Quatre-vingt six

Today is my grandmother's 86th birthday.  And by 86 I clearly mean 35 and holding.  Eighty-six years of magnificence.  She gave me all of my good looks, intelligence and humility.  I'm the most humble guy there is.  My grandmother scoffed at the national life expectancy for the United States, which was 80 for a female last time I checked - Haiti is a touch under 63.  She has a new knee and some arthritis in her hip, but otherwise is looking to eclipse the century mark.

And I tell you this not because I want to brag about my awesome grandma.  This is a blog about my experience in Haiti, so naturally I have to make some connection.  I've seen patients here that claim to be as old and older than my grandmother.  I've seen patients who claim to be twenty years her junior but look older than her.  The latter is far more common.  Yes, people don't always know when their birthday was.  The sense of time and calendars is more of a loose idea in Haiti.

But honestly, what do they really need calendars and clocks for?  As it stands, I'm sitting outside on my computer, it's 7 pm and the only light coming from anywhere but our generator is the reflection in the sky of Port-au-Prince, almost 50 km away (And I know all about that 50 km if you check out my post "48.6" #memories #sortof).  So what good is a clock when your day is completely governed by sunlight?  The unemployment rate is one of the highest in the western hemisphere, so days aren't scheduled around jobs.  Budgets are constructed on a day to day, or maybe weekly, basis.  The market is in town on Wednesdays and Saturdays, but very few events are scheduled on a month to month basis.  Heck, I don't need a calendar except it's a reminder of when I run out of time for my project.  I already forgot my malaria meds once, so I'm clearly not paying that great attention to days.  I don't have tv programs to keep me oriented, but neither do the Haitians.  I'm not gonna lie, it's not a bad way to live.  You just focus on the day at hand and appreciate the small things.

When it comes to appreciating things there is one patient that sticks out in my mind.  The gentleman was over 90.  He'd lived a hard life, and like my grandma had obliterated the national life expectancy for his native country, but still looked like he had another 10 years in the tank.  He came to our clinic for a couple reasons: chest pain and a hernia.  Naturally I'm more worried about the chest pain than a hernia as it can kill someone.  I ask the standard questions: Onset, Location, Duration, Character, Alleviating, Radiation, Timing, other Symptoms.  After all the translation I calculate an equivocal score in my mental tally for probability of cardiac etiology.  He's hypertensive.  Boom, let's just control his blood pressure (systolic was over 200 - not a record for my time in Haiti but certainly not healthy) and add on a baby aspirin.  Beyond that we'd probably be doing more harm than good.  #PrimumNonNocere.  Let's go look at that hernia.

It's massive.  And bilateral.  He's been rocking these things for years.  I don't think I need to go into detail as to why he's a bad surgical candidate.  Besides the fact that no surgeon wants to put an MI waiting to happen on their OR table, his hernia is enormous and still reducible.  The bigger the hernia the lower likelihood it has of causing major problems like incarceration.  I tell the guy all this information and he seems okay with by recommendation against a surgery.  But like any good physician should do, I ask about how it impacts his quality of life.  "Do you have any problems peeing?"  "No."  "Is it troublesome to walk and get around."  Obviously it is uncomfortable, and it causes pain on his inner thigh.  I'm not surprised.  "Can you still have sex?"  He cracks up.  I've never seen a man his age laugh the way he did when I asked him that question.  He was doubled over at the waist and stomping around.  "Yeah, we (he and his wife) can still have sex."  He says this in between smiles and giggles.  I would like to brag about taking the professional high road, but the room kinda devolved into a boys club, commending him on his sexual prowess and teasing him about the subject at the same time.  His happiness was too much for me to hold back.  If he had had teeth, they would've been shining.  His eyes sparkled, but that was probably due to the cataracts.  He got a kick out of me and my questions.  I got a kick out of his attitude.  #Refreshing.

It's important to have patients like these as a physician.  Being a doctor is a great job.  You have a role in people's lives that is very intimate and there is a great deal of responsibility and reward that accompany that. Sometimes medicine can destroy you.  Especially medical school.  I can't testify to much else beyond med school, but I have to think it's there too.  But occasionally you get a patient like this that totally refills your tank and you can practice medicine for months without burning out.  Go ahead, ask your doctor if they ever had patients like this and I will bet you they say yes.

We gave him a pack of hydrochlorothiazide and told him to come back to our clinic in a few weeks.  I haven't seen him yet.  I may never see him again, which would totally defeat the purpose of giving him blood pressure medication.  But I can hold on to his laugh and smile until I stop practicing medicine.  And I'll have to, because medicine is a grind - there are more bad days than good.  Thankfully, good days like this help you forget about all the bad ones.  #HealingPowerOfHappiness  #HappyBirthday #LoveYouGrandma

Fertility

In the United States we tend to worry about infertility, but the last two days opened my eyes to the problem of fertility in Haiti.  It started in morning clinic.  A woman reporting to be in her thirties, although she looked much older, was complaining of lower abdominal pain.  I do my due diligence and ask about her menstruation - LMP November.  "Is there any chance you could be pregnant?"  "No."  Trust but verify.  That's one of the biggest things I've learned in my time as a medical student.  So that's what I did.  Urine pregnancy tests are cheap enough such that nearly all women of child-bearing age end up getting one in U.S. emergency rooms.  There's just too many consequences for missing so basic.  

#Positive.  She had an infant with her, so I knew it wasn't her first.  Plus, maternity is what many Haitian women aspire for and she was nearing the end of her fertile years.  She had to have had at least one other child by now.  She had 9.  And she didn't want another.  I've never been in a situation where I've had to discuss abortion with an expecting mother, so I let Dr. Angie do it.  #ChickenedOut

She was committed to an abortion.  While I have yet to come across any previous instances where it was mentioned, from speaking with the patient it's an accepted and common act around Arcahaie.  She knew where to go.  She knew the process.  "You insert one pill into your vagina.  You swallow two pills with a beer.  And in one to two months your baby will come out.  Dead."  She called the pill 'Citrodex' (Cytotec is the brand name of misoprostol, so I'm assuming they are one in the same).  

Safe?  Of course not.  Even the patient knew women who had died during the process, probably due to hemorrhage.  But this was a risk she was willing to take.  She couldn't support 10 kids.  So I asked, "If there were a procedure that could prevent pregnancies forever, would you want that?"  "Yes."  She wanted it right now.

The story stuck with me, so naturally I added the question to my repertoire of extremely personal questions that I seem to get away with asking because I'm #1 white and #2 working under the guise of healthcare.  My next true test was during a survey the next day.  I was walking into a yard with my interpreter to check on one of my helpers when a woman started talking to us.  She wanted me to help her with 2 kids she said she couldn't support.  Money?  Food?  What?  No, she didn't want temporary measures.  She wanted me to keep them.  Back to the compound?  Sure.  Home?  She didn't care.  She couldn't support them.  

I thought about it.  How would the logistics look?  How feasible would it be to turn the Matana Mission into an orphanage?  Not very.  And anything beyond that would be borderline unethical and highly illegal.  They were adorable, and not the only children from that house that were offered to me or to some mysterious orphanage that they thought I had built.  Another woman had five and didn't want any more.  Four out of the five adult women said they would love to have a procedure that made it impossible to get pregnant again.  One said she wasn't done having children yet.  #Insight.  The women have it.  But existing methods of birth control are hard to come by in Arcahaie.  You can but a Depo shot every three months.  You can buy a pill to take daily.  You could try and find condoms.  But with budgets stretched thin most women can't reliably utilize any of these forms of contraception.  

#Ethics come to the forefront in this discussion.  And so does appearance.  What message would we be sending if we brought a bunch of white doctors to Haiti and began sterilizing everyone?  It would be a PR nightmare.  Giving out medication is an easy thing to justify and even if done inappropriately will garner a positive press.  But eliminating the ability of a population to reproduce, even if 'elective', is a tough sell.  

Personally, I see both angles.  The women I talked about in my story would likely benefit from the comfort of knowing they won't unexpectedly have another mouth to feed.  Budgets are tight.  Children are a huge investment, even in Haiti.  They eat.  They get sick.  They need to go to school.  All of those things cost money.  And my experience so far has shown that families end up trying to get a little bit of everything for all of their kids, which means they have food insecurity, poor healthcare follow-up, and attend school 3 days a week for 4 hours a day.  But at the same time, women in any culture may have buyer's remorse.  The number 1 predictor of regret with a tubal is a young age, according to U.S. data.  And all the women I talked to were young.  They weren't 37, nearing the end of their child-bearing years.  They were maybe 30, in their prime reproductive years, but with "too many" mouths to feed already.  

Like I said, other ventures are no-brainers.  "Let's treat this infection."  "Let's control their blood pressure and blood sugar."  "Let's repair this hernia."  "Let's cut out this woman's ectopic pregnancy."  "Let's build a school and staff it so more kids can get a reliable education."  "Let's organize a community garden to improve food security."  But when you're talking about tubal ligations or vasectomies, the water becomes as muddy as the canal water most people drink from.  Wonder what Paul Farmer, in all of his wisdom and insight, would have to say on such an issue?

Tuberculin

I feel like I could just copy and paste any of an assortment of excerpts from PF's books #TheyreAllTheSameStory.  But that's probably because this story is all too common in Haiti.  In conducting my investigative work around rural Arcahaie I came across a small house where a young woman sat by her kitchen fire.  She looked thin.  Skinny.  Emaciated.  Even one of the locals that I've employed to help me conduct these surveys pointed it out, "She looks sick."  He was right.  She did.  Her face was sunken beneath her high cheek bones.  Her neck could wear a cheerio as a necklace.  You could almost see the outlines of her scapula from the front.  Do you have the proper visual?  Beyond that she looked weary.  Sadness filled her eyes.  She was pleasant and very accommodating in answering my lengthy survey, but it wore her out.

I had to ask.  I'm not sure if it is offensive, but I find myself asking the questions that I've always found myself holding back.  Can't tell you how many times I've asked a woman with a little bit of a belly if she's pregnant.  That wouldn't be tolerated very well in the states, needless to say #SlapInTheFace.  I've talked about uncomfortable topics like abortion, sexual violence, crime, and even voodoo.  My interpreters aren't often keen on the idea, but they soldier through for me.  But this was tough.  And it was made tougher by the background image of a  6 year old dumping water over his 3 year old brother's soapy head.

She was diagnosed with TB in June, according to her friend and housemate.  I inquire if she had been diagnosed with HIV as well.  No.  Thankfully, but I wouldn't be convinced until I saw the lab work confirming negative serology.  Like I said, she just had that look.

She began treatment at the local Arcahaie Health Center.  For those that aren't aware, this hospital was built by Cuba for the Haitian people.  It is staffed by a number of Cuban doctors.  Like most doctors, they are overworked, understaffed, and underpaid.  My only encounter with them was inspiring.  I direct you to this article discussing the Cuban contributions to health systems the world over.  Granted politics are always an issue with Cuba, but you have to respect the work they do.

Unfortunately, the treatment for TB is a little expensive and this patient was unable to cover the costs.  She didn't return to see the doctor.  There is a sense of pride in the people I've met that makes things like medical costs something that would rather be avoided than negotiated.  She accepted that she could not afford much needed anti-tuberculosis treatment and never even attempted to follow up with the health center.

So now she sits, sleeps, and lives in the middle of a half-dozen houses.  Kids are running around, unaware of the deadly bacteria that are likely dancing in the air around them.  Her family lays down next to her every night.  They know of her diagnosis.  They also know she couldn't afford treatment, but that's the decision that had to be made.  Food had to be bought.  Water had to be treated.  Kids had to go to school.  And her lungs now harbor partially-treated tuberculosis, the leading infectious cause of mortality in women of child-bearing age.  She is on her way to becoming a statistic.

I certainly hope that I see this lady again.  I want to see her get the treatment that she "can't afford", we can't provide, and that she can't live without.  This is one of those cases where you want to see the good happen and the bad may crush you.  Time will tell.

Iatrogeny

Pretty sure I made the title up, but that hasn't stopped me yet.  Iatrogenic refers to an illness or condition that can be directly attributed to actions of medical personnel.  The easiest way to picture this is a surgery gone wrong.  For instance, a woman goes for a c-section and ends up with a hysterectomy because they couldn't stop the bleeding any other way.  Certainly an extreme case, but one that most definitely happens.  I bring this up mainly because I found out first hands that you shouldn't handle a bunch of pills and then touch your face.  You basically end up snorting or eating whatever powder residue sticks to your fingers.  I definitely ingested low levels of ciprofloxacin, aspirin, and even some calcium channel blockers.  "What did you give me?  My heart stopped racing and I can't pee."  To borrow a line from one of my favorite tv shows, Community (#sixseasonsandamovie).  Granted the medicines that I inadvertently ingested were at extremely low levels and never a real concern to my well being.  But it got me thinking about the topic, well my filthy hands and a patient this morning.

I was greeted in clinic by a very nice lady who came in complaining of pain in her leg and back.  Come to find out she had been hit by a moto, or fell off a moto #LostInTranslation, I don't really know.  And this occurred a few months ago.  She could walk.  I saw her walk in.  I looked at her knee and there were no bones sticking out.  Two for two on my ortho exam.  Naturally, I asked her if she saw a doctor when it happened.  "Yes."  Perfect.  Nothing for me to do probably.  "What'd he/she do for you?"  "He saw me and wrote me a prescription but I couldn't pay for it."  That certainly isn't uncommon around these parts from what I can gather.  They'll get a "prescription" but assume the costs for obtaining the medication far exceeds their means.  Sometimes that might be true.  Other times it isn't.  Regardless I ask some questions about the workup and diagnosis, which of course she doesn't know.  And then she jumps ship and starts talking about a rash.

The rash was "all over her body" and she couldn't stop scratching it.  She had some spots on her arms and legs.  I really couldn't convince myself that they were scabies, but I was trying to talk myself into it.  But she had nothing on her trunk or the distal aspect of her extremities even though she complained of pruritus over them.  After she had laid out the rash idea, then she started jumping back and forth with "acid" and a headache... Same old same old.  If you have it, it hurts.  Or at least that's what you tell the doctors in Haiti.

I was kinda stumped.  So I asked her if the spots on her legs were what itched.  "No.  Those have been there my whole life."  Hmmm.  Not helpful.  "Do you take any medicines?"  "No."  Okay.  I go back to examining her right knee to buy myself some thinking time.  "The itching is under/inside my skin."  Well that doesn't seem natural.  Even dry skin wouldn't give that sensation.

The knee is unremarkable.  Definitely tender.  Ligaments are grossly intact.  No crepitus or palpable fractures.  But it is stiff with passive range of motion.  I try again.  "Do you have anything that helps your pain?"  "Yes."  Really...  Turns out the doctor had given her something for pain that she takes three times a day.  I'm gonna go out on a limb and say it's a morphine derivative.  And I'm also going to wager a guess that the 'rash' 'inside her skin' is due to the pain meds.  I try and give her a lesson about why it's important to tell us about all medicines she's taking and how if I would've given her medicines without knowing she could've died.  Probably an exaggeration.  But who knows?  Maybe she was rocking 2500 mg of Tylenol a day already and I tell her to take 3000 mg.  That could knock her liver out and kill her.  Then I tell her that her itch is likely due to her pain medicine.  I offer some benadryl as that's the only medicine we have for itch.  And she eventually leaves, likely unsatisfied with the outcome of her trip.  As a side note, I think she might have had a carotid body tumor.  #LearningIssue

I mention this story because iatrogeny is rampant in Haiti.  Especially if you expand iatrogeny to include side effects of medicines.  In my jaunt through the market today I saw a number of walking "Walgreen's"  where people just had blister packs of pills strapped to a small stroller.  I've looked them over to see if there was anything worth buying for our clinic.  Most of the pills are tylenol or anti-histamines.  But I saw one table with boxes upon boxes of medicines.  Antibiotics, anti-inflammatory meds, and sleeping meds.  Didn't see any more Sildenafil today unfortunately.  But I did see a lot of ampicillin, amoxicillin, and even come chloramphenicol.  This is important for multiple reasons.  First off, as physicians we have to compete against a bunch of bacteria that have been teased with small but steady amounts of amp and amox.  Even the weakest bugs are probably resistant.  Turns out a lot of people also take doxycycline on a regular basis as "prevention" against cholera.  Sweet.  Drug-resistant cholera will be awesome this coming rainy season.

But the problems with free range of antibiotics goes beyond drug resistant bugs.  Although that is a huge problem that shouldn't be dismissed.  But antibiotics have other side effects.  In only one week down here I realized that every woman, if given the opportunity, will complain of vaginal discharge.  Probably because they know I won't take the time to look and they'll just get free medicine.  And also because they probably have vaginal discharge.  Keep in mind, this is coming from someone who has never had vaginal discharge.  This is coming from someone who has never had a vagina.  But I can imagine it's pretty distressful.

So we handed out flagyl and fluconazole like it was our job.  We treated empirically because we didn't want to take the time to determine what was going on.  The few times I went more in depth with my history, mainly for my own investigation, I found that most routinely take ampicillin as well as "wash" themselves up to 3 times a day.  Talk about irritating.  So we're killing off communal flora and we continue to irritate the mucosal lining on a regular basis.  Sounds like a recipe for discharge.  And it also sounds like a perfect epidemiological survey to find out what exactly is going on.  What is causing the discharge?  The discharge that our group alone spent at least a thousand bucks on treating in our one week trip.  Maybe the community would be better served with a little education.  #NeverEasy  #PillsAreTheEasyWayOut  Unfortunately, pills are seen as a complete necessity down here.  People take pills because of this perception that you won't be healthy if you're not taking pills.  The disheartened look I get when I tell parents that their kids are healthy and don't need medicine strains my will to practice medicine.  It's tough.  You wanna do right by your patients, but you also want to try and change the culture and perception.  And neither seem probable to happen in a four-day clinic.  But, that's why we're here and that's why we want to develop a long-term presence.  That's why we're training Community Health Workers so they can go into the community and educate everyone about healthy living.  The CHW's will continue on our work long after we head back to the states.  Hopefully the rest of these 7 weeks can help to determine the important health issues relevant to the community.

Haiti-itis

Okay, so this disease may not be on any coding forms your doctor could fill out.  But, in my professional opinion eighteen cases, some acute, some chronic, and some acute on chronic could be diagnosed in people I know.  Haiti-itis is a difficult condition to describe.  The life cycle is rather unpredictable, but it almost always starts with exposure to Haiti.  There are rumors of immaculate infections, but these are likely just misidentified viruses.  Most of the time the patient doesn't even realize he or she is developing this condition until days, weeks, months or even years after exposure.  Some scientists try to liken it to an addiction, a mere revving up of the dopamine reinforcement centers.  Perhaps it's in the specially prepared water?  Maybe Haitian hosts have created some elixir that sends just the right signals to distract the drinker from the fact that such extraneous efforts must be taken so they can drink water and not get sick.  Realists tend to argue it's the simple act of service that activates the pleasure and reward centers.  That's a tough point to argue because few things are as rewarding as filling a need.  And certainly that could be a large part of Haiti-itis.  But I believe this condition runs much deeper than that.

Coming from a country and a background of such excess and luxury as I have (and everyone else who may or may not be reading this) one may picture Haiti as some place for the destitute.  A place devoid of hope.  Stuck in pre-colonial 'America' where the bulk of the time must be spent simply on providing for basic needs.  And some of that is true.  Maybe that's why people come down here.  It's true, you do feel better about yourself.  You learn to appreciate the blessings you have at home, if you ever get to go back that is cause I'm still working on it.  And what's truly sick is you would spend days counting your blessings if you were trying to compare the two places.

I have a unique position.  My job is to walk around this area and just talk with people.  Ask them about their lives.  Their goals.  How they want to see the community improved.  Hear about their day to day struggles to find clean water.  Listen to their heartbreak when they tell me that they've lost 4 of their 8 children and don't have any idea what the cause was.  See kids' faces light up when I ask them what they want to be when they grow up.  "Dokte" is a very common answer.  Go get em.  Can't wait to be working alongside of you.

And I think that's it.  No, the people I traveled with don't have Haiti-itis because they're from the medical field and everyone they talk to wants to be a doctor.  Although it is nice to have your ego fed.  That "damn my job is badass" feeling is sweet.  But the fact that these people can be so open with me.  They go out of their way to find chairs for myself and my translator to sit on.  Then they grab a rag and wipe it down for me.  Dude, I'm cool just sitting on the ground.  And often times I do.  Which makes them laugh.  Can you imagine me going around Iowa City, knocking on random doors and taking 2 hours out of some woman's day to ask a bunch of questions like this?  Personal stuff too.  Money questions.  Asking to see soap because I don't necessarily believe you when you tell me that you have some.  Hell no.  I'm not sure where I would get locked up first, 2JP or the police station.

I truly think that the families think that I'm doing them this huge favor by sitting down and documenting their lives.  Writing down their struggles to finance education.  "The 'blan' is asking me what my family needs."  Even though I tell them that I make no promises.  I'm but one person involved with a group that just wants to provide better stopgap healthcare when we can.  But they believe.  Even though they've been let down by a number of NGOs promising to change their world.  Promising them the US lifestyle and then only making it harder for them to go to school.  For some reason they think that this time it will be different.  And they are happy.

#Challenged.  That's how I feel after a long day of surveys.  The gauntlet has been laid.  Hope has been given.  The people in this community accepted our team's presence for the week-long clinic and they continue to accept me in their homes to this day.  They want us to succeed.  I know my Haiti-itis will cause me to lose sleep.  I know others who report the same feeling.  Some people are jealous of my continued presence here.  I'm jealous that they can be at home with the friends and family that they love.  But I wouldn't want to leave now.  My job isn't done.  Even in March our job won't be done.  And that is the etiology of Haiti-itis, I believe.  Everyone left to return to their lives in the states knowing that there is much more work to be done down here.  Work for a people who are very easy to work for.  The love and adoration they give you is a very spiritual thing.  Acceptance.  Friendship.  Respect.  You can't help but want to work hard in Haiti.  And when you leave, you can't help but want to return so you can finish your job.

In April another clinic team will come from Iowa.  They'll provide medical care for one week and then they will go back.  And another team will find themselves suffering from a case of Haiti-itis.

Zo Po Pe

So, I'm not really sure of the spelling of the title of this post.  On our last ride as a large group the translators were trying to teach the girls some new words before they headed back to the states the next morning.  Some of these were common greetings, whereas others would be found on the Haitian adaptation of UrbanDictionary.com.  "Zo po pe" would be one of these.  As best as I can remember and could understand, this phrase is used to convey the message of, "I'm horny."  Forward?  Probably.  But the toilets flush the other way down here, so maybe this is the sort of thing the ladies respond to.  Needless to say, I got a kick out of the translators trying to explain the concept to our group as we were driving through PAP.

But that's not a disease...is it?  Being aroused?  I mean, there are paraphilias in which someone is aroused by something that is not considered conventional.  And those are often investigated as psychiatric illnesses.  However, I wouldn't guess that a great deal of people reading this would dare to admit to "zo po pe" due to an inanimate object.  I bet the number would creep up if we included the number of people who were too distracted by arousal to maintain attention at some job or task though.  I've certainly been "distracted" before.

Sex.  Sex is a huge part of human life and Haiti is no exception.  Pop culture quotes that humans think about sex hundreds of times a day.  And in the world of medicine, sex is a multi-billion dollar industry.  I assumed my personal exposure to such a topic would be diagnosing and treating various sexually transmitted infections.  Although, it's not like we have dark field microscopy, GC or chlamydia PCR, or even HIV ELISA tests.  But our approach has been to error on the side of treatment.  And condom distribution.  Funny thing is that for the first couple days we had a couple of the interpreters in charge of distributing them and only a small group of guys received the bulk of the condoms.  Bros stick together I suppose.

Ceftriaxone in the butt is a pretty good disincentive to engage in unprotected promiscuity if you ask me, especially if you have an inexperienced M2 administering the injection.  #VeryAggressive.  #NormanBatesStyle.  The Z pack is much more tolerable.

Yes, sexually transmitted infections have been the norm down here.  Dysuria and discharge very common complaints.  One patient, I thought, was leading me down that path only to pull a complete 180.  He was 28.  Educated.  Well-dressed.  And he was complaining of erectile dysfunction.

Awkward.  This subject is difficult enough when it's just you and the patient, but add in the translator and the obvious language barrier and it is a mess.  I thought STI first.  Then I thought he wanted "it" to be bigger (#DontWeAll).  Before I finally figured out that he wasn't satisfied with his erection.  Hmmm.  In the states, the few times I've seen family practice docs discuss this issue with patients, they pretty much just cut them off, handed them some samples of Viagra, and told them to report back with the results.  Sparing the details.

I'm torn.  Do I do the appropriate family medicine workup?  Do I ask about his regular sexual behavior?  Do I ask about erection variability?  Can I just give him some Men's Health pointers?  Or do I just sweep the issue under the rug because it isn't something we'll be able to pharmacologically manage anyways?  I'll take option five #AvoidTheIssue #NotThatTorn.

It wasn't until I reminisced about the issue later that I realized that ED is probably a big deal down here.  The two most common causes are hypertension and diabetes.  And as surprising as this sounds, those two diseases are super common down here.  Probably not the issue with the 28 year old that appeared in good health, but in the general population I wonder how many men would love to be able to talk with a specialist about erectile problems.

While that sort of complaint is certainly not something you'd forget about, I did push it to the back of my mind.  Until our last trip to the marche.  As we were low on supplies for every medical condition not treatable with Ibuprofen, I tried to look in as many pill baskets as possible.  The market in Arcahaie is quite the experience.  Perhaps I'll have to have a more descriptive post another time, but for the time being just imagine people walking around with large baskets packed full of blister packs of colorful pills.  Some of them are labeled.  But from what I gather people buy according to color and presentation.  I, however, was bound and determined to find useful meds and then try to haggle with the dealer to buy them.  Tylenol cold.  Ciproheptadine.  Paracetamol.  Ampicillin.  Nothing too helpful.  And then an older gentleman walked by with his own basket.  I began digging.  Usual stuff on the edges.  But what's this dirty, crinkled box on top?  I pick it up.  Sildenafil.  #VivaViagra.  I laughed and tossed it back onto his pile.  We made eye contact.  And we immediately start cracking up.  His 5 yellow teeth glimmering in the sunlight as he staggers to his left.  He knew what they were for.

So it's not uncommon and apparently one old dude is familiar with the pharmaceutical cure for it.  If I were smart, I would've seen how much he was selling that box for.  In a place where you can buy a course of ciprofloxacin for 150 Gourdes I can only imagine that Viagra is relatively cheap compared to the U.S. ($20 a pill is really tough when you're using student loans to pay)  Granted your supply is probably less assured than in the states, but now I know that the next time that a gentleman comes to me with concerns over his erection I can kindly deflect any further line of questioning and direct him to find the #LittleBluePill in the marche.  If I haven't bought all of them already, that is.  #DontReallyNeedThem  #SupplyandDemand  #ZoPoPe

Insomnia

The baby was 9 months old.  His diabetic, hypertensive mother decided to bring him in because he had “lost his appetite” and “couldn’t sleep at night.”  She said this, completely straight faced, as her chubby-cheeked little boy lay sleeping in my lap.  To their credit he looked pretty damn adorable.  Definitely a keeper. 

I entertain her concerns and give his heart and lungs a listen to.  His ticker was clicking away with a regular S1 and S2.  And his lungs had a hint of baby snoring in the upper fields, but no crackles.  Clean bill of health.  Another case of insomnia, another case of a baby just not adhering to the parents’ sleeping schedule.  It was a year and a half ago when I was in Des Moines talking to an entirely different patient population…about the exact same complaints.  Tout moun se moun.

However, the babies who decide to sleep all day and party all night in the spirit of Sean Kingston are not the only people who complain of “insomnia.”  Yes, they actually use the word insomnia.  I guess they get the Lunesta ads down here too #BigPharma #ProbablyNotAMajorMarket.  And there are some treatments that have been spread by word of mouth.  At the market you can buy some ciproheptidate (not to be confused with a very useful antibiotic, ciprofloxacin) which acts as an anti-histamine much like Benadryl.  And I’ve heard many people tell me that they make tea out of some of the leaves found around here. 

But what about me?  Finally a disease I can actually relate with.  Sleeping in Haiti has not been an easy thing for me to do.  And apparently it isn’t easy for many people based on the patients with that as a chief complain.  I can’t fall asleep.  If I do fall asleep, I find myself tossing and turning, waking up, and then unable to fall back asleep.  And in the morning I don’t feel well-rested.  Granted this isn’t an everyday occurrence, but often enough to be stressful.  So, in trying to understand my patients’ burden and disease etiology I’ve tried to dissect why I can’t sleep.

First, I have the back of a seventy-four year old, osteoporotic Vietnamese woman rice farmer (I apologize to my large following from Southeast Asia if you are offended, but you gotta agree that the fictional woman described probably had a bad back).  Even in the States I can’t seem to find a mattress that doesn’t leave me with spasms in the middle of the night.  Call it payback for the twenty years of insults I’ve subjected my body to in the spirit of recreation.  And I would be hard-pressed to find many backs around here that haven’t worked long hours in stooped positions.  It seems like most people are farmers or construction workers.  These guys have to work hard from a young age.  And the women may have it worse.  Laundry is done by hand.  I want to re-iterate 'done by hand, not because it is shocking, but because it's difficult to comprehend how much work it is to scrub dirt and grass out of a shirt.  Getting water means walking to the public tap or other water source, filling up a 5 gallon bucket, and then throwing in on top of their head to walk back to their crib.  Everyone has seen the pictures, yes, but that shit is hard.  Don’t let their form fool you #ModelsUseBooksRealWomenCarryWater.  And the amount of axial load they have to bear seems impossible #CSpineCleared. 

Tylenol for everyone!  If only it were that easy.  I don’t hurt when I lay down.  It’s only after I’ve been supine for most of the night that my pain kicks in.  So what else is going on?  Well, it’s 7 pm, I’m sitting in the dirt/gravel “yard”, and we have to power our one light bulb with a generator.  Yes, 7pm and it’s pitch black outside.  It’s great if you want to stare at the stars.  Especially if you have an iPhone with a stargazer ap that traces all the constellations out for you, thank you Angie.  But if you want to stay up, watch a sports game, or even socialize with the family you’re out of luck.  No electricity.  Early sunsets.  Pretty much a recipe for laying in bed way too early and not being able to fall asleep.

So I’ve solved the great mystery as to why people, and I, “have trouble falling asleep”.  We can’t stay up to watch the evening news – or Illini basketball in my case…wtf?  Penn State?  Really?  But eventually everyone falls asleep.  My schizophrenia calms down. I ease my mind.  And I drift off to a place where hearts are shaped like hearts and the smell of pie can make you float.  Then the parties start.  I've dealt with voodoo celebrations complete with shrill screams, drums, and firecrackers.  I’ve had the church next door wailing away hymns too.  But the culprits most responsible for destroying the peaceful night are the animals.  Goats, dogs, and roosters.  Oh My!

They all seem harmless enough, I know.  But imagine how you would feel having a chorus of roosters that don’t base their cackles on the sun…at all.  I don’t think there has been a sunrise that they have crowed at.  They prefer to sing the three hours leading up to the 530 am dawn.  Not gonna lie, every time I eat chicken while I’m down here, I feel extra happy.  The goats are much more tolerable.  Number one, they are fun to play with.  And number two, they tend to maintain regular office hours.  But they were included because when they do “talk” they just sound like they’re whining.  It loses its luster pretty quickly.  Perhaps the worst contributors to insomnia are the dogs.  These mangy mutts look more like slightly overgrown rats.  “They aren’t fed”.  They aren’t pampered.  No one is carrying them around in their handbag.  These creatures just roam…and bark.

I’ll end with one last story about my own insomnia.  It occurred two nights ago.  Stayed up till 11 watching Community so I could fall asleep.  Success.  Little did I know that there was a dog lurking outside my door, just waiting on me to get into REM before letting loose.  And let loose he did.  He didn’t stop.  Ten minutes passed.  Still going.  I try to cover my ears with an extra pillow.  No effect.  I turn on my iPod and slip in my ear phones.  Too loud.  I turn off the iPod and just use the earphones as plugs.  Barking still penetrates the plastic.  A half hour passes.  Then an hour.  I toss and turn.  Finally, I can’t take it.  I stumble out of bed, tripping over my mess that comes from living out of a pair of luggage pieces.  My daily contacts, now in their fifth day without having taken them out, try to fall out of my half-opened eyes.  “Where’s the damn door?”  I push it open.  The dog is still going.  It’s pitch black out – as we’ve discussed.  I step forward trying to feel for where the sidewalk ends.  I bend down, grab a rock, and execute the worst throwing form in the world in trying to sling a deterrent towards the noise.  The rock travels ten feet…tops.  Mulligan.  I’m still asleep.  Give me a break.  I grab another rock, reach back and chuck it.  Somewhere.  The barking stops.  It’s 2 am.  I can get a solid 2 hours before the roosters start in.  #Haiti #ccInsomnia

Vingt-Cinq

She was twenty-five, and by all accounts a beautiful girl.  I had just returned back from taking a presumed ectopic pregnancy "emergently" to the hospital in Arcahaie where she was admitted into the care of a group of Cuban physicians - As a follow up her family came by the clinic with some prescriptions for antibiotics and pain medicine.  We just gave them some money.  The surgery went well and she's at home recovering - #Crazy.  But I digress.  A twenty-five year old female is lying on the exam table when I get back.  I can tell by the look on Angie's face that things aren't going great.  I get a brief story:

She's been really weak recently.  She was dripping blood as she was being helped into our office.  And then comes the kicker.  She whips out her camera and shows me an image that looks like an aerial view of a volcano when it has erupted.  A charred looking mound with pockets of pink, red, and green.  It was her breast.

I'm not about to pop off and say that I've seen x number of breasts because that would be totally misconstrued by those who may forget that I had to do rotations in Surgery and Ob/Gyn.  But this was one of the worst presentations I've ever seen.  I've seen pictures of breast abscesses and the peau d'orange skin changes.  I've even seen mild cases of each in real life.  But those pictures don't even begin to capture what this woman had been tolerating for quite some time.

More story: She's pregnant.  She thinks she's 5, maybe 6 months along.  And that might be why she has avoided seeing a doctor for this ailment with her breast for as long as it's been developing.  Oh, by the way, she first felt a "lump" in her armpit area about 6 months ago.  She thought it was an abscess, and it eventually went away.  But then it moved anteriorly into her breast.  And now she says she has bumps on the other side.  Damn.

An exam is futile at this point.  She's been bleeding from this ulcerated breast.  You can't even call it a lesion because the tissue changes actually involve a greater circumference than her breast.  Not only that, but she's hypotensive, her pulse is thready, and she's symptomatic.  I don't think her breast cancer is her most immediate concern.

Angie has already hung an IV, and for what it's worth put her first line in since medical school.  The patient was recovering from the blood loss.  Her wound was dressed.  Now we had to figure out how to get her to a hospital for treatment.  She needed palliative care.  There aren't a whole lot of those services in Haiti.  A palliative mastectomy would likely benefit her as well as that might stop her blood loss.  So that's what we're convinced we should try and champion for.  And it's decided.  Wesley and I are going to head back out and take her to a hospital.

More story: She's already been to a "local" hospital and was denied care... Okay.  So we probably can't take her to Arcahaie if they weren't comfortable.  Our other option is St. Marc's about an hour and 15 minutes away.  Tap tap is on the way.  #Bon.

When it arrives we load the patient up and Wesley and I hop in the back.  We're off once again.  It was a coastal drive much of the way and the water looked absolutely gorgeous.  I'm talking major motion picture hottie gorgeous.  Fortunately I'm able to train my attention to check our patient in the front seat with the IV bag hanging from the rear-view mirror.  It's not like the drivers in Haiti use those mirrors anyway.

We make it to the hospital after stopping briefly for directions.  Wesley and I help the patient get into the emergency room where we are greeted by a nurse.  I calmly explain that she came to us, vitals in the trash, bleeding, and that we think she needs a surgery for her breast disease which is neoplasm vs infectious.  Oh, #btw's, she says she's 5-6 months pregnant.  The nurse takes down the dressing.  "It's cancer.  We don't have an oncologist.  She should probably go to Port-au-Prince."  Wow.  That's not the response I was expecting.

I stand back and collect my thoughts.  I call Angie for a peptalk.  I give her the low-down.  "They think she needs to go to Port-au-Prince."  PAP is the opposite direction if you don't have a map of Haiti open right now.  We'd actually go through our home of Arcahaie on the way.  What to do, what to do?  I decide just to try and refocus their energies.  This woman would garner no benefit from an oncologist.  Her prognosis is set, assuming it is cancer.  But her problem is blood loss.  I hang up the phone.  I grab Wesley and try and talk about prognosis with the patient's sister.  "Would she want to have a major surgery if it only extended her life by weeks?"  I'm not sure it was well communicated, but we were told to pursue whatever avenue we could.  Maybe it was so we could save the baby.

I go back into the "ER" and flag the same nurse down.  I ask her if a doctor would come see the patient.  "I know she has cancer, but that's not her primary problem.  Her problem is that she's bleeding."  I turn into a smartass... "Bleeding will kill her a lot faster than the cancer will."  Fortunately I think the translation doesn't carry quite the sass.  I've probably benefited from that more often than I should.  But it works.  She asks for the doctor as she asks for the Doppler to check the status of the baby.

The patient lays there as the physician directs a syringe into the middle of her breast.  Luckily we gave her a percocet at the clinic and lucky for her that she was narcotic naive because that had to have hurt.  At the same time the nurse runs the doppler over the patient's uterus.  Swoosh, swoosh, swoosh.  Clipping around at 120.  I lightly grab the patient's wrist.  Her pulse matches up with the doppler perfectly.  That's not her baby.  I shake my head at the nurse to let her know.  She re-positions.  Same pulse.  That's not a good sign.  Slowly I begin to realize that she's probably not pregnant.  She likely never was.  For her to have breast cancer at this young of an age and for it to be this aggressive, she has to have a genetic predisposition.  And if you are predisposed to breast cancer you are likely also predisposed to endometrial cancer or ovarian cancer.  Damn.

The doctor aspirates the syringe.  A speck of blood, but definitely not an abscess.  There is no pus.  There was no cavity of infection that he could find with his probe.  It seemed to be a solid mass.  "Do you think a palliative surgery would benefit her?"  He didn't want to operate on her.  He wasn't sure he would even be able to close the skin as there wasn't much not involved.  I wasn't sure she would survive an operation.

This isn't a happy story.  It's a reality story.  Twenty-five is ridiculously young to have what I have to assume was two primary cancers.  And ladies I'm not trying to be dismissive, but usually breast cancer victims do alright.  But we screen.  We over-screen as a matter of fact.  Xrays, ultrasounds, biopsies, oh my.  This patient didn't have that luxury.  She was from the mountains of Arcahaie.  There was no family practice doctor that she could turn to when she had this abnormal lump in her armpit that she thought was an infection.  She wasn't receiving any prenatal care even though she thought she was 5-6 months along.  And after speaking with her sister and the nurse even more we came to find out that she was told that she had breast cancer at another hospital.  A hospital where they could've treated it.  But she didn't get it done.  Be it cost?  Be it the fact that she thought she was pregnant and didn't want to lose the child?  I don't know.  But she certainly didn't have a champion or an informed guide helping her navigate the treacherous and confusing world of healthcare.  She had nothing.

Ectopy

The morning started similar to other mornings.  Roosters were crowing long before the 530 sunrise, workers were preparing for the days duties, and I turn over and smash a pillow over my head.  Typical.  I spend more time in bed trying to figure out the mapping procedure for this project than normal.  My translator isn't due to show up until 9 am so I can see help with the unofficial clinic from 8 till 9.

I finally break open the front door to my converted bedroom.  The building Angie and I are living in will eventually be a school building.  My room at one point housed 5 beds when all of the volunteers were here.  Now it is solely my domain.  My front door opens into the dirt and gravel yard that I have grown accustomed to seeing in this somewhat barren place.  My back door opens to a magnificent view of a mountain range flanked by some of the bluest water you can ever imagine.  This more than makes up for the fact that when i cast my flashlight throughout my hollow, concrete chamber I feel like I'm a character in one of the Saw movies.

As the sun and heat remind me that I'm still not in Iowa, Angie let's me know that breakfast is ready and we have about 5 patients to see before I go about my business conducting surveys and she starts her community health worker class.  Usual morning greeting.  Usual breakfast.  Usual day.  Until I walk to the treatment room.

The community health workers' first patient is a little boy whom we've been following for a nasty 2nd degree burn to his left leg.  But, he's playing enough to where his dressings are a light brown on the surface when we change them.  The female trainees have a ball cleaning, wrapping and then taping the same boy that sent many of them on a three-hour search through Arcahaie.  Next up is a young, healthy woman with a little crampy abdominal pain, possible dysuria, and discharge.  It's Haiti and she's a female.  I'm not surprised because that is the most common complaint I've received from women.  Urine sample, please.  I'm also told that our first patient, a woman seen before I finished breakfast, is off providing a urine sample as well.  Gonna be a discharge clinic.  Again, what else is new?

She came back and immediately I got the sense that something wasn't right.  Not that I have super-doctor-powers or anything because it was pretty obvious.  Her movements were slow and labored.  She didn't have a lot of postural support.  And her facial expressions screamed 'FML'.  Plus, it helped when Angie prefaced clinic with, "One of them may be actually sick."

I get a brief history as she returns with her urine.  No period since mid-November.  Been having daily bleeding since December 31 and now her lower abdomen is hurting.  "Any chance you could be pregnant?"  "No."  "When was the last time you had sex?"  "In November."  "Do you take any measures to prevent conception, pills, shots, condoms?"  "No."... So you could be pregnant...  And she was.  Mathematically it would likely be about two months.  But who knows.  Maybe she didn't really have her period in November and it's been a lot longer.  We certainly can't tell.  Still, any pregnant lady with pain and bleeding immediately moves up on the "scary diagnosis" list.

Angie and I take turns with an exam. Her abdomen is tender over the left, lower quadrant and suprapubic region.  I question whether or not there is a mass on her left inguinal region.  On spec exam the os is closed but there is blood coming from it.  I don't guess she has aborted her fetus, but at the very least it is threatened.  On bi-manual exam she is tender on the left worse than right and I think I sense something on the left side when compared to the right, but I can't quite put my finger on it.  Angie confirms my findings and says that she's pretty certain that there is a "fullness" on the left side.  Damn.  She needs and ultrasound and a scalpel.

We wrap clinic.  Nothing else is quite as interesting.  Little tyke with an ear infection.  Perfed his TM, but we offer some antibiotics anyways. My mind is with the potentially fatal case in the front room, waiting for a "tap tap" to show up.  It finally does half an hour after it was called.  We place the patient in the front seat with the driver.  I sit in the back with my translator, the patient's sister, the little boy with the burn and his mother.  For those that don't know, an ectopic pregnancy is a life-threatening condition.  It is a non-viable pregnancy stuck in the tube or elsewhere in the abdomen/pelvis.  It invades tissues and tries to set up the same blood supply that a normal fetus would require from the placenta.  That's a lot of blood.  And when the ectopic ruptures, that blood will poor into the patient's pelvis as if you had sliced through her aorta.  Notice I said 'when' as opposed to if.

#Anxiety.  I sit in the back of the pickup truck.  Holding on as we bump along the dirt roads.  I check my phone every couple minutes.  This woman needed to go under the knife an hour ago.  I can't even reassess her as she's in the cab.  The truck stops.  We are two minutes away from the compound.  A gentleman walks up to the driver-side window, just for a chat.  He laughs.  The driver laughs.  The woman in the passenger seat moves closer towards catastrophe.  #Frustration.  What the hell is going on?  He leaves.  We move forward, slowly.

We stop again.  The sister stands up and starts yelling and I see a gentleman come running towards the truck.  Partner?  Brother?  Who knows, but he hops in next to me.  We start again.  We drive past the intersection and head toward Arcahaie proper.  I haven't ventured this far south yet.  Still looks the same.  And we stop...  I ask Wesley what's going on.  We have to get a gallon of gas.  The 'attendant' talks over with a plastic canola oil bottle filled with a clear, pink liquid in one hand and a homemade funnel in the other. He dumps it into our gas tank and the male who had just jumped in the truck pays the attendant.  Curious.  Pay for the ride and then pay for gas when the driver needs it?  Sheesh.  #RawDeal.

The truck continues at its painfully slow pace until we reach the clinic in Arcahaie.  People are spilling outside the courtyard.  Not a good sign.  Wesley signals for me to follow him.  The family attends to the patient.  We weave through the crowd.  I put my stethoscope around my neck hoping that I can buy a little extra credibility.  Wesley finds a nurse while our patient finds a seat in the outdoor 'waiting room'.

I convey a sense of urgency to the nurse.  I drop the words ectopic pregnancy and say that she might need an emergent surgery.  She walks off, presumably to find a doctor for me, right?  She comes back a few minutes later with a stack of files.  She starts calling out names.  Not ours.  Not our patient's.  In fact, she's standing right in front of me but looking past me trying to locate the bodies moving towards her desk.  She calls another name, and another.  Not helpful.  Wesley notices my irritation and again motions to follow him. He knocks on a door with "Konsultayson" written on the frame.  Is that German?  Two physicians are inside surrounded by nurses and patients.  I have no idea how they get anything done.

They each rise to shake my hand and introduce themselves.  I'm a med student guys (#DirtUndertheTotemPole), no need to be polite to me.  I'm not used to it.  They are Cuban doctors working here in a deal between the two nations.  And from what I can tell they work their asses off.  One speaks Spanish.  The other tries his hands at English.  I explain the concern that we have a patient with a possible ectopic.  He goes to find the Ob/Gyn, immediately.  #Thankful.  Finally, a sense of urgency I'm used to seeing regarding medical emergencies.  He disappears into the main hospital while I wait outside with Wesley.  A female doctor emerges a few minutes later and comes straight to me.  Ob/Gyn, no doubt.

I work through Wesley, who works through a Haitian nurse, who communicates in Spanish to the doctor a very brief patient report.  #Doubt.  I worry that what I said wasn't enough to convey my concern for the patient because two of the doctors engage in a lengthy discussion in Spanish.  Finally, they tell me that they are going to take the patient to 'sonografi'.  #Success.  We'll know soon enough whether or not she has an ectopic.

She did.  The ultrasound room was crammed with patients and technicians, so I didn't follow the two physicians and my patient in.  But after about 10 minutes the Ob/Gyn came out and said in broken English that my patient did have an ectopic.  They plan to admit her right now and presumably she will go to surgery as soon as there is a surgeon and an OR room.

#Relief.  My patient is going to receive the treatment that we could't offer and the treatment that will save her life.  I ask how much we need to pay for her stay and surgery.  Then Wesley gives it a shot in the Spanish that he knows.  Nothing.  Free admission and surgery for our patient because she is Haitian.  Damn.  #Awesomeness.

Abdominal Pain

Abdominal pain is another one of the chief complaints that I avoided like the plague in my one month ER rotation in Iowa City.  Especially women.  Nothing is scarier than seeing the big board say something like, “22 yo F w/ cc of Abd Pain”.  Ugh.  Especially if she is a frequent flyer.  Let’s be honest though, if you’re having continuity of care in the ER it’s probably not a good thing.  Emergency doctors go into it because knowing their patients’ entire family history by heart is not a priority to them.  But even if she is not a frequent flyer the most likely etiology and the ‘standard workup’ are far from comparable.  At the very least she’s going to get a pelvic exam and a few blood tests drawn.   I guess it’s the annoyance of knowing I’ll have to do a pelvic on someone who is otherwise healthy that I got most annoyed with in the ER.  Not that I don’t see the utility of the exam, I just found it to be of very low yield for the complaint of abdominal pain.  And after all of the examination, serum levels, pregnancy screen, normal CT scan, and eventual pain medication you just get to tell the girl that we couldn’t find anything specific to attribute the pain to – i.e. you’re just a crazy chick, like most of them (bet I made some friends with that one…).  Now that’s not true.  Just because we can’t identify a cause for pain doesn’t mean it isn’t there.  I’m not insensitive enough to believe that.  I do find it incredibly frustrating because I like to see a cause leading to an effect because that offers me a place to intervene or reverse the process.  Endometriosis?  Shit is crazy.  What are you thinking uterine lining?  Where are you going?  Just dumb.

But the US isn’t the only country with a claim to abdominal pain.  Haitians frequently complain about it.  It comes with a myriad of characteristics.  And by characteristics I want to let everyone know that I found it impossible to articulate a translator and then have them articulate to the patient who would then respond in such a manner that the translator would be able to express the exact nature of the pain.  “Did if feel like something was pushing on your chest, stabbing your chest, or lighting it on fire?”  Three steps later, “it hurts in [his]  chest.”   Not helpful.  The same can be said for the abdominal complaints.  Although, enough Haitians have received tums to let it be known that if you use the word ‘acid’ at all you’re going to be getting something in return.  And sometimes I wonder if it isn’t game just to see how many magical pills you can get in one clinic visit.  But most of the time I just want to try and rule out big scary reasons why they would be having abdominal pain.

To be honest, I didn’t see a single patient where the thought of a big, bad, scary pathology was going on in the belly.  I could’ve guessed some peptic ulcers, maybe.  Definitely some endometriosis.  Lots of parasitic infections, including pregnancies.  I certainly hope I didn’t dismiss anyone inappropriately.  I tried my best to perform my due diligence and convince myself their aorta hadn’t ruptured.  Pretty sure someone else did notice a large AAA in our clinics, so we were mindful of these conditions.  However, it wasn’t until our last day of clinic outside of Port-au-Prince in a little town called Bonnet that my eyes were opened.

           
A small Haitian boy who couldn’t have been more than 12, and looked even younger, came up to me and told me that he had stomach pain as well as a few other complaints that he had accumulated over the past few months.  So I began asking the usual questions, “When did it start?”  “Can you point to where it is for me?”  “What does the pain feel like?”  “Is it there all the time?”  “Nausea/vomiting/diarrhea/constipation?”  “Any blood in your poop?”  “Any problems peeing?”  “Does anything make it better?”  “Does anything make it worse?”  And then I asked a question that I didn’t expect would have the impact it did.  “What does eating do to the pain?”  “It gets better.”  So for those who tend to be medically inclined, you ask that question when you think that the pain is a result of an ulcer and you’re trying to delineate whether the ulcer is above or below the gastric outlet.  If it is above the gastric outlet then food will make the pain worse because the additional acid secreted over the ulcer burns.  If the ulcer is in the duodenum then eating actually causes basic solutions and neutralizers to flow over it, effectively calming some of the inflammation.  But this was a 12 year old kid, did I really think he had a peptic ulcer in his duodenum?  I didn’t have Dynamed cued up to search the epidemiology of PUD in pre-teens.  So I asked probably the most insightful questions I’ve ever asked any of my patients, “How often do you eat?”  “Two to three times a day.”  Hmmm, that seems pretty reasonable.  Well, it’s about 2 o’clock now, so let’s see… “Have you eaten today?”  “No.”  Okay then.  “Did you eat yesterday?”  “No.”

 Well, shit.  I can’t go 4 hours without eating before my stomach starts yelling at me.  And here’s a kid with “abdominal pain” likely because he hasn’t eaten in two days.  How many kids did I let pass without asking that question?  Too many.  I asked some, but I also stopped when they responded with the “Two to three times a day” because I assumed they were telling me the truth.  I have my doubts now.  Even during my interviews in the community I’ve found that the Haitians are very adept at repeating what they think we want to hear or what is supposed to be the ‘norm’.

So I completed my interview and exam.  He wasn’t malnourished.  He was small and skinny, yes, but not the feeble, withered bag of bones that people envision when they hear malnutrition.  His belly was a little distended.  Could he have worms?  Most definitely.  We treated him for them because it’s easy enough and could make a world of difference.  But this kid was dressed in a school uniform.  Very soft-spoken and shy.  And he could’ve slipped through my fingers before I realized what the true etiology of his abdominal pain was.  But what could I do?  We had some little snacks at our clinic because most people end up waiting for us starting at 4 am.   But that isn’t a solved problem.  That’s not an intervention that will cure his abdominal pain.  This kid needed food security.  And you know what, now that I think about it I would wager that about two dozen other children that had a similar complaint over the course of my trip would benefit from food security.
 

In talking with our host, I’ve come to learn so much about Haitian culture.  For those who aren’t familiar with who I am staying with, she was a former assistant to a Prime Minister of Haiti.  She and her husband have a few very successful businesses in Miami and elsewhere, and enjoy the luxury of being able to leave Haiti whenever they’d like.  This is far from the situation most Haitians experience, so I try and recognize the perspective I’m getting when we talk about the local culture.  And before you ask, her and her husband’s hearts are ginormous and they want nothing more than to see a successful Haiti.  But she told me that most of the time the parents have no idea where their children are, and are not held responsible for the caregiving like in the United States.  That’s not too surprising.  But when she went on to say that sometimes the kids can be away from the parents for a couple days at a time and a lot of times the parents don’t go out of their way to make sure the kids eat I was taken aback.  I look forward to the day that I can labor over and spoil my child/children.  I’m excited to advance their diet and teach them to love all the flavors that the world offers.  All the textures that I’m struggling to digest even while I’m down here.  That sentiment is not shared here, according to my host.  And as evidenced by the number of “hungry” children but well fed adults.  I haven’t seen too many adults who struggle to take in enough calories.  Sure there are micronutrient deficiencies, but plenty of diabetes, overweight bodies and hypertension suggests that the adults are not struggling to find their food.

I don’t write this entry to make people feel bad like those depressing commercials featuring the “starving children” seen on tv.  Yes, childhood undernourishment and food insecurity is a huge problem in Haiti.  Dieticians would seize if they tried to do a food diary down here.  But I wanted to write this so that other people would be encouraged to ask that question - the “So, do you really eat?” question - even though the answer may make you uncomfortable.  Sometimes being in Haiti sucks.  What sucks worse is when you go to Haiti but then avoid the stuff that is gonna make you sick when you go back home.  And thinking about that hungry kid is gonna make me sick when I go back home.  And I’m glad, because if people didn’t get sick at stories like this then nobody would ever make an attempt to change it.

48.6

On my google maps search, it says that I traveled 48.6 kilometers from Port-au-Prince to Arcahaie on Wednesday.  It sounds innocent enough.  Just under 50 kilometers is a piece of cake and I make a trip over 10x that far on a semi-regular basis when I make a one-way trip between Iowa City and McLeansboro.  So it didn't seem like a big deal when I made the decision to return to Port-au-Prince with the rest of the medical team on Sunday night, completely understanding that I would be traveling back by myself.  I'd just get a moto and tell them to take me to the "Eternity Clinic."  After all, that's the name the interpreter told me that the Haitians called the place where I would be staying and where we were hosting clinic.  Eternity Clinic.  Check.  Mohalia.  Check.  Surely they'll know who she is.  Phone, I'll get that in Port-au-Prince and it'll be super easy.  I'll just make sure I pack everything I need in my hiking pack so I can sit on the back of a moto.  It may cost like 20 bucks, but that's fine.
Then I thought it would be a good idea to celebrate the end of the medical mission with the rest of the group.  We had a blast playing cards, drinking prestige, and creating a ruckus in PAP.  Upon returning to the mission compound, Chris greeted me by handing me a big wad of cash and instructions about how to dole it out and get receipts.  Got it.  Maybe.  Went to bed and woke up at 0600 not feeling great.  Get up, eat breakfast, say my goodbyes and wave as everyone else heads to the airport.  I go back in and talk to the guest house manager about how to get to Arcahaie.  "Do you have a car?"  "No."  "Do you know where you're going?"  "The Eternity Clinic?"  "Okay, how do you want to get there?"  "Well, I was thinking moto, but then someone said the buses might be a better option."  "Yeah, that would probably be good."  Do you know how to do that?"  "No."  "Do you speak Creole?"  "...No."  "Well, let me talk with one of the workers and see what they say..."
So they give me a ride to the "bus station" and  offer some pointers about how to navigate the trip, "Let our driver tell the bus driver exactly where to take you and then don't get out of the bus until you're there.  You should be the last one."  "Okay" I say, my head still heavy and my stomach gradually getting more distressed.  So I load up my stuff and get in the car.  Pierre, or Pi as everyone calls him, dutifully drives me to the "bus station."  And by bus station it is a dirt patch not even the size of a McDonald's parking lot.  He offers this bit of wisdom for me, "We won't put you on a long bus.  They're too slow so people break into them and rob everyone on there."  Sweet.  I'll take the short bus and any helmet that you can offer me.  No big deal.  White guy.  Pa parle creole.  With just short of three grand in his pack and pocket.
We get out of the car.  Luckily enough for me there is a short "bus" (a bus is like one of those small vans that your Division A high school cross country team would take to a meet).  I want to take this moment again to remind you that I was hungover and it was hitting me harder by the sun beam.  I was like a piece of low-hanging fruit for anyone wanting to pick on a blan.  So my house driver articulates to the van driver that I need to go to Arcahaie, I don't speak Creole very well, and that my final destination is the 'Eternity Clinic'.  "That's the morgue, right?"  The bus driver asks back in Creole.  Nope.  Not quite.  "What's the name of the lady you said?"  "Mohalia."  Crickets.  Oh well, we can figure it out on the way, right?  So I climb in back, over 8 other people with my giant pack and a small grocery bag of leftovers from the others.  "Just keep your head down and headphones in" I tell myself.  It's hot.  I'm crammed.  I really wish I would've counted just how many people were packed into this tiny van, but I wasn't really in the mathematical mind frame.
We depart.  Please Lord, Baby Jesus let this be the van that gets me remotely close to my final destination.  Did I mention I'd have a phone?  Yeah I did, but the only numbers I had were Dr. Buresh's which was about to board an airplane and three people still in Port-au-Prince who did not know where I was going.  No big deal.  I speak bad French.
The ride is rough.  Other people fall asleep.  The teenager next to me listens to his own music and occasionally glances over at me either in disbelief or distrust.  Or maybe he can tell that I'm nervous and struggling.  I fish around in my grocery sack and empty out a Ziploc bag... just in case this gets messy.  The older dude next to me falls asleep in minutes and is perfectly comfortable using me as a prop.  I'm cool with it.  I can't see the road very well and have very little inclination of appropriate landmarks.  "I think this tent city looks like one we passed to and from Port-au-Prince before."  As opposed to the other hundreds of thousands of Haitians still living in tent cities all around PAP since the 'quake?  Great, construction site that looks like it's going to be a fish farm.  That is familiar.  I'm heading in the right general direction.  I made the mistake to bust out my dictionary.  Ugh, doesn't take long for my head and stomach to reject that notion.  I rest my forehead on my hands, my bad and the seat in front of me.  I know I have a big forehead, but this was tight quarters.  Luckily enough for me I had the trusty 'Hangover Cure' playlist on my iPod.
We go over a speed bump.  Looks like we're passing our first small community.  I think it's familiar?  My stomach prays that that is the last speed bump of the journey, but we both know that the smart bet is the 'over.'  We drop off somebody in this town.  Is this Arcahaie?  That was pretty quick if it is.  And none of this looks familiar...
It's not.  We continue through the town and I think I recognize some of the paintings.  But then again, they often reuse the same painting design.  And 'Digicell' is plastered everywhere.  More speed bumps and more, confusing Creole banter between street-side vendors, the driver and the passengers.  Oh yeah, there is no side door to the van.  It's just open.  At least it was well ventilated I guess. I may or may not have dosed off.  I can't say for sure.
I'll fast forward to our arrival in Arcahaie because I'm sure you can only read so many sentences about my mental and physical state before you start thinking less of me.  I didn't know where we were until an abundance of people started getting out.  There was no Arcahaie equivalent of a "bus station,"  we simply turned into a local tap-tap.  Apparently everyone else had told the driver where they wanted dropped off cause he buzzed all over the area and people got out.  At one point everyone looked at me and the word blan kept getting thrown around.  I had no idea where I was.  Luckily the bus driver got out, came to the no-side-door-side-door and gave me the international sign for 'just chill.'  Gladly.  Nearly everyone had vacated the van and paid for the trip.  No idea what the cost was.  Finally it came my turn to get out.  He comes to the door and with a big grin points to me.  He found the 'Eternity Clinic'.  He had me get out.  That was a hilarious mess I'm sure.  Even without people in the van it was tough to navigate the lack of a passageway between the seats with a large pack.  I emerge back into the sunlight.  Rough.  He points down the street, "Eternity".  "Deux cent Goude."  I had a 5 spot American ready cause I guessed that it would be a little less than that.  Hand it over.  I'm in Arcahaie, I think.
I start walking in the general direction he pointed me in.  Nothing looks terribly familiar.  I start to replay the building fronts I had seen in my few trips to and from the compound at dusk, in the back of a track with 30 people, heading to the beach after a long clinic.  Yeah.  People had said that there was a police station near by but I had never seen it.  The only thing I remembered was a Digicell hut and a funky looking intersection of what seemed like a T of two major roadways.  Surely there can't be too many of those in a town of 100,000 people, right?  I mean, we had passed one that shared a structure about 5 minutes earlier in the bus, so that could technically be it.  Which would mean that my inkling that I was walking in the wrong direction would be perfectly correct.
All of a sudden the van returns.  The driver motions to get in.  He probably says it too, but heck if I know.  There is another guy in the van who actually speaks a little English.  Still not in a condition to do a whole lot of communicating.  Again, we stop.  The passenger with me points across the street and says, "Eternity".  I try and argue.  "That's not where I'm going, though."  Nothing is getting through.  The bus driver comes back to the side door, still beeming with pride that he got his blan safely to his destination.  I struggle out again.  On our side of the street is a gated building, "ecole et eglise."  He says.  And sure enough the Eternity Morgue was right across the street.  I had told my driver earlier that the facility I was staying at was also used as a church and a school.  It was kind of a guess, but eventually that will be true.
This is where the trip just gets funny.  The driver ushers me up to the gate and negotiates our entrance into the small compound.  He speaks with someone else and then leaves with a handshake.  God Bless that man and never let him know that this was not my final destination.  He was too happy.  A business-clad Haitian with bad ass lunettes du soleil (sunglasses) met me at the foot of some steps separating what I can only assume were the church and the school building.  He greeted me in English, but then stumped me in Creole after that.  I waited for someone else.  He arrived and also greeted me in English, shook my hand, but then reverted to Creole.  I shrugged my shoulders and offered a smile.  Finally, a third man came down the steps from an upstairs classroom.  He greeted me and introduced himself as a social sciences teacher.  He asked me about myself, where I was from, what I was doing in Haiti, etc.  So I answered him.  At this point I wasn't sure if the driver thought that these people would know how to get me to Mohalia, so that's why I went with it.  Holding out hope that this was the case.
It wasn't.  The conversation slowly shifted to the man asking me what I was expecting to do with 'only one person'.  And when his question of, "what are you doing here?" returned an answer of, "trying to get home" for a third straight time he slowly realized that we were on different planes.  "So do you want to say something to the children?"  "Uh, I guess I can."  "You have the principal here and the director here, do you want to say something to them?"  "Not sure what you'd like me to say."  "It was a pleasure to meet you.  Please come back soon."  The conversation was at least 15 minutes.  After 5 it was clear to me that these gentlemen were not aware that I was actually trying to get somewhere else.  But it was kinda funny.  I may have to pay them a visit and 'say something to the children' later in the trip.
So I left the compound and turned back towards where I thought the intersection might be.  I'm sure I was a sight to be held.  I was hungry.  It was passed lunch time and I had eaten breakfast, but my blood sugar was all out of whack because of, well we've talked about that ad nauseum.  I was hot.  My Cardinals hat on backwards and probably wet with perspiration.
"Hey, I think I've seen that building before on our way to the beach!"  That means I'm heading in the right general direction.  The walk is long and tortuous.  I have to dodge animals, animal poo, cars, motos and people as I move from dirt "sidewalk" to dirt road.  "Hey, large group of woodworkers carving up furniture. I'm pretty sure that those are familiar."  "Because only one small section of people in Haiti carve furniture."  Ugh.  "Come on brain, let me try and find solace in vague familiarity."  I press forward.  I see the intersection.  Fits the bill.  Motos all around.  Basically a three-way intersection.  Don't really see a Digicell building or the bar that I thought was close to the mouth of the road either.  "Hmmm, there's a blue and white building, could that be the police station?"
I make a commitment and turn left down the road that leads towards the mountains and away from the sea.  The aqueduct is running parallel to the street.  That's a good sign, because I know where the dam is and that's the source of the water.  "I can just follow the water home!"  So I walk.  It seems a lot farther than the previous trips in the truck.  People stare.  Some offer up the usual cat call of "Ey blan!"  Some try and sell me things.  One asks me to just give him a handout while his friends are laughing.  The sit behind a table with unpackaged cell phones out for sale.  They certainly didn't look like they were in need.  But I'm sure they found me entertaining.  Kids run to the gates of their yards to see the white man.  Most of them with bright smiles on their faces even while they were missing the all or parts of their wardrobe.  A couple decide to follow me on my trek up the hill.  I pass some Loto booths that also look familiar.  But they all look the same.  Still seems like a long way.  Then i see the building with the painted seashells in the wall as decoration.  Boom!  Nailed it.  I trek forward.  Only to realize that this walk was really far in this heat and with this large pack.  I tear open some Disney's gummies and share them with my two buddies following me.
Two miles later I see the hollowed out church that marks the turn to get to the compound.  I make my left turn and my buddies continue on.  We wave as we depart.  I'm sure I'll see them again.  I have arrived, Arcahaie.  Let's get busy.

66

Last night, at the close of clinic I was alerted to a critical patient that had just been sat down in the floor of our treatment room.  She actually couldn't get past registration and had to be dragged/carried behind a wall where our makeshift treatment room was set-up.  She was wheezing.  That word does not carry the morbid connotations that are necessary to describe how this woman looked and sounded.  It sounded like she was drowning as she was sitting in the middle of a desert.  She was unable to support her head even as she leaned against the wooden planks of our wall and sat on our dusty, concrete floor.  Her frantic family was hovering on either side of her, clearly distraught, and unsure of what to do.  Try as they might to find confidence in our faces, they probably failed at that as well.  We learned through our translator that she had a history of bad heart and probably suffered a heart attack about 8 months ago.  She had just visited her normal doctor this morning and her medicines were changed.  These symptoms struck out of the blue.  Our primary survey was complete and IV access was gained.  Her blood pressure was sky high at 180s/110s, her heart rate was tachy to 115, her shallow respirations were tachy to 30, and her oxygen saturation was %66.  Sixty-six percent of her hemoglobin in her blood was filled by an oxygen molecule.  We didn't believe the number, so naturally we tried it on ourselves (equipment has a funny way of malfunctioning in Haiti).  %99.  Normal.  Replaced it on the patient...%66.  We went to work.  She clearly had V/Q mismatch.  We dilated her bronchioles with an inhaler.  We threw all the IV diuretics we had at her.  Her lungs still sounded wet.  You couldn't hear her heart over the sounds of the fluid in her lungs.  Her eyes opened but the stare was empty.  One of our team members was already trying to arrange transfer to a facility better equipped to care for someone in as critical a condition as she was in.  And then, genius pointed out our early error.  We had administered a diuretic, but the woman was in no position or condition to pee.  So we scooted, reclined, and supported her body into a position better suited to place a urinary catheter.  The catheter was threaded on the count of "urinary sepsis."  A crude comment made to point to the insanity of the situation and the unrealistic concern that she would develop urinary sepsis.  %72.  She's climbing.  She's diuresing.  Her posture is such that she can open up some of those upper airways.  Her breathing is slowing, although still appears labored and sounds flooded.  Her heart is easing into a more comfortable rate.  The truck to take us to the hospital is on the way.  Things are pointed upwards.  We tend to a pair of other procedures in the same room that we had temporarily postponed when this patient showed up on our front step.  Our flashlights have to dart from the abscess being drained to the patient against the wall, a mere 8 feet away.  %80.  She's getting better.  She still doesn't talk.  She just rests.  She is our lone patient now.  She has produced over 400 mL of urine in under half an hour.  'Hopefully that came straight out of her lungs', we all think.  We decide to take shifts eating supper and keeping an eye on the patient.  %82.  The truck is here.  Both doctors, the pharmacist, the ER nurses, and a translator jump in the 'tap-tap' with the patient and her family to take them to the hospital.  There is no doctor there.  There are no nurses.  There is just a closed facility waiting to accept our patient, and our personnel.  She is started on a positive pressure airway.  The machine doesn't work so pressure must be manually created by our staff.  Let me emphasize manual again.  She is gradually tapered from a non-rebreathing oxygen mask to nasal cannula by the morning.  %99.  Dawn has broken.  The team was up all night in shifts.  At one facility a once-sick patient is walking through the front door and into a tap-tap with her family.  At another, a crew anxiously waits the return of their only physicians and news about the patient who most certainly had to have died overnight, or at the very least remains ventilated and on pressers.  Her saturation was %66...  For what seemed hours while she sat on our floor.  Death was likely.  Brain damage was an absolute certainty.  She needed to be ventilated or else she didn't stand a chance to survive.  But she wasn't and she's alive, with baseline cognitive function and was never intubated.  From %66 to %100.  Impossible.  Amazing.  Lucky.  Miraculous.  #Blessed.  Loved.  That was our patient.
As an addendum, she decided to come back and visit our clinic with her two sons, very well dressed Haitian business men.  She smiled.  Her lungs were CLEAR.  She walked with very little assistance.  She thanked us.  We thanked her.  And at that moment, we knew for sure that what we were doing was good.