse. “Bedica’s Birthday is in 2 days”.

Honestly, the date hadn’t crossed my mind when I was booking my travel dates. But at this moment I couldn’t even take any time to grieve or contemplate the message I had just read. I was in the middle or trying to navigate a resuscitation effort on a newborn girl.

The delivery came in the middle of the night prior. During clinic we probably see ten to twenty obstetric patients per day which means the hospital delivers upwards of fifty babies a month. This patient had seemed innocuous enough. She was considered term as our dates had her at >39 weeks gestation. Common practice is to induce in the office to ensure that they deliver at the hospital and not at home, miles away. So I placed cytotec intravaginally and told her to marché. Her labor curve went into the evening. She ruptured approximately 6pm, but didn’t make much progress initially. We opted to go to bed and I set my alarm so I could check on her every hour. About midnight I went and found her complete and ready to push.

It didn’t take long and we had a baby girl. There was no delivery team, so I scrounged for the clamps and scissors. I have been advocating for the nurses here to do “skin to skin” but it hasn’t caught on yet. But, I’m by myself so baby goes immediately to momma’s chest. Towel dry for stimulation. She isn’t crying.

I’ve been through this before. In fact, this happened last time I was here. I grab the baby and carry her over to the resuscitation table. This time I find an infant bag-mask and begin some positive airway pressure. It takes some time, but eventually she starts coughing and crying. Whew. Happy sounds. She’s still working a little harder to breathe than I would like, but sometimes you just have to take what you can get. I replace her on mom’s chest and try in my best broken Creole to tell her that “the baby isn’t breathing great, so we need to keep watching”. And with that I head to bed.

My alarm goes off in my ears an hour later and I walk down to the post-partum “suite” to find the nurse getting the mom situated in a bed and the baby with supplemental oxygen flowing by nasal cannula. She looks more comfortable wrapped snuggly in her blanket and wearing her pink toboggan. Her breathing still looks a little labored, but improved since a couple hours earlier.

I check in on her throughout the next day. They turned off her oxygen around lunch time and mama was happy to report to me that she was breastfeeding well for her. I sneak a peek under the swaddled mess of blankets and see her resting comfortably enough. “Thank goodness” I think to myself.

It was shortly after dinner that the Haitian resident flagged John, my interpreter, to grab me. There was a patient he wanted me to see. I thought maybe another mom was about to deliver and he wanted to let me know, but we bypass the delivery suite to the recovery beds. He points to the far bed and I know immediately. I go check on her. She’s limp. She’s tachypneic. She’s turning blue. I grab her and bring her to the delivery room where the neonatal resuscitation table is. Thankfully, the bag mask is still out from when I used it to deliver her approximately 18 hours prior to now. I try my hardest to pace my breaths, but they say in times of distress we often tend to over-ventilate. We pump too hard too quickly. Go big or go home, right? #NotAGreatStrategyInThisSituation

The nurse lugs in the suitcase sized oxygen machine from the inpatient rooms. I ask if there is a way to hook up the oxygen flow directly to the bag mask. Nope. Alright, we place the three-size-too-big nasal cannula into her nares and I try to continue to provide any sort of positive airway pressure that I can. She’s dry. It doesn’t take a chemistry panel or even an advanced degree to recognize that. The Haitian resident calls for Dr. Leo and Dr. Ulysse to come examine the baby. Dr. Ulysse quickly is able to secure an IV in the baby’s right hand #MadSkills #CubanTraining. The nurse brings a bag of IV fluid. I’ll take anything at this point. “How much does she weight?” “2.3 kilograms.” That’s 2300 grams for those of you playing at home. And that’s her birthweight. Something is amiss.

I pass off the bag mask to John and he’s doing a wonderful job. For the next twenty minutes I’m on my phone, with no internet access mind you, punching away on the calculator function to figure out how much fluid to give and how fast to give it. Maintenance is 8 mL/hr. Dang. That’s not even a mouthful of spit. Okay, we need to “bolus” her like 20 mL twice. I grab the IV tubing wheel and roll it until I count one drop every 3 seconds #OldSchool. Now. Antibiotics.

Neonatal sepsis is treated by “Zosyn” in our hospital now - because we can. If you’re taking a board exam the answer for treatment of neonatal sepsis is ampicillin and gentamycin. I’m gonna go out on a limb and assume we do not have Zosyn here. I ask the nurse for ampicillin and gentamycin for IV use. No ampicillin. Penicillin it is. #AlwaysSettle

I didn’t realize how difficult it can be to be a pharmacist until this very moment. I mean, I always find it super annoying to have to figure out how much of an oral suspension for a kiddo to take to get the appropriate dose of medication. Now I’m reconstituting penicillin, figuring out how many thousands of units this baby needs to receive every six hours, and how many mL that would be #MathIsHard The answers for those of you playing at home are 115,000 units which equates to about 0.14 mL of the reconstituted penicillin. Now I have to do the same to figure out how much of the gentamycin to give her. #FML In order to keep things simple I took a piece of tape and wrote the drug and dose on it and put it on the syringe I used. Unfortunately the IV tubing we were using didn’t have a port for me to administer additional medication. Screw it, I.M. it is.

I resume my position manning the bag mask. Minutes feel like hours. Her little lungs fill with each pump of the bag. Suddenly the nurse points to the IV fluid chamber. It stopped flowing. Her little R hand was swollen up to twice its normal size. Our IV had infiltrated. A wise man once told me that subq fluid still got fluid into the system, and in this situation I was going to take what I could get. But the nurse pulled the IV catheter before I could say anything. Dr. Ulysse was able to come down and place one in the other hand in short order #LikeABoss We continued our resuscitative efforts. This time I paced out the fluids to one drop every 8 seconds.

Needless to say, pumping away on an ambu bag for a long period of time can get monotonous. Even with trying to count in my head and stay gentle with the amount of pressure I create, it’s easy to for me to get distracted. Time is crawling and there is no end in sight.

The Haitian resident places his hands on her chest and comments, “Li fret”, indicating that he thinks she’s cold. I look down, feel her chest, and immediately grab my stethoscope. There’s good reason for her to be cold; her pulse was at best 20 bpm. Her hands were already blue.

90.5 is what her axillary temperature measured. Before the thermometer even alarmed I had started CPR with rescue breathing and chest compressions. I cycle as fast as I can. Occasionally she opens her eyes and a spastic movement squeezes enough air out of her chest to make a squeal. Cycle after cycle and I feel like I’m getting nowhere. I check for cardiac activity and can’t detect anything that seems like it would offer perfusion. And so I continue. I spin her around because up to this point I was operating with her head towards me and feet away from me. With her feet towards me I can wrap my hands around her torso and use my thumbs to compress her chest. I can also visualize chest wall expansion with each breath. Bruises are already setting in from my trauma. And we just lost our other IV.

The Haitian resident, recognizing my fatigue and dwindling faith, points to the wall and offers simply, “Nou gen epinephrine?” I’m not even sure what I would be giving it for. We have been resuscitating this girl for an hour now, what good could it possibly do?

The patient’s father and grandmother walk into the room to me doing compressions and rescue breathing. I’m not sure if it was the look on my face or if they caught a glimpse of their little girl on the table, but you could see the despair in their eyes. Why not? “Please give me the epinephrine.”

Hmmm, I have a 3 mL syringe with 0.5 mL of solution in it. There is a piece of tape with “Epinephrine” written on it. No dose. No concentration. Nothing. And nobody knows. Well, I don’t have an IV or an endotracheal tube, so at least the route of administration isn’t in question. I grab her thigh and plunge the 18 gauge needle into the muscle. I push the plunger. No carefully planned amount. Just push the plunger. And then resume compressions.

Minutes pass by. Why not? I grab the other thigh and empty the rest of the syringe. Tick tock. Tick tock. I listen with my stethoscope. Wait a minute, that heart rate is improving. I stop with compressions and resume rescue breathing with the ambu bag. I see some more purposeful movements in her arms and legs. She’s even offering some of her own breaths.

I continue supporting while the Haitian resident continues to stimulate in the hopes of producing a cry. I take another listen. 108 bpm. Dr. Leo swings back by to check on the baby. We tell him we lost our IV again. He turns to the family and tells them that the baby may not make it through the night. And with that he is off. We’re gonna do what we can without an IV. I stop with the rescue breathing and see how she does on her own. All things considered it isn’t awful. She has a little accessory muscle use, but her rate is hovering around 70. I set the bag down. We replace the nasal cannula as I had removed it when I started with compressions. And I stepped away.

Her next doses of antibiotics were due at 1255 and 0255 a.m. My phone was set. She needed some sort of volume, so we attempted to have her breastfeed. It went okay for a few minutes. She didn’t really latch, but her mother was able to express some milk manually. 8 mL an hour is her maintenance, so if we can do that intermittently I would call that a win. Still, she quickly tired without the supplemental oxygen, so I placed her back on the resuscitation table. That’s the only place in the hospital with a radiant warmer, and her temp was still low 90s. She still has the bag of IV fluid hanging on the pole beside her. Why not? I open the tubing and let a little trickle into her mouth. She immediately does her best to latch onto the end of the tubing and begins suckling at it. #FluidIsFluid at this stage of the game. She gets about ten drops before she starts coughing. I’ll take that all day, every day, and twice on Sunday.

New resolution, wake up every hour, see if she can take some expressed breast milk and then supplement with the IV now PO fluid. This is going to be a long night.

I head upstairs. There are still several people in that room, and for most of the resuscitation there was a mom of a different baby still being cleaned up from her delivery. Right now our little girl is holding her own. Her heart rate is stable. With the 4LNC in she’s breathing much more comfortably. She has some purposeful movements in her arms and legs. Not much more you can ask for given our situation. I don’t have telemetry to give me a constant update on her heart rate. I don’t have a pulse oximeter to assess her oxygenation. I don’t even have an IV to give her the parenteral nutrition and fluid she so desperately needs. She was only 2.3 kilograms, meaning that even if she were a 37 week baby she would be close to SGA. How certain can we be of our dates in Haiti? Did we induce a premature baby? Questions that will never be answered. Problems that won’t be resolved. We have a second year family medicine resident trying to care for an NICU baby.

I grabbed a sheet and several blankets – it gets cold in the mountains at night – and head back to the delivery suite. We don’t have any women in active labor, so I’m calling dibs on the bed. Yes, the same beds that have been covered by more blood, poop, and amniotic fluid than I’d care to count. I plan on posting up there for the night. My syringes are ready to go. I plug my phone into the socket; alarms are ready to go. Let’s do this.

Teen Pregnancy

2014-12-25T01:35:00.000-06:00

A teenage mother in labor for the first time is likely one of the more frightening human experiences possible. The teen pregnancy rate in the U.S. is 26.6 per 1000 girls aged 15-190. Just imagine: You’re sixteen. You’re currently thirty pounds heavier and always experiencing new pains, kicks, and spins. Your pregnancy was out of wedlock, so now you have to deal with guilt, shame and judgment from everyone around you. Peers. Parents. Religious leaders. Everyone. You’ve never done this before, so you can’t even be sure that this series of pains is labor. After all, you’ve “cried wolf” a dozen times prior to now and some resident keeps telling you you're not in labor or you just peed yourself. Your confidence in understanding your own body is shook.

Now walk for several days. Perhaps all the walking is what helped initiate the labor process. Maybe your water spontaneously ruptures coming down the side of a mountain. Your feet carry your weight as well as they can, delicately dancing along the rocks as one misstep will likely lead to a tragic miscarriage. You’re exhausted. You can’t catch your breath. You don’t have your bottle of Smart water with you. You try to eat but more than three bites and you feel like you have to vomit. You’ve been wearing the same clothes for several days. You actually discarded your underwear because this new discharge had already ruined it.

You arrive at your destination. This land is completely foreign to you. The people. The facilities. Maybe even the language. You’re here to register, but this baby isn’t going to wait. Unfortunately the facilities are overrun with passersby and you’re told there isn’t space available. The Story has probably become a little clearer at this point, but this

story is duplicated every day in Haiti.

Mary gets pushed to the “manger” for her delivery. I remember growing up and seeing our nativity scenes. Mary is dressed in a beautiful robe. She has a sense of peace about her and she is smiling. They’re chilling in a wooden barn with a couple animals and Joseph is right by her side. Our church program were similar. I was a donkey, then I graduated to a shepherd and then finally the creme de la creme - a Wise Man. So I thought I knew all about how the miraculous birth went down.

The real story is that they were likely in a cave, or a small chamber carved out of the rock. It was used for feed storage and animals likely sought shelter there as well. #Newsflash Animals stink. They poop all over the place. Spoiling grains stink and were likely infested with rodents and bugs. Labor hurts #FromMyPersonalExperience. Labor pains would be banned by the international community as a form of torture. As a first time mom I would say that once her labor contractions started baby Jesus wasn’t born until 28 hours later #RoughEstimate. Joseph was in a corner or outside, terrified. He had no clue how to help Mary in her time of struggle #NoLamazeClasses. Also, what was he thinking wedding a woman pregnant out of wedlock? It was social suicide.

I’m sure Mary had never prayed to God like she did that day and night while she was in labor. I’ve heard several of those prayers, albeit in a different foreign language, but the tone says it all. “Dear God, this hurts like hell. I don’t think I can do this. Please give me the strength and help it end as quickly as possible.” I’m paraphrasing of course. The animals not only were terrified of the noises and screams, but probably assumed she was crazy and dying. There were no interns or around to provide encouragement and anticipatory guidance. She just kept contracting until she felt the need to push. And then she did. Thank goodness she didn't bleed or seize. No one received the baby. He was probably born on the ground. She would have been exhausted, so Joseph was probably the first to pick him up. The placenta would follow. Did they tie the umbilical cord and grab a nearby rock to sever it? In the age before tetanus vaccines that was a roll of the dice. I always joke to the delivery team nurses that I assume Jesus's APGAR scores were 10/11 at 1/5 minutes. But I highly doubt it. He transitioned. He might have been early, or small for gestational age. But what were they going to do? Odds are he was a breastfed baby too. #WWJD #Breastfeed

My last day in Haiti I was in the delivery suite with the Haitian resident. Our patient had come to the clinic in labor earlier the day before, and now it was about 2 in the morning. It was her first child. My alarm to get ready to head to Port au Prince was set for 330. I’m 90 minutes ahead of schedule. As we continue to labor with her a frantic family runs through the front door. The older woman is holding a bundle in her hands. I get the story through Dr. Leo.

This is the grandmother of a new baby. She looked thirty. The mom had delivered at home and they were concerned about the baby. That was it. I don’t know how long they walked. I’m not sure if they made an attempt to come to the hospital for delivery and just got caught at a house before they could get here. How long ago did she deliver? What was her prenatal course like? How far along was she when she delivered? Ugh. So many questions left unanswered. But there isn’t time for questions like this sometimes. When you’re in the hospital, you develop a sense about those sort of things. This patient looks sick, I will probably forgo asking about their social history and focus more on getting them taken care of. Or, this patient is 100% healthy, maybe I can use this opportunity to address vaccination status #GetThemAll

I take the bundle from her hands and immediately my heart sinks. I place the infant onto the resuscitation table. I’m not sure it was ever cleaned from any of the other times I had been forced to use it during this stay. I know for fact the bag mask hadn’t had a chance to be cleaned; it still had evidence of other babies on it. Sanitation be damned. Breathing is more important than germs. But the mask has no role here. I fully uncover the baby. The placenta is still attached to the umbilical cord. He’s not moving. He’s cold to touch. I place my stethoscope on his chest. Silence. I glance over to Dr. Leo standing by the grandmother in the doorway and without saying a word he knows. He asks the Haitian resident if there is any epinephrine, but I had to use it up three nights ago. I begin compressions and rescue breathing, but stop. I don’t think I can handle giving CPR to an infant again, so I don’t #EmotionalBurnout. There was nothing to be done from a medical standpoint.

Mary’s home delivery was a blessing from the start, but one that was wrought with suffering, fear, doubt, and a roller coaster of emotion. Women and children die in the U.S. at a rate we care not to admit and we have the most advanced care in the history of human existence on our side. Just imagine the odds Mary and Jesus were up against that first Christmas. An unwed, pregnant teenager in a foreign land being tended to by complete strangers and having to deliver in a stinky cave next to a donkey. Sounds like a circus sideshow. But what an awkwardly poetic present from the Big Guy (or Gal) upstairs.

Jean working for HandsUp!

My thoughts and prayers are with that poor family this Christmas Eve and Day. In fact my thoughts go to Haiti most days, but especially when my faith or consumerism is front and center on my brain. Hello, Christmas in the U.S.

I think of Jean Gabin who defines living paycheck to paycheck. Yet this is the first thing he wanted to do with the money I gave him for his work: Buy the thirty children in his “Hands Up for the Children of Haiti” program a large Christmas feast so they would be happy and want to sing Christmas songs. He’s an unbelievable human being.

I think of Dr. Leo and what he and his beautiful family are doing for the people of Gran Bois. Again, unbelievable. And I think about my own life and family and how ridiculously blessed we are. Blessed to have a loving family. Blessed to be an American. Blessed to have the freedom to travel to a place like Haiti. And blessed to be a Christian #ToWhomMuchIsGivenMuchIsExpected

I want to take this opportunity to wish everyone a Blessed Christmas. Being home with my family after spending a week with my Haitian family has been amazing and I truly feel spoiled. To say I appreciate all the support from my friends and family doesn't properly characterize how I feel. Even amazing doesn't. So thank you all #ThanksgivingWasLastMonth

Gwo Tet De

2014-06-11T17:35:00.001-05:00

“He’s blue guys. And not crying.” They continue with drying/active stimulation. “He’s got good tone” the other resident responds. Looks kinda floppy IMO, but I’m not manually checking him. You know how they always tell you that good communication is key in high intensity situations? Well, that is definitely true because I felt like with the language barrier we couldn’t communicate what we were thinking and what we needed to do. Seconds seem like hours as we are waiting for any signs. Finally, we each grab for a cord clamp. I guess our thought cycles synced up. Clamp. Clamp. Cut. She grabs him by the shoulders and carries a floppy, blue baby over to the neonatal resuscitation table ServeHaiti recently provided to the clinic. Sidenote: I was actually here the day the docs brought it down. They were so proud. Certainly seems like a great idea…Until it’s not useful.

We place him head towards us, face up. “Do we have any suction?” I ask as she is bulb syringing his mouth and nose. She’s getting some yellow gunk, for sure. “You see it” she responds. “Stethoscope?” Fortunately there is one hanging on the wall, because none of us had brought ours in the delivery room. We hadn’t needed one all night. This was obstetrics. Who needs a stethoscope?

I place the plastic diaphragm on his chest. #HolySh!t That doesn’t sound normal. Let’s try the other side and hope it’s better. More normal, if he were an athlete. FWIW heart rates in the 50s are not good for newborns. “Oxygen?” the other resident asks. Our nurse tries to hook up the one in the room, but it isn’t working. “Any mask?” No. Of course not.

I do the only thing that comes to mind. I start compressions. I have flashbacks to a premie that Dr. Angie and I delivered in Arcahaie. The thought crosses my mind to give mouth to mouth rescue breathing like she did, but I’m already fighting with their hands while they place a nasal . My face getting involved would just be too many moving parts occupying the same space.

About now I try and stretch to the far reaches of my memory. As an intern in family medicine at Wesley we go through tons of certifications. And rightfully so. As the family doc we could literally find ourselves in most positions where those different class and certification skills would be necessary. Give me an adult code blue and I’m good. ATLS? I probably wouldn’t be the worst at it. But here I am trying to remember my neonatal resuscitation program. And it’s not going well. All I can remember is PPV, which we didn’t have. So next best thing in a bradycardic infant who is hypoxic is chest compressions, right? Where’s my iPhone? There needs to be an app where you take a picture of a patient and it magically tells you everything to do.

I keep mashing away. Every now and then he gives me something to work for by moving an arm or leg spontaneously, as if fighting the pain I’m surely causing on his chest. I pause for heart rhythm identification. Oh wait, no ekg leads, no O2 sat monitor, just me and a plastic stethoscope. “Well, the funny sound seems to have gone away. He’s hinting that he might try and breathe on his own, but still not very consistent with it. And his heart rate is still low for an adult. Resuming compressions.

His eyes open and no longer appear lifeless. I can hear the occasional grunt from his mouth and nose, which are now turning pink. #PositiveReinforcement His arms and legs are offering more signs of tone. And we finally have the nasal cannula in place, powered on, and all done without unplugging the resuscitation table…again. BTW, did anyone bother to calculate APGAR scores? No? Okay.

You can see the bruise.

I replace the steth on his chest. Please be normal. Please be normal. It is! Good, brisk heart rate without any murmurs. He’s pink. Moving spontaneously and with slightly better tone. His respirations still leave a lot to be desired, but without deep suction or PPV I’m without any other options. He’s gonna have to cough and cry it out. Already a bruise is developing on his chest where I did compressions. I talk to the Haitian doc about need for antibiotics and extended stay. At Wesley he would have been a special care admission at the very least, but likely an NICU. Course, he probably might have been intubated at the onset.

#WardrobeFail x 2

And it’s events like this that make it ever so clear why it’s nice to have a team. The whole while we were working on the baby the mom sat there unattended. And then when we were comfortable with the baby we turned our attention to mom for her repair. I’m used to continuous nursing care and monitoring; this was incredibly painful for me. I didn’t even offer to sew. All I could do is retract (ain’t no way I’m gonna do my first third degree perineal lac repair without direct instruction) and watch from across a bed as the infant retracted away.

But to bring the longish story to an end, he’s doing much better. He and mom were recovering in the next room when I checked on them a couple hours later. He was pink and breathing fine. I still hope they decide to do 48 hours of observation if not also IV antibiotics. He went through so much those first minutes of life that it’s worth an extra 24 to make sure he leaves the hospital healthy. Heck, they're all GBS unknown so they should all stay for 48 hours. But you try telling that to a Haitian family that needs to get back home to take care of the rest of the kids.

#NewbornSelfie

As a stateside update to this story, I was recently involved in an emergent cesarean section for fetal distress. Turns out there was a placental abruption and the newborn was basically cut off from the maternal blood supply. Thank goodness we had an operative staff and neonatologist on site. It simply became a matter of me stepping out of the way and letting the specialists do their jobs. The surgeon dropped off a floppy, gray baby into a functional resuscitation table where four hands began drying/stimulating. The neonatologist got a deep suction catheter ready and suctioned about 6mL of cloudy, thick secretions.. One of the nurses auscultated for cardiac and breath sounds. PPV was applied to help with oxygenation. Slowly but surely the baby was weaned to room air. There were three surgeons controlling the hemorrhaging uterus and closing up mom’s abdomen. The entire team worked like a well-oiled machine and the outcomes reflected it. Sometimes it’s easy to think we overkill our preparedness in the United States, but when something like this happens it’s crystal clear why it is so important.

Gwo Tet Un

2014-06-10T18:38:00.000-05:00

I was getting impatient. I had woofed down about a half portion of my evening meal. The eleven year old that swings by the clinic to mooch actually scoffed at the amount of food on my plate. Talk about being made to feel like a punk. But I had done this because the last two of our laboring women were theoretically about ready to deliver. The first was a primip who was term and being helped very gently along so she could just go ahead and have her baby at the hospital. The other was a G3 who one might think would be a pro at this stuff. They both took forever.

Maybe it’s because I didn’t get to go to La Fite. Maybe it’s because they kept saying something to me about the ‘blan’ but I had no clue what it was. Or maybe I was just ready to get some more food, but I’m sure I was wearing my impatience on my face. And my co-workers can attest that I would never do that at Wesley.

We deliver the multip, finally. I can only imagine what the heart tones would have been doing because she came out swimming in thick meconium and a cord around her neck. Baby transitions okay and we actually do some skin to skin. A full hour is too much for them to handle here, but I tried my hardest to institute a change. Ten minutes in and I see that they’ve already pulled the baby off mom so they can tie the cord and clean her up. And forget about four hours of recovery time in the delivery room because she was immediately told to walk back to the back “post-partum” room where two other new moms had already claimed the best beds. No Jacuzzi. No flat screen TV with touch screen, on demand movies, and food ordering service. I’m not exactly sure how the ServeHaiti can compete for these pregnant women when they aren’t getting pampered properly.

But now we turn our attention to the primip. She had come in yesterday during clinic, but hadn’t technically hit active labor until about 3 pm today. But when they live miles away over a couple mountains and a terrain that even a moto can’t traverse your only option is to keep them around till they deliver or basically guarantee that they deliver at home and you hope to see mom and baby within the first week. So she got to “maché” around the compound all day and night. But now, she was our only remaining pregnant patient and she was close to active labor. The pit is running.

Keep in mind these women are unblocked. There is no epidural taking the bite out of their pain. They scream, they pray, they sing and squirm in every way possible to try and distract themselves from the pain. Because of this though, I have to fight every urge to check her and figure out where the hell we’re at. Do I have time to finish my meal? Ugh. It’s painful. And normally I’m one who is hands off of my laboring patients. I finally get up the nerve, or lose the battle to my impatience however you want to look at it, and check her. Complete and +2ish. Perfect. Let’s ‘pusse’ this baby out. Yes. That is Creole for push. And yes. That is said repeatedly, at louder than playground voices, during active labor. #KeepAStraightFace #IDareYou

She seems like she should be a good pusher. I feel like all Haitian women seem like they would be good pushers. I’m not sure why and I’m not sure if that’s racist. But I feel like that’s a compliment? My apologies if someone is offended by that assumption. Making good progress. Baby is crowning. Finally, I can see the end of my work duties. I mean, I’d hate to violate hours.

Then he’s still crowning. Still crowning. She’s unblocked but damn we’ve been at this for a long time. I apply gentle stretching forces with my gloved hands to try and facilitate the path. With the next push I insert my finger into her rectum. Gross, I know. But I was going to try and hook the baby’s jaw and pull him forward. I couldn’t reach it. This kid’s head was huge. We try and doppler for heart tones, but she waves us off as another contraction hits. She’s running out of gas.

At this point the Haitian resident and I discuss our options. We have no surgeon, or operating room, or sterile surgical supplies. We have no vacuum or forceps. Alright then, good talk. It’s either we push him out or we send her on a four hour drive in a massive downpour to Port-au-Prince. We talk episiotomy and get the scissors to the bedside. I try and offer some push coaching, but who the hell am I kidding. My botched attempts at Creole probably add to the confusion. Fortunately for me the Haitian resident speaks a little English and she and I have been practicing languages with one another throughout my time here.

With the next push I reach as far as I can. I find his jaw and thrust it forward. Every OB in the world is probably like, wtf are you doing. And they’re probably right, but in the situation it seemed like the most reasonable recourse. He comes out. And, yeah, massive tear. And he too is followed by a pile of meconium. I pass him up to the patient’s abdomen so we can start cleaning and skin to skin. I take a peak at the tear we are gonna be repairing still waiting to hear a cry.

I hear nothing. I take a peak up to her belly.

He doesn’t look good.

Takotsubo

2014-06-01T22:10:00.000-05:00

A heart is a terrible thing to waste. Songs are written about this very fact on a daily basis, and I’ve been known to listen to a T. Swizzle heartbreak song before. In the hospital setting, we go to great lengths to either confirm or “rule out” a primary cardiac issue when someone presents with anything related to the chest: pain, shortness of air, cough, and even nausea. We get stat EKGs, troponins, chest x rays, and an ICU admission with telemetry all because someone comes in and says, “Ya know, my chest kinda hurts.” Because we’ll be damned if we’re the one doc who misses a heart attack. And even with all that…we… miss… heart attacks #Whoops

I’d like to think that when I’m finally put into the position where I’m the one making the calls that I’ll use a little more clinical judgment than I’ve seen a few of my practicing professionals exhibit. But, when that time comes am I going to allow myself to “miss the heart attack” or will I order those two extra tests and sweet talk whoever the hospitalist is into watching them for 24 hours? Even if it’s 99.9% likely a pec strain they suffered while trying to do P90x for their first exercise in six years.

I say all this because day one on the job in Haiti we had two patients come into our clinic with chest pain. I’m not sure if they were well known or not, but Dr. Leo seemed to know who they were and what they’re history was. First thing was first, we had a brand new EKG machine from the states… Better use it (Allows us to upcode their visit!!). So I figure out how to affix leads and get the first patient set up. Ten minutes of button mashing later we have a printout of the limb leads. Perfect. Couple more button mashes and the precordial leads print too. Now what… Myself and two of the other docs look at it kinda perplexed. I called it sinus tach with probable partial bundle branch block. However, the Haitian resident was calling it atrial flutter with a 2:1 conduction. It’s nice in American life to turn to your super friendly cardiologist and say, “What the hell is going on here?” It’s also nice to have the machine auto calculate all the intervals, the rate, and even offer a preliminary diagnosis. Not so much here. So I do the next best thing. She had a medical record chart. In the chart was an EKG performed about a year ago by a doc in Port-au-Prince on a machine that offered a preliminary report. By in large the tracings looked similar enough to where I would call it unchanged. #ProblemSolved #InternMedicine

The story behind her heart problem is a little more curious. She’s 43 and 4 months post-partum. Her chest pain and dyspnea started 2 months ago. I’m no ECHO expert, but even I saw a giant heart when I placed the sono to her chest. Peripartum cardiomyopathy is rather rare, but sure seemed like we had a rip-roaring case of it here. And with her massive ascites, it almost looked as if she were still pregnant. I placed a paracentesis catheter, blind mind you with a regular IV kit #Improvisation, and we drained 3 L out of her abdomen and started her on heart failure medication.

The second patient was 13 years old and had florid heart failure. Her heart murmur indicated this was also a structural problem with one of, if not more than one, the valves. Again, I’m not an ECHO-ologist so I couldn’t point to the aortic valve and say that is massive regurgitation, but clinically the management is likely going to be the same. Refer to Port-au-Prince should she or her family ever gather enough money to: 1. Send her there. And 2. Pay out of pocket for any test or treatment they offer. Not likely going to happen. So we’re stuck managing what is likely a surgical problem with medication. Fortunately, @TheDrSinclair had just given a baller lecture on the medical management of heart failure. And thank goodness that we actually had all the meds. I didn’t realize how insecure basic medications were to the Gran Bois clinic until this trip. After a quick check in with my OB consult on call to ensure that nothing too different was required in the post-partum period we were squared away with both patients.

As the patients recovered in our inpatient unit I started thinking about how I saw them walk up to our clinic. Yes, they were both using a moderate amount of assistance, but still. They both had nasty heart failure and had hiked from their homes to our clinic. I can’t say it’s a La Fit kind of hike, but I know for damned sure that it’s more than the flat two miles my lazy ass would have to walk to get to work every day. And we’re in the mountains. I’ve been dyspneic ever since I climbed out of the truck. I don’t know how these people do it. Basically the patients pass a stress test on their way to the clinic #CardiacRiskStratification

As an aside, we started blood pressure medicines on an 82 yo m today in clinic today who’s pressures were 180s/110s. This was the first time he had ever come to the Haitian clinic. His chief complaint: a rash on his back. He left his appointment with an ACE, a diuretic, and some hydrocortisone cream. I’m just thinking to myself, “He could run circles around 90% of America…I’m not sure he needs a daily pill.” You can follow him on Twitter at @Im82AndIHikeMountainsOnTheReg. But this just goes to show, whether in Haiti or the U.S. we physicians are sometimes guilty of not seeing the forest through the trees.

Breech

2014-05-30T21:55:00.003-05:00

It’s a word we hear a lot these days. From a breach in security to army/swat movies talking about busting through doors it’s something that is not uncommon. Well, I feel like it’s definitely not rare. You don’t have to argue with me on this, just roll with it. So it should come as no surprise that we doctor-type people have our own special situation that we refer to as breech. And that is when the baby is coming out bottom first.

If you’ve ever seen a normal, uneventful delivery – of which many OB’s would say there never is – then you know that babies are supposed to come into this world sliding head first. Sounds like a good way to get a concussion (See that? Full circle.). A breech delivery carries with it a number of risks to both mom and baby, and being as obstetric doctors like to do everything they can to minimize risk and thus liability (and rightfully so) they’ll often try and turn a breech baby prior to delivery or just perform a cesarean section. Both reasonable options. However, anyone who is trained in obstetrics learns “how” to do a breech delivery. You just never do it. Except I did. Just now.

OB is one of those fields that I came into not knowing what to expect. It seemed pretty simple. Millions of babies are born all the time without any doctors or nurses present and definitely not with all of the interventions they have us doing at Wesley. #BusDriveItself But the more I’ve done it the more it kinda terrifies me. What am I gonna do that one time in a hundred when there is a shoulder? How seriously should I take the heart tone phone calls when it’s 3 a.m., I think they’re hogwash for the most part, and I really don’t want a cranky attending? And a cranky attending can happen either with a phone call or with sitting on the “tones”. Post-partum hemorrhage? Stat c-section? The. List. Goes. On. And. On. Of what can go wrong with the laboring and the delivering…and heck even the after delivery stuff with both mom and baby.

But I’m in Haiti. It’s the middle of the night. My wi-fi doesn’t refresh well enough for me to youtube a quick breech delivery. And…I didn’t really know it was breech until it started happening. There’s one thing I also forgot to tell you. The baby was an IUFD and she was somewhere in here early 20 wga based on a femur length. So we were inducing a still birth. From a mechanical standpoint it would be really hard to screw this up. But from a psychosocial standpoint, how do I get it right? She was “diagnosed” yesterday in clinic after showing up with the complaint of no fetal movement for 5 days. We sono’ed her, “Ou bebe pa gen couer.” That’s it. That was the delivering bad news. She was still half-naked.

The time is 0020 and it really seems like her contractions are pretty regular and dammit if she doesn’t act like they hurt #PaGenEpidural. I really don’t want to, but I’m kinda tired and would like a rough idea of where we are at. We’re AC with a very tense amniotic sac… That EXPLOOOOOOODES with digital pressure. #BadTimeToNotHaveShoesOn. The fluid is a reddish brown, almost like metabolized blood products. With the bag out of the way I run into something not normal. But then again, when was the last time you delivered a 24 wga infant? Never? Me too. Misshapen face? Hand? Butt? Anencephaly? I don’t know. I depend on smart people to tell me these things.

With the amniotic fluid still pouring out - I mean, like a fountain. I decide now might be a good time to throw on some shoes. The “mom-to-be” is still screaming with contractions and her parents sit anxiously outside the “delivery room”. Every time I walk by the start talking to me. And every time I try. I try so hard. And FAIL. No clue what’s being said to me. For those that aren’t familiar, creole is a language that really lends itself to being “lazy”. Very guttural. And then people just make up their own contraction patterns that don’t make a whole lot of grammatical sense. She when people mumble quickly and quietly I am just out of luck. And that’s exactly how I perceived grandma and granddad.

The child came. When I realized I was in fact feeling a butt presentation I tried my darnedest to remember the moves. Leg. Leg. Hips. Arm. Arm. Head. #AndYouShakeItAllAbout #ActuallyTakeThatBack… #NeverShakeABaby Not sure how it all worked out or looked, but I got baby out. But now what. Everyone is still asleep. I clamp and cut the cord. “Eske…ou vle…’hold’ bebe ou?” Confused looks. “Yeah, I don’t know your word for ‘hold’.” Porte? Mette? Nothing worked. You’d think everything around it and the context would make it kinda obvious, but apparently not. I even pantomimed, and anyone who has played charades with me before can tell you how I’m at least mediocre. “ Eske ou vle we [see] bebe ou?” She said something and it wasn’t a “wi” or a “non”…so I just uncovered him and held him up to her and her parents. They stared… “Oh Jesi” x 1. And that was it. They were done.

I took him away. Her pain was gone. Her grief seems non-existent. She still has that pesky placenta, but that too will pass. Again, her parents ask me a very lengthy question, of which I understand exactly zero words. “Mm pa konnen. Dormi asweya.”

For those who are curious. I examined him in another room. Appears to likely have been chromosomal. Lymphadema in the hands and neck. Single palmar crease. Small jaw. In Haiti there is no paperwork. No death summary. No delivery note. No formal autopsy with karyotyping. He is still sitting in the delivery tray with the packaging from my sterile gloves covering him up. I can only assume he will be burned, but I would at least like to offer the family the chance to take him home and offer him a proper burial. Just another day in Haiti.

Boule Un

2014-05-21T18:49:00.002-05:00

The burn was unlike anything I had felt before. It literally felt like I had been shot. The group of Haitians that had gathered around me started cackling at my clear discomfort. The klarin sonson had done it’s job, it had made the blan cough.

I’m not one to succumb to pressure, especially in Haiti. If I handed out money every time a kid came up to me with a “bum senk goude” I’d be more broke than my loans would indicate. But this time there was enough of a burning curiosity in me that pushed me over the edge. I’m in Gran Bois working with the ServeHaiti clinic and Dr. Leo. There’s a couple of “bars” about a mile down the dirt road. The one I went to was aptly named “Brother’s”. It was really like my B1G homes of Iowa City and Champaign. There were some signs in the back and I’m pretty sure one of them said Wing Night Wednesday. It was Creole, so I may be taking some liberties with the translation.

The scene was bumping with some God-awful rap blaring over speakers that were probably bought at a Costco in 1984, broken, shipped to Haiti, then “repaired” three years ago. A group of pre-teen boys were playing dominoes on the one table. I think the pool table was around back, but I’m sure it was occupied. I had just bought some minutes so I could make some phone calls back to the states and my old buddy, purple shirt “Vote Roger Galle” found me and started in his best English to get me to give him something.

I’ve been through this rodeo a hundred if not a thousand times. “Bruddah. Can you help me. I have no money. Give me two dollars. Be a good bruddah.” And I respond, in limited Creole but phrases I’ve become fairly adept at, “I cannot give you money and no one else. I came all the way from the U.S., you should give me money. I am hungry too.” They usually get a kick out of my failed Creole, which is enough to satisfy them. But this guy was persistent, and then he pointed to the jugs of moonshine on the counter in Brother’s.

I had been eyeing the shine since earlier in the day when I was helping a couple workers in the garden plant some plantain roots. We were walking back to the clinic and when they thought I wasn’t looking they bought a small bottle of it and killed it behind the bar. #BlanSeesAll. When I joked to them about it they started laughing, but did say it was good. I wasn’t sure, there were too many leaves in the jug for me to feel too comfortable with it. But the seed was planted.

And all it took was “Vote Roger Galle” to keep hounding me for free stuff for me to cave. The agreed upon transaction was for me to buy a small bottle of the moonshine and then everyone could pass it around. That way no one was left out and he could say I was a good brother. So that’s what we did. Twenty Goude is all it cost for a half-pint sized bottle of this concoction. It was red. And I was first to go.

There was no countdown. There was no chaser. No LMFAO song or drinking game to offer me any sort of encouragement. Just me and my manhood…And thirty Haitians watching closely with bated breath. So I closed my eyes and took a pull. And I couldn’t be a wimp; it had to be a fair sized pull. And I’ll be damned if I didn’t give myself alcoholic liver disease and gastritis all in one fail swoop. I composed myself quickly and held up the bottle to pass on to the next taker, and around it went. #USA However, no one had near as much fanfare as I. When the bottle was finished Mr. “Vote Roger Galle” gave me a firm handshake and we were officially brothers. And so it was. I stumbled my way back to the hospital with a rumble in my tummy that I was no longer accustomed to and the people went about their day with a new story about the "blan".

As an addendum I was able to secure a nice bottle of moonshine and bring it back to the states. In fact I had a couple. Unfortunately, in my rush I did not properly secure them in my suitcase. When I saw my bag for customs in Miami off the baggage claim it was clear that something didn't go well. The front of my suitcase was clearly wet. It's not like my flight was Splash Mountain or something. It was clear that there were a couple lost soldiers riding in my bag. And when I finally grabbed my bag the smell knocked me down. Definitely was one of the moonshine bottles that bit the dust. But that's okay. I still had one survive.

Frèt

2014-05-16T23:56:00.000-05:00

I’m cold. And anyone in the Midwest is probably really pissed to be reading that right now. You’re right, my afternoon was filled with sunny skies and a blissful 85 degree temp. Cap it off with forested mountains in every background and there isn’t much to complain about. But it’s night time in the mountains, and I’m getting a little chilly. After spending a week in La Fit about a year ago with an amazing team, I realized that on the next recommended packing list would be plenty of warm clothes and bedding. It’s the rainy season. We are in the mountains. And it’s cold.

But that’s not why I chose this topic to write about either. Two years ago today was when I got the life-changing, gut-wrenching Facebook message. Guirlene: Bedica malade. And then minutes later: Guirlene: Bedica mouri. I was destroyed. I lashed out at my computer. I made frantic phone calls. I drank a bottle of rum, poured out an emotional roller coaster on this blog thinking it might be my last ever, and started walking towards the pedestrian bridge over the Iowa River.

Stages of grief always seemed like a silly concept when I was in school. And then I lived them. Sort of. I was definitely angry. Angry at everyone in Haiti who had let this happen to her. The health workers for their lack of working on health. At Charles who was in country, had a vehicle and seemingly was lost in trying to seek medical attention. At Chris and Ginny for letting her go back. At myself for getting attached. And at God for all of the above. Didn't really help as anger never does. But hey, it’s an immature defense mechanism that is easy to turn to in our weakest moments, and I did.

Denial and bargaining are more with my inability to face her parents with any deal of comfort. It’s Haiti. They’re used to dying children. There is no guilt. There is little grieving. They’ve moved on. But Americans can’t. I can’t. I’ve seen parents bury children and it’s always unbearable to watch. And then the days, weeks, months, and years following can be just as bad. #InterestingStatisticThatIHeardButCantVerify 80% of couples who bury a child end up divorced. Not surprised.

I think it’s because we never really reach stage 5: Acceptance. How do you accept losing a child? That’s not the way nature was designed. And so because it doesn’t make sense we hang on to our anger. It’s the easiest emotion to possess and one that will ensure that we never forget. Anger is effortless. Love takes work. Love admits fallibility, but in anger you’re always right. It’s vindicating. And everyone around you is the victim. There is no doubt that it can easily couple itself with depression. Sleep disturbances, anhedonia, guilt, distracted thinking, suicidality. There’s your five SIGECAPS there. And so we languish. Relationships get choked out like the seeds cast among the weeds. Work falters like the seeds cast on desert sand.

And so I am cold. No longer angry to the point of no return, but unsure of where to go from here. I can say that I will try and not write about this topic again. But with the looming graduations and the requisite celebrations afterwards this unfortunately is likely to be lived by more people than is acceptable to me. Thus I thought worthwhile writing. Perhaps it can help another struggling with loss to have some introspection, or at the very least can offer a gist to an outsider of what someone might be going through.

Amnesia

2014-05-15T19:13:00.001-05:00

Concussions are a huge deal in the U.S., and for good reason. So many kids get them from playing sports year round and obviously there's the big kerfuffle in the NFL regarding long term consequences of repeated concussions. But what is a concussion? A brain bruise? Any contact to the head that causes severe symptoms? A stinger? Having your bell rung? Seeing spots/stars? Are these all concussions of old? Maybe. And maybe even bumping your head on the bookshelf is enough to cause a "concussion" with respect to repeated trauma and long term effects. Fact of the matter is we have a pretty poor understanding of concussion. How hard does your head need to be struck to cross that threshold? What direction does the force need to travel and what parts of the brain are the most susceptible. How long is the recovery? How do we make it better? What is the long term prognosis? #NobodyKnows

One of the more common symptoms of concussions is amnesia, which can be of events immediately prior to the incident (retrograde) or of events happening after the incident (anterograde). Some events are so bad and you come to in a dissociative fugue, or the Jason Bourne disease. Ideally anterograde amnesia resolves and even some of the retrograde amnesia starts to clear with time and frequent orientation. That's kind of how I've felt these last few hours.

It's been nearly a year since I last stepped foot into Haiti. I've been so caught up in my first world problems that I've failed to make down once in a calendar year. Seems inexcusable. And, like most trips, you always have to expect the unexpected. So, true to form, I receive a call as I'm leaving for the Wichita airport that my ride to my final destination will be delayed by a whole day. Kind of a big deal when you're only in country for 7. But, I couldn't change that so I got extremely lucky that Dr. Angie was in country and available to play host to me on the first leg of my trip instead of the tail end like she and I had tentatively talked about. Ok. I think everything is settled. I run to Walgreens to pick up a script for ondansetron. I nearly laughed as the pharmacist started explained what it was and how to use it. But, no time for a discussion, I did have to make my flight. I get dropped off, and in the fluster of an awkward departure I totally left the zofran I had just picked up, my spare apple charger, and my toothbrush... #Peachy.

My travel day was quite the blur, but I found myself in Port au Prince today morning. I was being picked up by an old friend, Smith, and driven back to Arcahaie, the place I had called home for a short but significant part of my life, just two years ago. Really? That long ago?

Things have changed. It has been soooo long since I have been here. My creole is beyond rusty. I see relatively major buildings and have no idea what they are. Turns I used to know by heart seem foreign. I feel like I've lost it all. As we get closer to Arcahaie more comes back. Cabaret, where Smith and I stop to buy some school supplies for his class, is the same bustling market that I remember. The seasons have always dictated what fruits and veggies are on display, so I find no surprise that there are plump watermelons and mangoes lining the road. The same cat calls of 'blan' greet me as Smith and I walk through the rows of shanty shops. The same, disgusting fish displays find themselves a little too close to the stand selling me my toothbrush.

We press on and I suddenly find myself walking the familiar path up to Do Digue. I've taken these steps hundreds of times before. But as I cross the threshold of the town everything looks different. A new, concrete plaza sits where a dirt-floored, community meeting place once was. A water pump is established adjacent to it, in the city center, with people lined up to utilize the free water source. Kids that used to be scared toddlers now run around me smiling, and know my name. Sorry kids, can't return the kind gesture. Even Nola's house is a different color! I'm lost. I feel like I've stepped into a new world.

Smith and I settle in under the shade in Nola's yard and catch up. A lot has happened since Nola and I first met two and a half years ago. Clearly a lot is completely new to me and totally awesome progress. But the more we talk the more I wish my amnesia were a little bit more...expansive. Sure my brain will let me forget to bring my anti-nausea pills on the plain and my toothbrush, but I can't forget the frustrations, the hardships, the tragedy and the loss that I've unfortunately come to associate with Haiti.

I know some very special people that seem to have that ability. Tough days are forgotten before their prayers are said. Outlook is always sunny. Arguments, lies, mistakes, and injustices all seem so easy for these people to move past. They get the big picture. I struggle with that. Disagreements between like-minded people with near-identical goals go unresolved because of people like me and we end up with 15,000 NGOs in a country the size of Rhode Island. But this is neither the time nor place for such theology. I'm trying to catch up on life.

I ask Nola about my God child. "Li en ba." Descriptive... We walk until this scared little toddler is walking in front of me. Next up is Norline. Before long I learn that both my kiddos are growing up. Baby David isn't Baby David anymore. Heck, he's not even David. He's walking. Talking a little. And knows how to push buttons on an iPhone. Norline is just as adorable but muuuuuch bigger. Someone's feeding her well. It doesn't take long before I have them both on my lap. But then it seems like far too soon that I need to pass them back and head out.

I have one final stop and I make this one more out of obligation because it doesn't fill me with joy like he others. But I stop to visit Carole and Jean Roo. As the moto stops and I descend I still have no idea what to say. I never do. It's nothing but disappointment and failure. I'm somewhat relieved to hear that everyone is away from the house at the moment. Smith and I hop back on the moto to head back to Angie's house. For now I can continue to feeble attempt of selective amnesia.

Onz

2013-06-06T21:18:00.000-05:00

With every trip to Haiti I like to think that I leave a little bit of myself down there and bring a little bit of Haiti back with me. Sometimes it's very tangible like dropping off medication or gifts. Most of the time what I bring back is pictures and memories. In turn I use to tell stories to let other people experience Haiti. As some of you may know, Rachel and I just finished our much anticipated clinic trip to La Fit. This was a site never before explored by CHI. I'm not even sure that this site had seen a United States team of clinicians.

The clinic was a raging success. But I'm not writing about our clinic, yet. I'm writing about something I brought back with me from Haiti... #Cholera. I didn't notice much of anything immediately upon my return to Iowa. Rachel and I spent the weekend with her family and celebrating the wedding of two of our best friends in Wisconsin. I certainly "re-acclimated" myself to American food and drink faster than normal, but seemed to tolerate it well. I've had issues with this process in the past.

Our water source was captured rain water.

It hit me just under a week after my return. My stomach had been a little upset off and on, but nothing like this. I woke up in the middle of the night and had to go. You know those commercials about the "going problem" regarding male prostate issues? I had a going problem for the twosies. I couldn't sleep. I literally had to go to the restroom eleven times from the early morning till noon. I finally started with Loperamide, which slows down intestinal motility. All that did was increase my abdominal pain.

As a medical provider I'm used to telling people to use oral rehydration therapy. Antibiotics don't help with most causes of diarrhea and IV fluid is for extreme cases. So that's what I tried.

I felt miserable. My stomach was cramping. I thought I was going to throw up every time my body moved. I reached for the zofran. It helped, but my abdominal pain just increased. It seemed like my GI tract was full of evil and due to the medication I was taking it had nowhere to go. Thought it was going to dig out like the baby in Aliens. And then the fevers hit. I was chilled to the bone and shivering during June in Iowa. I broke into a cold sweat. I chased it with Ibuprofen and tried to sleep on the couch under four blankets.

I broke down and texted Dr. Buresh:
"So, I've pooped like eleven times today. Don't feel great. No blood. Drinking enough to still pee. Traveler's diarrhea? Or something else?"

Before he responded I was already leaning towards cholera. During my clinical encounters in Haiti, the number 10 was my cutoff. If a mother or patient complained of diarrhea but it was less than 10 times per day I assumed it wasn't cholera. I had 11 in the span of 12 hours. I became patient number 654,737 to contact cholera in Haiti. I downed a double dose of Cipro and fell asleep on the couch watching The Hangover Part 3.

I dreamed about La Fit, but not about tracking the source of my infection. I woke up the next day dehydrated. Mucous membranes were not moist. My radial pulse was quicker and weaker than normal. My first stop was to the bathroom. Rachel fixed me an electrolyte cocktail to help me regain my fluids. I was lethargic. I walked to the car to find my wallet and threw up after having already taken a zofran. My fevers returned.

As I laid sweating on the couch I couldn't help but realize how fortunate I was. Yeah, I said it #Fortunate. I was miserable. But I was suffering in the comforts of a 900 sq ft apartment with a big screen tv playing sports center. My girlfriend was doting on me to make sure I was taking enough fluids. When it looked like I was struggling she actually called Dr. Buresh to arrange some IV fluids. I was living it good. I had Ibuprofen for my fevers. I had antibiotics on call. I had loperamide and zofran. And best of all. I could count on the fact that the water I was drinking from the tap wasn't filled with gram negative bacteria that would just prolong my illness. I had it way better than the Haitians.

I know. Major revelation, right? But I had never had a disease like cholera before. A disease basically eradicated from the U.S. but common in many nations without proper sanitation. I've never been dehydrated and unable to ingest enough fluids. In my survey one of the questions was "When someone has diarrhea should they eat or drink more, less, or the same as usual?" I commonly got the response that they should eat less because "they have no taste in their mouth." There have been times that I've not had an appetite when I'm sick, but I have never had quite the repulsion of food that I have with this illness. Even flavored water got detestable. And all it is is sugar packets and tap water. Awful.

And I think about Haitians who are stuck in their one room house with mud walls and a leaky tin roof. I think about how the only time they have access to medicines like Ibuprofen, Tylenol, and basic antibiotics is when we hold a clinic. I think about how we don't pack medicines like Loperamide and Zofran because they aren't cost effective. I think about how they drink the same water they got infected with initially in order to rehydrate. I think about how if they want to see a physician they have to walk five hours over a couple mountains and pay more money than they can truly fathom. Most of the time when they see a physician they then have to send their family out to scour the city pharmacies looking for all the supplies they'd need for treatment.

There is just so much to take for granted when it is second nature. But every now and then you gotta get the poops to bring you back down to Earth. Unlike many Haitians, I'm going to recover from this illness and be just fine. Until I travel again I won't have to worry about drinking contaminated water. I can take comfort in the fact that every time I poop I get to flush the evidence far away. I know that I can purchase some Ibuprofen or Tylenol in bulk for a trivial amount of money. I've been #Blessed from the get go and it is my duty to share my blessings with others.

Altitude Sickness

2013-05-01T19:31:00.005-05:00

Brace yourself...this is a long one.

I was in a fog. It was early November, 2012 and I had just seen the tragic aftermath of a brutal attack on a Haitian. However, this fog was physical. Having finally completed the primary objective of the last week of my month-long journey I now found myself standing among the clouds. Rachel and I spent the entire morning climbing #MountainBeyondMountain with Dr. Leo and our "bodyguard" to reach La Fite (pronounced LA-feet). La Fite is an extremely remote village in Northeastern Haiti, near the Dominican border. Dr. Leo had actually seen an eclamptic lady from the La Fite area in the Gran Bois clinic days earlier. Her family and friends had taken shifts during the 5 hour hike carrying her seizing body on top of an old mattress .

My body was sore, out of breath, and muddy but I couldn't help and take peace in the scene I found myself in. It truly seemed like something out of a Lord of the Rings movie. Everything was green. I was on top of a mountain with scattered wooden homes dotting the landscape. We were greeted by an overweight gentleman who claimed to be in charge of the "mission." He was passionate about his community and about trying to secure a commitment out of the blan to help. He formed a committee of local leaders to develop a plan to secure community access to healthcare. Word carried across the mountains to Dr. Leo and while he tried mightily to make the hike monthly he realized that he was not properly equipped to handle this remote clinic by himself. ServeHaiti is our older sister in the Haitian NGO game and the sponsor of Dr. Leo’s clinic. The leadership discussed this need for La Fite and decided to involve their younger sister, Community Health Initiative to see if they could manage semiannual clinics.

After a tour of the clinic building he showed us to a gathering of Haitian villagers who had come to receive medical care.

Rachel and I were not alone at this place. There was a small group of blan there working on their own projects. A small group of Canadian men were doing carpentry on the clinic building and there were two South American nurses holding clinic in the church. Now, I will never say a bad thing about a nurse. I have had my ass saved innumerable times already in my young medical career and I know that I will continue to have my ass saved by nurses as I continue to practice medicine. However, these two very well-meaning ladies were in over their heads with this clinic. They had few medicines and the ones they did have were being completely misused. As an example, they were prescribing a form of Benadryl as both an antibiotic and a prenatal vitamin to different patients. Granted the "Treat What You Can" mantra often leads to diagnosis bias, but that isn't anywhere close to being appropriate.

We quickly set up shop to help in seeing patients. We have one translator between the two of us and he isn't used to being a medical translator. Needless to say I believe that Rachel and I were also guilty of providing sub-standard care. You can get the gist by key words, "Gripe" means cold. Cough, runny nose, fever, etc. Same illness in Haiti as in the U.S. Listen to the kids' lungs and depending on nutrition status you might lean a little closer to treating with antibiotics than in the U.S. And just like our normal CHI clinics, everyone got real vitamins and albendazole. Dr. Leo recognized early that we didn't have the infrastructure in place to provide proper care to the patients, though Rachel and I felt bad about throwing in the towel. As soon as you start thinking about the alternatives for these patients you recognize how important this clinic visit is to them.

These villages have no clinic near them. The closest clinic is the Gran Bois site that we left from that morning. The path to reach this oasis was not easy. We departed after a satisfying breakfast, one probably never experienced by a Haitian in those parts. We launched with a vigor as I knew that we would be making a return trip that same evening. The path was a combination of climbing the Mega Crag in #GUTS and completing the #PhysicalChallenge in #DoubleDare...times a million. We climbed three mountains, forded two rivers and traveled over five hours...each way (for realsies, all those tall tales by parents about commuting “uphill both ways” were becoming all too real). There were narrow paths that had turned to mud in the mountain rains with soda can sized stones for stepping. One false step on the slippery rocks could mean a nasty spill into a mud and animal excrement mixture #TwoThumbsPointingAtThisGuy. Incline grades easily topped 60% in places. It was a struggle made even worse when you realized that the villagers out here do it on the reg #HaitiFit.

It became painfully obvious that the only reasonable solution for providing healthcare to the upwards of 15,000 Haitians living in La Fite and nearby villages was to have medical teams come to them at regular intervals. #Duh. This was something Dr. Leo already knew. He had been trying. But monthly trips were increasingly difficult for him to do as the patient load at his clinic grew and his resources stretched thin.

CHI has knack for providing healthcare for rural Haiti. The quarterly clinic model has been successful as far as initial data reports can tell, and is something that can work in most places given enough resources. Both human and material. CHI has a body of volunteers from across the country who drop their lives for a week to come work as a clinic team. People with backgrounds ranging from cosmetology to cardiology, all with willing hands and able bodies. Each volunteer pays their own way, and donates $1,200 to contribute to the costs of purchasing medicines, translators, meals, etc. We are very fortunate to have this financial support, so we never have to use outdated medicines, share interpreters, or have understaffed clinics similar to what we saw in La Fite. Seeing such disparities is extremely frustrating when we know that there are feasible solutions on the table.

Before we departed on our trek back, we reached an agreement with the community committee. They provide a roof, treated water, and one hot meal a day and we do what we do best: pull together a team of medical volunteers and use our talents to provide standard of care. We made a promise to go back, and now Rachel and I are honored to making the return trip with an enthusiastic team of volunteers, Dr. Leo, Cindy the mule, medicine to treat pain, infection, worms, hypertension, diabetes, etc…and most importantly show these people of La Fite that humanity hasn’t forgotten them.

While we have been blessed with many eager volunteers to come, we understand it is not feasible for everyone to up and leave their lives, and come up with the money. More than bodies, it takes cash to make this operation run. I’m not big on hitting up people for donations, but if you are reading this, and feel compelled to contribute to the cause, 100% of your dollar will go towards financing this clinic. The details are below. Just $10 can buy a bottle of antibiotics to treat a dozen kids for pneumonia. I cannot thank you enough for reading my blogs and giving us support for our work with CHI. I have already seen many positive changes within the country, and simple demonstrations of love and caring, in the form of medicine, money, or just time, will make all the difference in Haiti’s recovery, so again, thank you.

To donate: please visit www.chihaiti.com. When donating via Paypal please put "La Fite" in the comments section or when writing a check do the same. That way we know that the donation is for this trip. This population has already done so much to accommodate us that we would hate to not fulfill this medical void.