Hypothermia part 1

The untreated water washes the blood off my hands and down the drain.  My brow is still dripping with sweat.  I don’t know why I think ‘still’ when I know our job is far from done.  I walk back downstairs in the ServeHaiti clinic to see our patient lying still under the x-ray machine.  All I can think about is how lucky we are that the rest of the group left this morning. 

Two nights ago, Rachel and I arrived to a mission in Gran Bois.  Gran Bois has a clinic sponsored by an NGO called ServeHaiti.  ServeHaiti has a large contingent of Iowa members including some of Rachel’s neighbors.  They have been active in Haiti for over ten years and this clinic shows the payoff of hard work and a serious financial commitment.  They are able to employ two fulltime Haitian docs to staff this place.  Our arrival was met with much fanfare as they really didn’t know when to expect us.  We spent one day with the whole team, but this morning we waved goodbye as they loaded up into the three vehicles and set off to return to the U.S.  And thank goodness.

Our patient was carried through our front door on a stretcher just as we were departing for a five hour hike into the mountains to visit another clinic site.  To think, if he had come five minutes later we may have never seen him.  He was shivering and far from responsive.  The story we got was that he had been missing for two days and they found him on the ground.  They carried him back to the post-partum room where our only empty bed is and we get to work #TraumaActivation.    

His airway is intact and appears to be midline.  He’s tachypneic over 50.  I auscultate with my stethoscope.  No breath sounds on his right lower area, but faint sounds up top.  I’m concerned about a pneumothorax.  I check for neck veins.  None.  I percuss his chest.  It’s tympanic.  Well, shit.  Now what?  As I continue with my primary survey, he starts to come to and suddenly becomes very active #NotAGoodTime.  I guess it’s safe to assume he is neurologically intact.  His distal pulses were regular, so even though we didn’t have a blood pressure cuff available I knew his numbers to be good enough to perfuse his fingers and toes, so it must be good enough to perfuse his brain and heart.

The nurses and Dr. Leo were trying to set up the EKG leads, blood pressure cuff and O2 saturation monitor.  I ran to grab a thermometer.  I shove it under his armpit. . . . 92.3 F.  Blankets.  We need lots of blankets.  We finally get the monitor running and Rachel squeezes the finger clip on his index finger to measure his oxygen saturation. . . . 80%.  We’re in for a long night.

We ask Dr. Leo to grab the oxygen machine.  We tell the nurse that we need a couple IVs running fluid.  I start the secondary survey.  He’s dirty.  His pupils are equal and reactive to light.  Dr. Leo brings back the oxygen machine and we drag around some extension cords to hook it up.  He tells us to look at the patient’s scalp.  I run my hands over his head and his skin scalp spreads apart.  He has a full thickness laceration about 6 cm long over the crown of his head.  There is no blood, so I missed it during my survey.  That’s not a good sign.  Scalp injuries bleed like crazy.  This was a major scalp injury and it had stopped bleeding without any medical attention.  He must have lost a lot of blood.  Dr. Leo tells me to wash his head off so I grab some water and soap and begin scrubbing.

Oh shit.  I find a second laceration longer than the first.  I palpate the depth only to feel a rough irregularity in his skull.  My stomach drops.  This man had been struck by a machete, twice.  That’s the only thing that makes sense.  Rachel points out some odd scratches on his hands that we couldn’t place before, but now we know them to be the characteristic defensive wounds when someone is being beat.  I tell Dr. Leo we need to go ahead and get chest xrays to see what’s going on. 

The patient is still making purposeful movements in that he’s trying to fight us at every step.  He’s got an IV in both arms.  He continually tries to pull them out, pull off his oxygen, and take off his monitors.  We get him in a wheel chair and maneuver him into the main room of the clinic.  Dr. Leo already has the x ray machine set up so we just have to lie him down.  Thankfully the father of the newborn baby sharing a room with our patient is helping us or else we’d be struggling to have enough hands.  We lie him down and get him comfortable.  There are no IV poles to hang his fluid and antibiotics that we started.  I take one for the team.  We have to move forward.  Everyone clears the room while I hold his hands to the side and the IV bags up in the air.  Maybe if I cross my legs my junk will get less radiation?  He shoots the image and takes the film back to load it onto the computer.  Yes, digital imaging.  Rachel comes out to tell me that he does have a pneumothorax and significant mediastinal shift.

Midclavicular line, second intercostal space.  That’s the board response for any patient with a tension pneumothorax, which I’m not convinced this patient had.  He just had a significant pneumothorax that was compromising his respiratory status.  I need a 14G needle with a stopcock valve.  We have an 18G used to put in an IV catheter.  Okay then.  #AlwaysSettle.  “Do you feel comfortable with this, Dr. Leo?”  “Oh yeah.”  Okay, that makes me feel better.  Cause I’m terrified.  Rachel offers me some sound reassurance and I pierce.

The whoosh of air and faint spray of his blood that returns through the needle onto my face is actually a relief.  He’s still tachypneic.  I listen and he has breath sounds on the right side.  They sound like shit, but they’re there.  I let myself get nuked again for a repeat image and see that his heart and mediastinum are relieved.  We also see an extremely clouded right lung.

I steal away from the hubbub to clear my head.  I head into the restroom.  I stare into the mirror trying to comprehend what we’re doing at this clinic.  Dr. Leo just told Rachel and I in between images that this man was found at the base of a seventy foot pit with his hands tied behind his back.  He was the unfortunate prisoner of some monster, or monsters.  And to make matters worse, he was one of the gardeners that helped Dr. Leo with the garden.  I wash the blood off my hands.

Dlo Twa

Water can be the source of so much joy all while it can be the source of so much strife.  Yesterday we ran through our second trauma in as many days.  A six-year-old girl had fallen into the river and was pulled out after an unknown amount of time.  She was carried into our clinic floppy.  Her eyes were shut and his muscles relaxed.  It became #GoTime.  I grabbed her and set her on our exam table.  She was groaning and tachypneic.  Rachel and I rolled her on her side to see if we could discern breath sounds.  Crackles all along the right side, but she was moving air.  Rachel got vitals while I checked for neurologic status.  Her eyes were closed and she was sluggish to open them for pain.  She had sounds coming from her mouth, but would not respond to questions or use words.  I pinched her arm.  Nothing.  I pinched the skin over her ribs.  Nothing.  I pinched her leg.  Maybe a muscle response.  GCS is not good.  “She needs to be intubated.  If only we had a pulse ox to see how she is oxygenating.”  PERRL.  Heart sounds are good.  No signs of trauma from the fall.

Our interpreters are fiendishly translating four different women giving their accounts of the events, yet none of them witnessed it.  We continue to stimulate her by firmly rubbing her sternum and speaking to her.  Slowly we see more life coming out of her.  Her eyes open with more purpose.  She mutters a few words.  Eventually we get her to give us a ‘thumbs up’ with each thumb.  She’s sleepy, but appears to be improving without intervention.

We call Dr. Buresh for guidance as we tell Guirlene to work on getting a tap tap to take her to the hospital #TwoInTwoDays.  I give him the 30 second presentation and ask his opinion.  We don’t have oxygen.  We can’t ventilate her.  We can’t even monitor her.  She needs broad spectrum, IV antibiotics, which we do not have.  Her lungs sound full of water and she’s doing a pretty terrible job of replacing the water with air on her own.  He reminds us to maintain her c-spine because of the unknown fall history. 

Guirlene reports that no taptaps are available.  Mahalia volunteers her car.  I drive it around so we can load and go.  We log roll her and slide her onto the folding chair just like before.  I think I need to patent this.  We take her out to the car and carefully load her into the backseat.  Rachel rides alongside her to maintain c-spine.  Thankfully the girl continues to improve clinically and even flashes a smile.  I navigate the SUV out the gate through the throng of community members that had followed the child over.  I head down the road.  Potholes are the least of my concern.  Large ravines have been carved through the dirt road from the storms.  Maintaining c-spine precautions won’t be easy.  I cringe with every bump and turn, but the girl is a trooper.

We arrive at the local hospital and I take John in to find a collar for our patient.  The nurse immediately diverts us to the doctor who is in the back administering an IV injection.  She finishes up and quickly says she can’t speak English.  #JohnToTheRescue.  I explain that we need a collar to protect our patient’s neck.  She tells the nurse to call for the Cuban doctor on call.  The front exam table is vacated so John and I head back out to bring in the girl.  I crawl through the back seat and push her out the other side so Rachel can maintain c-spine.  We get her onto the exam table as the Cuban doctor walks into the “ER”. 

He starts speaking… in Spanish.  #RachelToTheRescue.  She’s been trying to speak Spanish this entire trip and now she finally gets her shot.  She shines.  We tell the doctor that the little girl was brought to us after falling into the river from an unknown height and was submerged for an unknown time.  She was somnolent when she was brought to us, but has slowly improved.  Her lungs sound crappy on the right side.  And we’ve been doing our best to maintain c-spine precautions. 

They accept the transfer.  However they also do not have any breathing assistance machines or xrays.  She’ll have to be sent to another hospital.  They notify the ambulance drivers while the Cuban physician places an IV.  The Haitian physician begins writing transfer papers.  We wait for her to be loaded into the back of the ambulance and are even hit up to help pay for gas.  But, we had every confidence that the little girl was going to make it to St. Damien’s http://saintdamienhospital.nph.org/ and not incur a single cost for her treatment.

Dlo De

The hurricane’s rains brought more than the obvious destruction.  Haiti has been struggling with an outbreak of diarrheal illnesses ever since the last set of natural disasters.  When infrastructure is devastated the incidence of disease grows.  Makes sense though, right?  The rural poor of Haiti already can’t afford to build latrines and don’t pay to treat their water.  Or at least that’s what my limited personal experience has shown.  Cholera ravaged the country during the last rainy season and I think we encountered our first patient after this storm.

He was a sixty year old man and by the time he got to our clinic at nine in the morning he had already had five stools.  It took him a little over an hour to reach our clinic.  I try to not think about where he would have defecated along the route.  He has crampy abdominal pain along with his watery, clearish diarrhea.  No one else in his family has it, but he reports with an ominous tone, “They will be struck soon.” 

His blood pressure is 90/60 but he is not tachycardic.  His oral cavity carries a terrible odor and his four teeth look like petrified wood #FossilMouth.  However, it was still moist.  I perform my abdominal exam and note that his aorta is fairly obvious.  His pain is worst in the mid upper epigastric region.  His lower quadrants are relatively benign.  No guarding.  No rebound.  Otherwise normal exam.  I discuss with Rachel the advantage of treating him for severe cholera.  He can tolerate PO, so that should remain the crux of his therapy.  We teach he and his a wife how to prepare ORS and prepare a liter for him.  He lives far away and it has been our practice – and others before us – to over treat especially when someone lives far away.  So we opt to give him the 300 mg Doxycycline recommended for moderate to severe cholera infections.  We ask him about dehydration symptoms.  Chest pain?  Dizziness?  Light headedness?  Syncope?  Weakness?  Yes.  Yes.  Yes.  No.  Yes.  Of course.  Just like everyone in Haiti.  #OverTreat  #OverTreat I keep telling myself.  I get the equipment ready and Rachel places an 18 Ga needle in his left arm.  We run in a liter of fluid wide open.

He says he feels “much better” but we still give him a  tortilla with peanut butter to help him with a little more strength for his long journey.  Mr. Matay, our translator for this patient encounter, has to remind him to say thank you for us helping him out.  It’s okay.  A lot of patients who should be saying thank you in the United States certainly don’t either. 

He waves back as he leaves the compound and promises to come back and see us.  He kinda missed the counseling about us leaving the country in a couple days.  Raymond quickly seizes the opportunity to plug that we should relocate here permanently because there is such a need.  “Did you not hear?  I am starting a residency program here!  The paperwork should be finished just in time for you guys to be the first class!”

#PeaceOutERAS

Dlo Youn

The families in the Northeast know exactly how devastating this disease can be.  Hurricane Sandy, after having passed through the Caribbean, touched down in NYC and ruined Mayor Bloomberg’s plans to hold the NYC marathon.  People are displaced and living in the many NYC hotel rooms.  Disaster relief is pouring in but people are still being forced to ration gas, food, and power.  Sounds like another day in Haiti.

The storm was its own disaster in little Haiti.  While the area where I am staying was largely spared, the Lower Peninsula had extensive storm damage.  Arcahaie lost its bridge connecting itself to Port-au-Prince, but the bridge that was washed away in Les Anglais completely separated families from their homes.  Four lives were lost when that bridge gave way.  Days passed and mothers and fathers were still unable to reach their homes and children.  The river was powerful and no one was foolish enough to challenge it.  One of my classmates, @AlexHubbell, was down there at the time and witnessed the devastation first hand.  I know it got him fired up.

However, I found the rain a welcome relief from the days without water to bathe in.  While the clinic team was here we would often run out of water in the cistern supplying the showers.  My showers were brief and unsatisfying.  Once I resorted to the bucket method.  Hurricane Sandy brought downpours that offered a salvation.  I lathered up outside and caught the runoff from the tin roof.  I can’t take full credit for the idea, for Dr. Bybee was out dancing around under the runoff before I made the decision.  I just provided the soap.  The water was chilly, but nearly unlimited.  By the time the drops slowed we had gathered a small crowd of bathers and a greater number of gawking onlookers.

 As the rain continued unabated over the next days I had to turn to other methods of entertainment.  Always the scientist, I decided to conduct a study to determine exactly how well my @FroggTogg would work given the conditions.  I donned a set of green scrubs and put on my @FroggTogg.  By design, my scrub pants would get soaked while my shirt would be spared.  The fabric was the same and I would perform different movements to ensure that there were no leaks.  The experiment was a wild success.  After nearly an hour “playing in the rain” I finally surmised that enough time had passed to call the study good.  I went under cover and removed my jacket.  Sure enough, the only part of my shirt that was wet was where it was tucked into my pants.  The water had soaked up through the fabric exposed beneath my @FroggTogg.  Hey, @FroggTogg, how’s that for an ad campaign?  #IllKeepYouDryInAHurricane.  

Wouj

The Red Zone.  In Iowa they call it the “Case-IH” Red Zone.  Can you tell that we play our sports in the middle of a cornfield?  #FieldOfDreamsReference.  I’ve been going through crazy football withdrawal since I’ve been down here.  Here’s hoping my fantasy teams survive and my return will inspire them to a playoff run!  In keeping with my fantasy football theme, I’m going to borrow a bit from @MatthewBerryTMR and do a love/hate on the color red.

Things I love about the color red:  According to Will Smith in Wild Wild West red is strong, it is the color of passion #DidIReallyJustReferenceWildWildWest.  Studies show that red is the color that girls wear when they are on the prowl.  And Rachel looks pretty dang good in red if I do say so myself.  I would be remised if I failed to mention the STL Redbirds #12in13?  And in Haiti that Digicel sign in bright red can often be a welcome sign when you need to charge up your phone.  But that’s about all that is positive about the color red in Haiti.

I learned during my first trip down here that wearing red is a fashion faux pas.  It’s not like the people I’m working with have a very expansive wardrobe, but the color red is intentionally avoided (unless you’re Digicel).  If you wear red then you are telling other people that you are in mourning.  You are saying that within the past year you lost a member of your family.  Needless to say, an NGO can experience a big problem if they try and dress their employees in the wrong color.  So whenever I see red I see it in a different light now.  As a medical person, I often wonder what the past medical history of the decedent was.  I wonder if they were a victim of the social adversities that plague this country.  I wonder if there were treatments or medicines that would have gave them a second chance at life.  I wonder if the family attributes death to Earthly causes or if they assume it was a voodoo curse.  Basically I think too much.  But at this point you almost have to because this culture has made a point to make the color red something sacred.  In the U.S. you wear black to a funeral for fear of having color display something other than a somber mood.  Even though we should be celebrating their life and praying for their life eternal we choose to don black clothes and walk in silence to pay our final respects.  And after that, you may carry the grief of death in your heart and mind, but we don’t announce our grief for the rest of the world to see.  Some keep it bottled up deep down inside so that it never crops up again.  Such a stark difference.

#ChangingGears During a teaching lesson shortly after the big clinic had arrived I had the unfortunate opportunity to talk about a little girl with reddish hair.  Now, I didn’t perform any epidemiological studies or genetic testing, but I don’t think that there has been too much Irish DNA injected into the gene pool down here.  The red hair you see is often brittle and more coarse than normal.  It’s a sign of disease.  I take a peak in the little girl’s mouth and it too is a fire engine red.  The tongue almost appears irritated.  The gums weepy.  The corners of the mouth cracking.  Red dominated above her shoulders.

I grabbed a MUAC tape and wrapped it around her arm.  She was a tad older than 6, so technically it was no longer sensitive or specific for malnutrition, but it was important to do for the sake of teaching.  The mid-upper arm circumference is the best measurement for detecting malnutrition in kids and pregnant ladies.  It’s quick, cheap, and easy #TheseAreAFewOfMyFavoriteThings.  And it has solid sensitivity and specificity for a screening tool. 

She was at the bottom of the green.  According to the color lesson, she was not malnourished, but per her exam she was suffering.  Her age might indicate that she is malnourished as her arm should be expected to be larger than a younger child’s.  A few times we have had kids who measured in the red zone of the MUAC.  Not near as exciting as when your favorite team enters the red zone.  But certainly a million more times significant. 

Fortunately for us working in Haiti there is an awesome resource located in the mountains near Casale.  The hospital turns no one away and they even have inpatient treatment available for children suffering from severe malnutrition.  They are pretty rockin and have been extremely helpful during my time here.  I have complete confidence that they will do everything possible when presented with a child who is malnourished.  I know I've mentioned them in previous posts, but @RealHopeForHaiti (http://www.realhopeforhaiti.org/) do some amazing things.  When they get a kid that's in the red zone, they don't fumble.

3000

I think I overestimated my strength.  I basically challenged a two ton beast to a game of tug of war this evening #MoreThanICouldChew.

Mission Matana has a cow (bèf) named Bella and she is preggers.  Throughout the day, Bella just hangs out in the yard and eats grass.  She has a twenty-five foot rope tied around her head that is “secured” to around the stems of about six weeds.  I would wager a guess that she can go about anywhere she wants and no one could really stop her.  In the evenings, it is Guirlene’s job to guide Bella down to the canal so she can get water.  I honestly don’t know how often this happens, but it just so happens that this evening Guirlene asked me to help her.  I’ve never really guided a cow before, but she only has one functional arm #BeenThere so she could use a hand #BadPun.

I’m not a cowboy.  My jeans are breathable.  My back pockets do not contain skoal can rings.  I own only one flannel shirt and no ten gallon hats.  I’ve ridden a horse, but never on a cattle drive #ButThatWouldBeAwesome.  And I’ve let a “Yall” slip every now and again, but that’s probably the extent of my behavior that could be considered remotely close to that of a cowboy.  Basically, what I’m trying to say was that I was making this up as I went.  I had my rope.  We had a cow.  And she needed to fetch some water to drink.  I started pulling.

I yank and she starts ambling through the yard, slowly.  She tops every now and then to nibble on some of the vegetation and I get out in front showing her where we’re going.  It’s a little intimidating to stand a few feet in front of a cow with a set of horns trained at your lower back.  So much so that I instantly change my mind and step to the side to let her go out front.  And then something clicked.

I’m not sure what it was.  Whether it was a landmark in the yard.  Maybe she realized that she had just crossed the threshold of her previous confinement.  But Bella knew that she was no longer tied down.  And Bella started running.  I gave a firm tug on the rope to try and keep her under control.  She slowed, but immediately picked up her gait.  Guirlene starts yelling, “Lashe!  Lashe!”  And, suffice it to say, my Creole lessons never involved cattle driving vocabulary.  Hmmm, ‘lashe’?  Wonder what that means.  I definitely don’t want to lose the cow because I’m sure that would be a big ordeal.  Maybe I’m supposed to use the rope in some sort of whip fashion?  Like ‘lash’ with the rope?  I’m being pulled by the taught rope connected to the 3000 pound beast, but try to send a wave through anyway.  It has no effect.  I’m now in a cross between a controlled fall and a run behind Bella.  I wrap my hands in the rope.  I take a quick hop, set my feet and give a sharp pull of the rope.  Her head careens left and she stumbles, but regains her pace almost immediately.  “Lashe!  Lashe!”  I hear behind me.  I try again to whip Bella, failing miserably to do anything but lose my balance.  I hop.  Plant my feet.  And pull.  She doesn’t even notice.

I resolve that I need to just run with her at this point.  I clearly can’t slow her down right now, but maybe there will be an opportunity for me to regain control.  We tear off through the field with Bella leading the way.  If I was a running back in the NFL and she was my lead blocker, we would destroy all of the records #BeastMode.  We cross over the back alley to the nearby house and then find ourselves in weeds again.  Would’ve been nice to apply some bug spray before this little adventure.  And then I see it.  The canal is up ahead about thirty feet.  It’s make or break time.  She’s full speed and heading straight for it.  And just when my visions of her falling into the canal and breaking her legs get painfully graphic, she stops.  Takes a couple slow steps.  And drops her head into the canal.  That wasn’t so hard. 

I anxiously stand beside her waiting for Guirlene to make her way down the path.  My heart rate is still up from being drug through the field.  Guirlene steps through the weeds and has a big grin on her face.  “Lashe” she says.   “M pa konnen, lashe.”  I hand her the rope insinuating that I want her to show me what I was supposed to do.  How was I supposed to send a ‘lash’ through the rope and into Bella in order to control her?  What direction did I need to direct the yanks on the rope to get her to slow down?  She’s laughing.  “Lashe” she says once again.  And throws the rope on the ground.

The trip back was much smoother #QuickLearner.

Coliforms

I’ve put my translator, John, through a lot of shit during our time together.  Anyone who has read my previous posts probably detects that I’ve lost my patience with him and definitely said things that I shouldn’t have.  I’ve been bossy, in a bad way.  I’ve been motivational in a good way.  I’ve been rude.  And I’ve tried to always end our days on a good note.  That would prove to be more difficult on this occasion.

For those of you who haven’t been keeping up with other CHI contributors, @ShaunHarty wrote about his time in Arcahaie working on the clean water project.  First he went around testing all the different water sources for coliforms #PoopBugs.  The tests were positive everywhere they shouldn’t be, including the water I was drinking at the compound for ten weeks #UnstoppableGITract.  It became clear that the people were going to be collecting contaminated water.  We can’t stop that without partnering with the government to create a water system seen in the US #NotUpOurAlley.  So we did what we could.  We partnered with the Gadyen Dlo project to borrow their design and infrastructure to help out the local community.  Long story short, they distributed a crazy amount of buckets and helped set up this entire chlorine distribution market.  Community Health Initiative added four new Haitian employees and we are fairly confident that nearly 500 houses have clean water security that they did not have before #Ballin. 

I was in Arcahaie during the dry season earlier this year, so people didn’t really complain of diarrheal illnesses – although 20% of the houses surveyed reported recent diarrheal illness.  But, in speaking with them they offered insight into their struggles with clean water security during the rainy season.  They recognized that cholera, other diarrhea etiologies, and even malaria were much more common during the rainy season.  I could never get any person to specifically say it was because there was more fecal contamination of the drinking water, just that the water was “dirty.”  Looking at the river I would agree.  It almost looks like a dirt road. 

Although the water project is pretty much awesome the impact is limited if other issues are not addressed.  One of these is appropriate waste disposal.  Another CHIer, Mike Barthmann, has been working with Top Digue on some latrine.  He’s contacted a number of other NGOs that specialize in latrine design and implementation #PoopSpecialists.  Community meetings were called and small groups were encouraged to voice their opinion. 

And then my job was given to me.  My primary goal was to survey the local area about their water useage, latrine situation and a potential engineering project to connect them to other roads leading to markets.  Beyond this, Mike was pumped to check out one of the old latrines to see if they actually worked and broke down poop into compost.  And then Sandy struck.

Plans change in Haiti.  I already discussed this point in the Yellow Spotted Plague post.  So Mike was forced to cut his workweek short due to the weather and leave some work for me to complete.  So I donned my #FrogToggs rain jacket and headed over to Top Digue with Steve.  The hurricane rains were dying down, so this seemed like a perfect time to dig out a 3 year old latrine #PetrifiedPoop.  My dad always talks about being an archaeologist.  Perhaps I should tell him this is the training ground.

I don latex gloves, a surgical gown and a disposable mask and begin pulling rocks off of the latrine.  Steve helps and we carefully avoid the broken glass.  “Just one to two feet” of rocks cover the former hold of the latrine.  The process is slow going and my terrible back picked now as the perfect time to remind me of how badly it hates me.  Minutes pass and a young lady shows up with a borrowed shovel.  It is one of the same young ladies that cooked diri avek sauce pwa for me last time I was here.  We begin shoveling.  Every now and then one of us bends down to take a sniff to determine if we’ve struck brown gold yet or not.  A few Haitians take a turn with the shovel, but needless to say our effort and willingness to get face first into a shitter earned the blan some respect. 

The deeper we go the more we expect to see positive signs for life: worms, bugs, root systems, etc.  We don’t like to see non-degradable material like plastic, foil, clothes, tins, etc.  Compost latrines function by combining carbon-based material such as yard waste with fecal matter and allowing it to digest into combined sludgy dirt than can then be used as compost.  The compost is rich in most vitamins and minerals and studies have shown that unlike American fertilizer this product will actually leave the soil better than before.

We found two unmatched sandals, food wrappers, old clothes, and a mandible.  When I stumbled upon the teeth with the shovel the crowd of people got awful excited.  I had no idea what was being said, but I can only imagine it was some form of conjecture about the species of beast the bone and teeth came from.  My bet was on goat, which is a shame because usually they cook the entire head in their stew #Wasteful #NotSoTasty.

We shovel even deeper.  I’m about waste deep in the pooper at this point.  The rain has stopped and the sun is turning my scrub gown into a bright blue oven.  Sweat pours down my face as I take my turn with the shovel.  Just trying to earn the street cred I so desperately need for my own personal gratification.  I keep waiting to see something that will tell me definitively that the composting latrine was a success or a failure, but then I realized that the only “sign” we could possibly “see” is a layer of preserved human feces.  My stomach lurches.  Four years of medical school and I’m digging for poop #WhatADeal. 

I’m about waste deep.  Another local brings a long, metal rod filed on one end to produce a point.  John starts to break up some of the dirt so I can shovel it out of the hole and with one quick toss the pole drives two foot into the earth.  That seems like we just reached our make or break point.  I look at Steve to see if he registered the same thought.  Obviously he was light-years ahead of me.  “If there’s just soil on the pole I think it’s safe to say that the cold compost system worked.”  I pretended like I knew the difference between cold compost and hot compost and did what had to be done.  I pulled the pole out of the dirt, bent down, and took a big whiff of the brown material on the end of it.  No smell #ThankGod.  The peanut gallery was sent into giggling fits seeing me smell what they assumed would be a bunch of poop.  But we did not have poop.  We had soil.  This soil would probably create a welcoming environment for any plant that they decided to plant in it, as is our plan.  Hopefully our latrines won’t be twenty feet down and covered with three feet of rock.  We’ve got a long way to go yet before we start building, but we’re moving down the #CHIt road.

Fracture

The river was rushing mightily from the mountains.  Four straight days of heavy rain have taken a normally shallow stream and turned it into a weapon of destruction.  Banks being beaten mercilessly.  Plants and trees slowly remitting to their harsh undoing.  The brown river did not discriminate with its wrath. 

During my time here in the spring I was told of a yearly flood that ripped through the town of Repo and the lower levels of Delice.  This could very well be the 2012 version as the river seemed like it would continue to rise until I was crying out for Noah.  Little did I know that the river had bigger targets on its mind than the meager “kay” that inhabited the low-lying flood plains.

We arrived to Haiti on a typical Sunday morning.  A relatively uncomplicated trip that gave us about 3 hours’ use of a La Quinta hotel room #ThreeHourTour and then sweating through customs with four bags of medical equipment.  We were picked up and taken to Arcahaie with ease.  Others were not so lucky.  Dr. Angie and her husband arrived to Port-au-Prince two days later in the afternoon.  The hours passed with no notice from them or Peter, the driver that was to pick them up.  Rachel and I waited and finally they rolled in at nearly midnight.  “The bridge was out” and they had to take a detour.  The entire traffic system was thrown out of whack.  Buses and tap taps without clear routes.  The poorly designed back road now carried the traffic of the main highway.  Needless to say, traffic was not moving.  The story I received from Angie and Steve was that in their second hour of sitting in the detour traffic jam that a set of motos came cruising along the side of the road.  They had to ditch their luggage, but were able to finally get back to the compound.

I visited the bridge, just a short walk from our compound, and saw for myself why it was closed.  An entire section of the support was lying in the river.  However, you could still walk across it and they were letting motos drive across it.  Tap taps waited on either side of the bridge ready to take passengers to their destination.   But you can’t leave a lame gazelle in the path of a lion and expect it to still be there in the morning.

The days were as dark as the nights and the rain continued its assault.   Guirlene, Rachel and I had just returned from visiting a patient and were trying to settle in to ride out the storm.  There isn’t much else you can do in the midst of a hurricane aside from seek shelter and read under your headlamp, but Guirlene was determined to finish her daily duties for the missio.  And then it happened.  She was hustling quickly from building to building wearing her loose flip flops and hopping over puddles collecting on the rain-soaked tile.  Her footing was bound to fail.  Dr. Angie and Guirlene shuffle into the downstairs bedroom supporting Guirlene’s right arm.  She had a FOOSH.  We doped her up with the few narcotic pain medications that we had saved and braced her arm. 

The rain did not slow down to celebrate its new victim.  It had loftier goals in mind and Guirlene’s wrist was a small piece of collateral damage.  The river gushed over the dam towards the sea.  Nobody was on the road when the bridge started to shake.  The rushing water beneath obscured the sound of the bridge’s impending death, but the supports were failing.  It was a rapid demise.  A large chunk of the center of the bridge suddenly wasn’t there as it was gobbled up by the rapids below.  The northwest was now completely separated from Port-au-Prince.  

Yellow-Spotted Plague

There were no systemic symptoms, but the patient complained of a rapid-onset, non-pruritic rash for the past two days.  Rashes are common in Haiti.  Generally speaking, hygiene is not a priority although cleanliness is valued.  Houses are small while families are large.  Contagious rashes spread through families quicker than rumors through a junior high school cheer-leading squad #FastLikeUsain.  So, in just hearing this complaint of a rash, regardless of how it was described, infectious etiologies were at the top of my differential. 

On exam the lesions ranged from 1 mm to 1 cm plaques, or slightly elevated above the skin.  They were not erythematous, but the lesions clearly had a yellow color to them.  They were well demarcated and the patient reported that they were not tender to palpation.  The lesions involved the upper extremities, abdomen, chest, shoulders, back and face.  Mucous membranes were not involved.  The patient denied fever/chills, weight loss, nausea/vomiting, diarrhea/constipation, headache, upper-respiratory infection symptoms, and urinary tract infection symptoms.

The patient was me and I knew very clearly the etiology of my skin “lesions”.  They were drops of yellow paint from helping out with the finishing touches on the new guest rooms.  Yes, I came all the way down to Haiti to help paint.  Yes, I’ve gone through four years of medical school so I can come to Haiti and help paint.  #Overqualified?  To be fair though, my painting skills were pretty bad #Underqualified. But that doesn’t matter in Haiti.  The workers around the Matana compound are pumped to see a ‘blan’ working after hours to help them out with painting. 

Dr. Chris mentioned to me before my last trip that you can arrive down in Haiti with all these big plans, bright ideas, and will to “help” only to find out that instead of needing a clinic doctor they could really use a motivated and dedicated worker.  The example that you can set by working hard and not complaining can do wonders by providing a role model for the other workers.  During our lessons with the new health agents today they were discussing “pwoblèms” the community faced.  Number four on their list, “Having to work too hard.”  Talk about cultural differences.  

My list of projects when I came down here included: looking into water and waste disposal for a nearby community, using the microscope to study disease etiology, and investigating a possible bridge site.  What I’ve found so far is that the community is already committed to getting a pump installed, we have no microscope, and an engineer is coming in a couple weeks to investigate the bridge location.  So now I’m a painter and I found a half-constructed church that needs completed. I see patients every morning and then go about finding ways to stay busy all day long.  Today that was entirely clinic based.  Tomorrow it’ll likely be setting up for a larger clinic and buying some supplies.  But even that might change.  Frustrating?  Perhaps, but that’s also one of the joys in coming down here.  If you keep an open mind you can open your heart to more people and truly connect with them.  It may not always be a glamorous operation, but are we working in Haiti to tell stories or to help out?  

Relapse

It has been approximately 204 days since I left Haiti earlier this year.  I wrote of Haiti-itis previously, but I didn’t anticipate myself going through any withdrawal in the near future.  I was burnt out.  The physical and emotional toll of the last three weeks got to me and I wasn’t sure when I would muster up the energy to return.  Bedica, CHI’s little angel, made it to the U.S.  What more did I need for closure at this point?  I had pages of pages and data to analyze and, like I mentioned, I was burnt out.  Dr. Chris asked me to help lead a team to the area where I had spent my weeks in, to the mountain clinic that I found and contacted, to reconnect with the people whom I had come to know.  I declined.  I wasn’t ready.  And there hasn’t been a day since that I don’t regret not going with that team.  Bedica passed away three days after the left and I have been dealing with guilt and emptiness since.  At this point I never wanted to go back.

I certainly went through some dark moments after I received the news.  I penned a blog post that forced an immediate phone call from my parents who urged me to take it down.  I distracted myself with studying for my Step exam.  Interests were no longer interesting.  Fun was no longer fun.  But then I got back into medicine and my world slowly started coming back together.  Tough decisions were about to be made regarding my future so I had to have a clear head.  As I applied to residency I leaned on my interest in international health and my Haiti experience for my applications, but I still had no desire to go back.  However, that’s exactly what I started planning with Rachel Bender as she looked for an international experience to sneak in after SICU and before interviews.

Before I could second-guess myself flights were booked and projects were designed, and redesigned, and redesigned…  As the date got closer though I couldn’t help but think about running away - canceling my flight and staying true to my resolve not to return.  It sucks.  I’m not ready for it.  For someone like me who absolutely loathes emotions, especially crappy ones, why would I voluntarily subject myself to returning to Arcahaie?  I don’t know.  But I’m here.

The ride from Port au Prince was just as familiar as it was during my last days in the spring.  However, this time I had managed to arrange a comfortable ride in the backseat of an SUV instead of a cramped truck.  It certainly cost a lot more.  St. Medard hasn’t changed much, if at all.  The windy, gravel road up to Mission Matana appeared slightly more developed.  Maybe some houses that were mere shanties with tin-roofs were more substantial.  The landscape was definitely greener.  But familiar faces were everywhere.  Even kids that seem to number in the thousands around here had faces that I honestly thought I could place from my previous trip.  They were probably wearing the same clothes, so that helps.

After Rachel and I settled in at the mission I offered to show her around the communities a little.  It had been a while since I had been identified for being a ‘blan’.  We cut through the houses and followed the canal to the back road.  A path that was painfully familiar.  I directed us north to avoid the past and address the future.  The dam was finished, I think.  The water was flowing well and some kids were enjoying the well-fed canal system.  Standing on the top of the dam I pictured a bridge connecting the river banks.  “Doable” I say to myself.  We continue up the hill towards Top Digue, CHI’s newest community.  I take us straight to Nola’s house, one of our health agents and a certified nurse midwife.  In a word #Badass.  I knew Rachel was pumped to meet her and I honestly think that she is going to do some great things if we provide her with the assistance she needs.  She’s very bright, has natural leadership skills, and community support #TripleThreat.  Our conversation is as extensive as my creole allows.  So it lasted two minutes of which half of the time was spent in awkward silence #StoryOfMyLife.  Doesn’t matter.  She got the message to come to clinic tomorrow so we’ll call it a win.

I was ready to turn around and head back when a young girl started talking to us.  It was just the usual pleasantries at first, but then she started gesturing around her head and saying words I didn’t know (there are many words that I don’t know).  And then she motioned for us to follow her.  Okie dokie.  We continued down the path and then slipped through a gate into a small, dirt yard.  I about fell over.  Sitting on the ground, naked as the day she was born, was our little girl with hydrocephalus.  Her mother screamed, ran over to me, and gave me a great big hug.  I don’t really know why.  I bent down and picked up little Charles Norline.  She was a giggly as ever.  We stayed there for probably twenty minutes, taking family photos and, most importantly, smiling.  And while it was a reminder of the baby smile I wouldn’t be seeing this trip, the sound of her voice brought back that feeling that me being here is a positive thing.

I’m not ready to walk down the back road, but I may finally be ready to be here.

Atresia: 5-17-12

A letter to my dear Bedica:

Dear Bedica,

The thought of writing this letter makes my computer screen blurry.  There is a fog completely clouding my brain and the tears are worse than any downpour God could have the clouds muster.  I am heartbroken, for you will never be able to read this.  And not because it's in English, but because you are no longer with us.

My fingers tremble with every keystroke.

You were our own.  Family.  My daughter.  My sister.  Whatever you were, you were in my heart.  And with all of our time together and the frequency with which you pooped on me I have to imagine I was in yours as well.  I spent the majority of your life with you.  When your mother showed me your problem you were a patient.  Another medical condition.  #2mofWithAnalAtresia&SevereMalnoutrition But after weeks, then months, of caring for you, you were no longer my patient.





Bedic, you were going to be beautiful.  Even at the ripe age of 6 months I knew it.  Course, some of my friends would joke that you fall into my key demographic @MattWatts @DougSorenson @NicoTurla #Room201.  You were showing life and energy during our play dates.  Eye contact.  Head support.  And a hell of a social smile.  Forevermore limited to pictures.  I think that's what is the worst part.  You never smiled when you were in Haiti.  Evidence of how sick and malnourished you were I'm sure.  But a month of donated breast milk - and like five pounds - later, no one could stop you from showing off your gums.  Your skin was so much better.  Your gorgeous poof of hair was no longer brittle.

You were healthy.  You were going to grow big and strong.  Blow past your developmental milestones.  Pincer grasp?  Nailed it.  Stack nine blocks?  At two years and 9 months, easy.  Bilingual from your coos on.  Agente Santi before high school.  And you were definitely going to go to school.  CHI would have made sure of it.  I would have made sure of it.  College?  In the states, of course.  I would have strongly lobbied for my alma mater @UIllinois, but I would have been open to suggestion.

Imagine the possibilities of your collegiate education.  Medical emphasis would be too easy for you.  That's almost cliched.  But at the same time you would be an amazing patient advocate.  Art would be sweet.  Your masterpieces would've lifted the spirits of every man, woman and child in La Digue.  Or literature.  You would've written some badass novels I'm sure.  Engineering?  I know a guy that could've helped you get %50 in general engineering classes.  He builds bridges now.  Maybe you two could've designed a nifty zip line system to help us get back into the mountains easier #NoMoreFiveHourHikes.  Education?  Knowing you, you would've been an educator in everything that you did.  I could do this forever.  #ImagineThePossibilities  #Limitless  (By the way, the #, or "hashtag" is something that I don't really understand either, Bedic, but I like it as kinda a subject signpost.  You would've loved it once you set up your twitter account @TheRealBedica)

Instead of the above, you passed on to heaven.  I can only imagine that if it were possible for people to become angels that you would be one.  You're too damn adorable for God to pass up giving you wings and a halo.  But I'm not sure if that's how things work.  I will know soon enough. Until then I can only pray that you will be taken care of.  I can take solace in the fact that you will know no further pain or discomfort.  Whatever ailed you these last few days can no longer bother you.

It came as a surprise to me.  I was excited and anxious about your return to Haiti.  And obviously we could not keep you here indefinitely.  Your mom missed you.  Your dad missed you.  Both of our governments tend to frown upon Americans taking Haitian babies and keeping them without going through the proper channels.  I have been plotting out my own return to Haiti whenever the realization that you wouldn't be staying in Iowa City dawned on me.  Weekend trip to check on my girl?  No problem.  Heck, another month of work for CHI would go so quickly if every morning I got to walk to your place and hold you for a bit.  Maybe we could avoid the pooping on my part.

I was thinking this October.  You would've been so big by then.  Almost a year old.  Maybe not big enough to walk yet, but I definitely could've taught you how to give knucks.  I would've spoiled you.  Solange's amazing fresh fruit juices every morning for breakfast.  Mashed mango nightly under the stars.  It was supposed to be a movie worthy story.  But instead it's a heartbreak.

You suffered the fate that a majority of your peers succumb to.  My surveys confirmed the common thought that diarrheal illnesses wreak havoc on kiddos with your particular vulnerabilities. And I don't mean your past medical history.  I mean the fact that you're in rural Haiti with no money, a poorly educated family, poor access to treated water, doctors trained in substandard conditions are far away, cannot receive routine blood tests due to monetary concerns, and I can just go on and on and on.  The more I list the more anger becomes my prominent emotion.  You would've learned this eventually, but I hate emotion.  However, anger is just one of the many emotions one is supposed to experience during the stages of grief.  Thank God I don't really care about psych cause I don't know the others.  Guess I'll figure them out.

This sucks.  Death sucks.  #Devastated  You didn't get the chance to learn about my past, but I'm not naive to having unexpected passing of loved ones.  It hurts, every time.  And no offense to my grandma or Adam, but this one seems particularly painful.  Have you met either of them yet?  Don't think they speak Creole, and if they do don't believe any of the stories they try and tell you about me.  Definitely not true.

I can't seem to bring myself to finishing this letter.  It's awful.  I know I'm prone to rambling, but this is pretty impressive #FlightOfIdeas #RumDoesThat.  I guess once I click send/submit/publish it's over.  For good.  Our story comes to an end.  You touched my heart, Bedica.  No doubt about it.  You've also made me realize how incredibly selfish I am.  I want you here, back in the U.S.  I want you safe in your SIDS proof crib and wearing that pink, Hawkeye onesie I bought you.  Curled up with one of the twenty blankets that all those awesome people aware of your story gave us.  I want to be able to hold you again.  Play patty-cake.  Support your head while you take a bottle.  Hell, I wouldn't even complain if you pooped on me.  But that is not how this story ends.  I love you Bedica and will always dream about what you were destined to accomplish.


Sincerely,
Dr. Matt

Atresia: Starfish

The surgery is over.  For those who haven't been kept updated on the story of Bedica and her condition, I apologize.  Shortly after I departed - empty handed - Dr. Ginny Ryan from the University of Iowa was able to fly down to Haiti, meet for my scheduled appointment at the U.S. Embassy, and navigate a few last minute bureaucratic obstacles before carrying Bedica onto a flight bound for the U.S.  Talk about a welcome home reception.  Well, there wasn't really a big one to my knowledge.  The flight was rescheduled twice because of the delays Dr. Ryan ran into #SoundsFamiliar.  And then she had to be in the operating room the next morning #DidIMentionShesPregnant #NotSoFamiliar.

The timing could not have been better for even before I left Bedica's health was deteriorating.  It wasn't until a trained Obstetrician saw her, saw Bedica feed, and subsequently tried to have Bedica's mom pump breast milk that we realized that Bedica probably wasn't getting all the nutrients she needed.  She was slowly developing a rash on her cheeks and glossitis of the tongue, both known signs of nutrient deficiency.  Her energy was poor.  So Dr. Ryan and her husband, whom I might have mentioned a time or two, Dr. Buresh took Bedica into their home already bustling with three children.

Bedica had her first consultation with one of the University of Iowa pediatric surgeons the next day.  Dr. Pitcher looked her over with confidence that we could save this girl's life.  His only concern was her nutritional status.  Patients that start malnourished usually do not fare well on the operating table or in the healing process.  So her surgery was postponed until we could show some weight gain.  And gain weight she did.

Ginny and Chris have some wonderful neighbors.  Their refrigerator was full of donated breast milk from the local breast milk bank as well as from women in the neighborhood.  Once they found the bottle mouthpiece that Bedica had the greatest success with, she started putting down the calories by the gulp #GoodEater.  Yours truly even got to spend a couple days with her, feed her, and even change her diaper.  I can't imagine a more awesome feeling.




Her energy improved.  Her milestones became more obvious.  Her skin cleared up.  And, most importantly, her weight increased #NotQuiteAnIowaUnit.

Her surgery came and went.  She spent the night prior in the hospital.  I can only imagine that she was the talk of the pediatric floor.  The next morning Dr. Pitcher performed the operation without complication.  She went home to Chris and Ginny's house later in the day, with a new butthole.  And it works.  She showed off as Dr. Buresh and I were giving her a bath a few days later.  I know doctors, especially surgeons, get excited when discussing bowel habits, but this is on a whole different level.

Bedica is continuing to rehab with her new, temporary family.  Even though her surgery is completed, she still has sutures in and needs daily dilatation to ensure that her new anus does not seal again.  Once she is fully recuperated, we will fly her back so she can be with her family.  I think it goes without saying that her mom misses her dearly.

While the story is just beginning, it appears this chapter is complete.  Once Bedica arrived in the U.S., Dr. Kerchner sent me a very nice email reminding me of the boy walking along the beach tossing starfish stranded in the sand back into the ocean.  An old, jaded, cynical man walks up and asks the boy what he is doing.  "There are thousands of starfish stuck in the sand.  Do you really think you can make a difference by yourself?"  The boy calmly bent down, picked up a starfish at his feet and hurled it into the ocean.  "Made a difference to that one."  She and I share the belief that that is how we need to approach our jobs.

#Starfish #LivinThaDream

As time goes on I'm sure I will encounter more starfish.  Patients that need an advocate to lobby for their care are found in the United States as well as Haiti.  And sometimes that's the most important role for a physician.  Sometimes I have a hard time believing that we actually were able to get Bedica's starfish back into the reef.  I never would have thought it possible if you would have asked me while I was in Haiti.  And now we as a community can celebrate her life.  This story doesn't deserve attention because the people in it were "doing good."  The people in this story did the right thing, which was get their patient the care she needed.

Tremor

My body is shaking.  I hold my hands out and they show the slightest movement that remind me of those real dramatic scenes in Saving Private Ryan.  My whole body shivers.  My teeth clatter.  I'm cold.  It's the first time in about ten weeks that I am actually cold.  I'm finally home.  And this morning I'm in church.  A cold church, relatively.

I can't attribute my 'tremors' to the temperature.  It certainly was a factor, but just minutes before while we were 'passing the peace of Christ' my preacher asked if I would take a few moments and speak to the congregation about my experience.  How do you say no?  This is the church I grew up in.  The pews are (sorta) filled with the adults who have shaped my life - family, friends, neighbors, teachers, coaches, Sunday School teachers, and my pastor.  They have supported me with their prayers, with their voice, and some with their pocket books.  I am who I am today - for good or bad - because of the people I was asked to address.  I gotta let them get a look at their product.

I have no idea what I'm going to say.  I got back into the country nearly 48 hours earlier.  I arrived to my home less than 36 hours prior.  I had slept probably 8 hours split between each night and couple that with the 3-4 hours a night I was managing on my last two nights in Haiti and I could easily write a new post on insomnia.  I haven't even mentally debriefed.  I haven't reflected on my trip.  Hell, I haven't let go of Bedica yet.  But after the offering and before the children's sermon, I make my way to the podium.

My 'tremors' haven't abated.  Maybe it's an intention tremor.  They get worse when you try and perform an action.  These were definitely getting worse as I was ascending the pulpit.  I start. I ramble. I try and make a couple jokes. I offer thanks to everyone.  And I apologize for not knowing what else to say.  I apologize for my tremors.  And then I have to apologize for crying.  I'm not an emotional person.  I absolutely hate emotions.  But up there, I lost it.  It was frustrating.  Perhaps that was my reflection over my past two weeks working for Bedica.  Whatever it was I repeated my thanks and left the podium, straight out the sanctuary, and into the boys restroom by my old Sunday school rooms...


My hands were trembling.  It's my next to last day in Haiti and I got up early because I couldn't sleep.  I was excited.  Today was the day I was going to walk into the U.S. Embassy and secure Bedica's non-immigrant visa.  But right now I was trying to figure out why my hands were shaking as I was dipping my spoon in my oatmeal.  Am I having tremors?  Is there another earthquake?  Surely not.  Maybe it was just my excitement for the day.  Definitely was weird though.

Mike and I load up to head to Port-au-Prince.  We have to take him to the airport.  He's going home.  After a pair of exchanges we arrive near the tap tap station in PAP.  John is already on the phone with our driver trying to direct him to us.  It doesn't take long before we have a throng of Haitians surrounding us, waiting for us to give out whatever we must be giving out.  I get a phone call.  It's Dr. Buresh.  I pass off the child to Mike and step away from the crowd to talk.

"Are you guys okay?"  "Uh... yeah.  We're in PAP getting ready to take Mike to the airport."  "I got an email saying there was an earthquake this morning and just wanted to make sure you guys were okay."  Curious.  We knew it wasn't a huge earthquake, only a 4.6.  After reading subsequent reports it sounds like it was centered near Port-au-Prince and I had probably felt an aftershock.  Nobody was harmed.  But with the memory still fresh from the 7.0 magnitude quake of just over a year ago, people were reportedly running into the streets scared...


People were all around me.  I was in the backseat of a busted up Toyota being driven by a very knowledgeable driver with some sweet driving gloves.  The sidewalks were full.  Traffic was packed.  Bedica and her mom were sitting next to me.  I don't think they were aware that I had just failed to secure her visa.  She wasn't aware that everything that we had been working on was being put on hold.  I was.  It sucked.

But something else occupied the city.  As we headed back towards City Soleil the traffic got heavier and the foot-traffic even thicker.  Then the driver told us, "There are no buses at the bus station."  How do you know?  We're not anywhere near the bus station right now.  This is the last thing I wanted right now.  I just wanted to get home, to America.  And the first step to that was getting back to Arcahaie.

"The city is hot."  "John, that means nothing to me.  What is going on."  It was impossible to get a direct translation from him.  I think he often tries to sensor things so as not to scare me or give me a negative perception of Haiti.  Pretty annoying, but I understand why.  He finally opens up.  "They are shooting in City Soleil."  Awesome.  The same City Soleil that we were currently driving to the heart of.  The same City Soleil that the tap taps to Arcahaie usually drive through and park in.  The same City Soleil that the UN eventually gave up on trying to disarm because they were losing too many men.

It now became obvious why the traffic and people were behaving the way they were.  We were clearly going the wrong way.  An empty tap tap sped by us but then had to slam on its breaks as it came up to more traffic.  People flooded into the back of it, fighting and pushing their way on board.  Some hung on to the side of the vehicle.  They were doing anything they could to get away from the turbulence.  I was convinced.  Let's turn this car around.  I no longer feel like it is necessary to verify if the bus station is active or not.  If Haitians feel like it is important to leave in droves then it is probably the best idea for a white person.

We have the radio on some sort of public station.  People are yelling.  I have no idea what's being said.  We're speeding down the road past people running on the sidewalk.  John points out a sign of President Martelly that has been painted over his face.  The people have turned against him.  A report just came out that he might in fact be a dual citizen #GodForbid #Sarcasm.  The man shouting on the radio is one of the Senators.  John translates for me.  "I did not know that he was a dual citizen.  But, if the people want to remove him then they should remove him."  Very supportive.  Exactly what Haiti needs to heal.

We drive through the city.  Traffic thins out and the number of people on the sidewalk normalizes. The sun is setting.  The driver wants to take me by a market.  It's huge, and empty.  The large stone buildings are charred and there are charred remains of what was probably the usual wood tents that make up a majority of markets.  "Why was it burned down?"  "Someone wanted to make it look bad for President Martelly."

The city was hot, like John said.  The excitement had nothing to do with the small earthquake.  It was a reminder that this country has a long way to go before the word 'stability' can enter the conversation.  Even beyond the dual citizen scandal there is another one brewing that involves hundreds of millions of dollars in foreign aid being stolen by people in power.  Already one high-profile person was assassinated in the wake of this scandal.  We can only hope that it is the last and the truth comes to light quickly...


I'm back in the United States.  My tremors haven't recurred since church.  My mind is still pre-occupied with the Haiti that I left Friday morning.  The scandals.  The turmoil.  The patients.  It's not something that I will shake easily.  Although it seems to make me shake easily.  The time will come when I will make my return to Haiti.  I can't predict when and I can't predict what the circumstances will be.  But I know I need to take the time to properly reflect on this experience.  I'm happy to talk about my time even if it appears to make me sad.  Some stories end well, some end poorly, and some do not yet have a conclusion.  I guess that's what keeps us coming back for more.

Anal Atresia: Hope

Hope isn't a disease, nor a number as far as I know, but it's the best term to discuss the near-conclusion to our story.  I emerged from the Ministry of Immigration on Tuesday with Bedica's passport in hand (notice the name change from how I had previously - Begika -  spelled it as this will be important to our story).  My final posting or contact with the outside world was a photo I was able to upload to facebook showing her passport.  That would be the last instant that we had power inside the compound for quite some time.  No power.  No internet.  #AsPrimitiveAsCanBe #IsMerryAnnSingle?  The lack of power/internet I believe was ultimately my undoing.

The steps I needed to complete before securing the VISA were muddy to say the least.  I knew I should secure a better "letter" from a Haitian physician as the one I was currently rocking was a google.translate job that I bs'ed one day by writing in cursive.  It had certainly worked up until this point, but I wanted to be as legit as possible when approaching the embassy.  I also needed to fill out the online application for the VISA.  And not only did I have to fill out this 10 page application that asked such gems of questions as, "have you ever been involved in any attempts to engage in human trafficking?" and "Have you ever enlisted child soldiers?"  But I also had to have the mom physically click the submit button.  No idea why.  And I have no idea how they expect anyone from Haiti to jump through these hoops.  The questions are absurd and not contextually appropriate.  What is her address?  Let me think, the stick and tin lean-to off the road leading from Carrefou Poy?  The only number is the one spray-painted by the post-earthquake inspection team that gave it the okay.

Okay, I'm venting.  But it is kind of a ridiculous questionnaire.  Again, I had to have the mom to click the submit button.  This is also impossible to do without power.  And for those of you wondering why I hadn't worked on this earlier it's because the second page of questions request the passport number. So, handcuffed until last Tuesday.  And then powerless.

The last things I needed were various documents from the U.S. including a letter from the medical team that would take care of her, notes from the host family stating that they will provide for her, and then some sort of confirmation from CHI that we wouldn't be expecting Haiti to pay for anything or using tax dollars.  Dr. Buresh had sent me most of this stuff the previous week.  For those of you waiting for the foreshadowing to come back, this is the time.  The previous week when we had all been operating under the understanding that the little girl's name was "Begika Emilise."  That's how my interpreter had spelled it to me during the first interview.  The parents had nodded when I showed it to them.  But when I finally took the time to look at the birth certificate and then the passport, to the people of Haiti her name was not "Begika" but "Bedica".


I was torn.  My phone batter was nearly dead.  It had few minutes.  I had no internet.  Do I find a way to get in touch with Dr. Buresh to get him to change the papers?  Or do I use the remaining charge on my computer to see if I can change the baby's name?  I opted for the latter.  You'd be surprised what you can do with a screen "snipping tool", Paint, and Microsoft Word.  After about an hour I had some fresh new documents with the baby's correct name and legit looking signatures and letterhead.  So that was settled, but I still had no way to print them and now my computer was about dead.

I cast that aside and took mama and baby to another clinic by my translator's house.  The local physician with whom we've established strong ties repeatedly rejected his ability to write a letter in support of our cause.  I do now know why.  He is a recent graduate of their medical school in Haiti, so perhaps he felt that he didn't have enough seniority.  It clearly states "A letter from a Haitian physician...".  It doesn't need to be the Grand Chief of Pediatric Butt Surgery.  But I certainly can't force the issue.

The other clinic is very nice.  Small, but appropriate.  John says they usually work from 6 am till 6 pm.  They had one physician there, a general medicine physician, but they also claimed to provide Ob/Gyn and Peds consultations.  Granted, there aren't residencies that I'm aware of in Haiti, so it's basically a person saying they specialized in a field.  The general med physician saw our patient.  He agreed with my assessment.  But once again I found a physician who did not want to write the letter.  I still can't understand why.  He punted to the clinic's "Medical Director" perhaps because he was an older, more respected physician.  Only problem, the medical director wasn't in yet.  We would have to return.

And we did.  We came back and sat down in the waiting room.  It was filled.  However, I think that most of the people were there because the tv was playing the Barcelona soccer game.  Cheers would erupt when Messi would score his goal and the doctors would come sprinting out of the exam rooms to catch the replay.  I guess I can say I'm no better as I was watching the Cardinals playoff games while I was doing ER shifts #12in12.

Finally he took us back.  He sat down behind his desk and asked what we needed.  I explained the situation.  "We need a letter from a Haitian doctor describing the baby's condition.  We need their declaration that she is healthy enough to travel to the U.S., but that she needs to rather urgently to get the surgery performed because it cannot be performed in Haiti."  The word "cannot" is used rather loosely.  The surgery can be performed.  Heck, I can "do" it.  But if you want the kid to have a good outcome, heck, if you want the child to survive, you need to take her to the U.S.  We tried Zanmi Lasante.  We tried the Italians or Spaniards that have the hospital in PAP.  We were told that the General Hospital was trying to achieve 100% mortality rates for this procedure.  So all of our local options were drying up quicker than a goat hide in the Arcahaie sun.  We needed a letter, and since I was leaving in two days, I needed it stat.

"Come back tomorrow so the pediatrician can see her."  "I DON'T NEED A LETTER FROM THE PEDIATRICIAN.  A FOUR-YEAR-OLD GIRL CAN MAKE THIS DIAGNOSIS."  I explained to him in a much more watered-down tone that he couldn't understand anyways.  The other doctor had already seen her.  All I need is a letter.  He discussed with the other physician...  "We'll get it to you first thing tomorrow morning."

FML.  So much of this journey has been spent walking away from an office at the end of the day with the 'promise' of having what I need be there "first thing tomorrow morning."  It hasn't been the case yet, and on Thursday (today) it would keep its hitting streak alive.  I had yet to find that single person who was a problem solver.  A person who would look at a pile of nails in their path, and instead of turning around (like I'm convinced most Haitians would) he/she would lay a tarp over it, or build a bridge, or make wooden shoes.  I don't know what, but they would do something.  Everyone seems very content to just sit back and let everything happen.

I went home.  Still no power.  Maybe there would be some tomorrow.  People were coming to fix the generator at some point #HaitiTime.  I was left with my thoughts.  At this point my thoughts are pretty sparse, so I fell asleep at approximately 9pm #GoodOrBad #BrainDrain.  Unfortunately, Mike was sick and probably could have used an IV.  Apparently I'm a bad roommate and slept through all of his cries for help #StillAlive  #BackInTheUs#BackInTheUS#BackInTheUSofA.

The next morning John was supposed to pick up the letter at the clinic and then grab the mama and baby on the way to the compound.  Both are on his way.  I call him at 8am.  It doesn't ring.  I call him at 9am.  No answer.  He calls back.  "I'm still waiting for them at the clinic."  So much for them working from 6am till 6pm.  He finally gets the paper and calls to ask what he should do.  "Like I said ten times before, bring the paper and the patient to the compound."  Why, you might ask.  Well, late in the morning the people finally came to work on the generator.  It fired up about 10am.  I went to work on the application.

Ten pages, at least.  I finished just before John arrived with the mama and baby.  "John, can you tell her to push the submit button?"  He stutters.  She doesn't move.  I take her hand, put it on the left mouse key and say, "Presse."  You better believe I bloggie'ed the crap out of that action.  I wasn't going to let them tell me she didn't submit the application.  I loaded everything onto my flash drive and we took off as quick as we could.  Mike said his goodbyes and came with since he was heading to the airport.

We left the compound at 1130.  Boarded a bus/tap tap at about 12 and stood waiting in City Soleil for about half an hour for my go-to driver to come pick us up.  Mike's flight was at 5, so he opted not to make the trip to the embassy.  We drop him off at the airport and the guys in red shirts pounce on his luggage.  We arrive at the embassy at around 2pm.  The sign says they operate until 3:30pm.  I know heading into this visit that I do not have an appointment, which you are supposed to take the time to schedule for a non-immigrant visa.  I did not have that luxury.  You are also supposed to print out the application confirmation.  I had it on my flash drive, but did not have available printing #NoKinkos.

I talk to the Haitians guarding the front and explain the situation.  She guides me back to the more formal security gate.  Fortunately the workers I talk to are bilingual as John had went with the driver to find food for everyone.  I carefully explain the situation and hand over the doctor's letter.  He reads it, and he clearly cannot understand it all, but it obviously strikes a cord with him.  He realizes the serious nature of the child's condition.  I mean, as soon as you hear that someone doesn't have a butthole, you probably freak out #WhatWouldYouDoWithNoButthole?  He starts making phone calls.  Dial tone.  Answering machine.  Endless ringing.  No voices.  He re-iterates that I'm supposed to schedule an appointment.  I re-iterate that I was only able to submit the application this morning and my flight leaves at 0930 tomorrow morning.  Again, he realizes my relatively desperate position.

The phones still go unanswered.  I decide to try my one and only trump card that I have access to, my hosts.  I call Mahalia who readily offers up a personal friend of hers that works in the Embassy.    The clock clicks past 2:30.  I walk to the other end of the building along the outside wall.  He meets me outside the gate.  We exchange pleasantries and then he starts up with, "You need to schedule an appointment."  #BeenThroughThis.  "I can't."  He says there is no way around this, you have to schedule the appointment and then email the lady to request an urgent meeting.  "You mean I can't call her?  I can't show up and try to speak with her face to face instead of dancing around the internet?"  Is it just me or is that kind of ridiculous?  That would be like going to the police station to file a complaint and them saying, "I'm sorry we only handle that business by phone."  WTF.  I'm trying to eliminate a few steps in the process here.  I only need enough of her time and energy as it takes to pick up a rubber stamp and place it down on this little girl's passport.  Or hell, if she's pissed off she can slam it like it's Wile E. Coyote's head under the mallet.  I don't care.  Just stamp the damn passport.

He couldn't help.  I thank him for his kindness of coming to see me and quickly brush past him.  I had limited time and I had to try something else #WhoYaGonnaCall.  Unfortunately there were no ghosts to be had nor do I have Bill Murray on speed dial #HowAwesomeWouldThatBe.  So I called the next best thing, my mom.  "Mom, are you by a computer?"  She's actually in a car dealership where they have a public computer #WhatADeal.  I have her log into my email and send a message to the PAP embassy.  Subject: Medical Visa Bedica Ermilus.  Content: Need appointment today. Medical emergency.  Signed -Me.  Dramatic?  I think not.  Then, she is able to find my submission confirmation and in the email are links to follow that eventually lead to a scheduling page.  I tell her to schedule one for the first available.  It's Monday, March 12th.  Whatever.  Get it on the books.  #ThanksLoveYaMommy.

I run back to the other entrance with the scheduling confirmation scribbled on my hand.  It's about 3:15 at this point.  Keep in mind that I walk when I talk, so I had actually crossed the street at one point, entered into a bank, got frisked and wanded by a security guard, contemplated bribing a bank teller to print off everything off my flash drive, but then walked out dejected before having even tried to speak Creole all in the midst of having my mom pull off the epic Toyota Showroom Scheduling Spectacular.

I rush past the first security guards praying I don't get tasered in the back.  I enter the main security doors and tell the very helpful guard that I have a appointment code now and have sent the lady an email.  He gets a look of absolute "Oh shit."  The person that you have to talk to...just left.

Foxtrot.  Uniform.  Charlie.  Kilo.  He tried.  To his credit, he tried.  Hell, he might've got himself in trouble by trying so hard.  And I certainly hope that wasn't the case.  From the look on his face he felt like a failure too.  I felt bad for him.  But I also felt bad for Bedica and Carole (the mom).  Not because this would have been the might success for them, that will come with the surgery, but I have been pushing and pulling them back and forth across Haiti for nearly two weeks and I fell one step short of securing the child's trip to the U.S.

It won't be difficult to complete the process.  It will just take somebody to bring the baby with them to the embassy with the paperwork that we have assembled and with a pre-arranged appointment (piece of excrement) to get the rubber stamp go-ahead.  Then the 'Blan' Knight can come down and whisk Bedica away to the land of germ theory and post-operative nursing care where she can safely have her surgery performed with expectations of a great outcome.  And honestly, I've had so much of this kid's shit on me that the surgeon better do a damn good job so that never has to happen to anybody else #BabyPoopIsNotTheNewAxeBodyFragrance.

I will leave Haiti tomorrow morning, bright and early.  A week ago I was nearly in tears with all the struggles I was facing in trying to power through this process #TearDuctsSurgicallyRemoved.  But now, I can leave with the comfort of knowing that I did what I could and she is way closer than Vegas odds-makers would have placed her.  I didn't know what my chances of success were when Chris told me to focus on this.  In rereading the emails we received from others who have been involved in Haiti, they said that they usually take 7-10 days to get everything lined up.  Some steps can take up to a couple months.  The quickest they've been able to do it is 5 days, but that was before many of the regulations were in place and it was a medical emergency.  I've used up the last two weeks of my trip trying to make this happen.  I've dealt with public transportation, a well-intentioned but under-equipped translator, extortion, bribery, a lost birth certificate, 2 hour lunch breaks, week-long karnival celebrations, work days ending at 1:30 pm, and my own frustrations and limitations and still managed to come to the front gates of the final goal.  My grail.  My El Dorado.  But unlike the explorers of the past, I have faith that my quest will come to fruition and Bedica will get her surgery.