Chanje

“Is it still bad there?”  If you’ve ever traveled to a similar situation as Haiti then you’ve probably heard this question.  It’s full of sincerity, but complete cluelessness.  Of course it’s bad there.  It wouldn’t be carrying a CDC travel advisory warning if it weren’t bad.  Haiti had years of corrupt leadership followed by multiple military coups that effectively robbed the country of its natural resources and money.  It has a self-centered big brother in the United States that will only offer help if it offers a greater amount of benefit to himself.  And in the last five years it has been hit with half a dozen natural disasters that destroyed what meager gains in infrastructure the country had made in spite of the aforementioned hurdles.  Drop that info and ask the person if they suspect that any country wouldn’t be bad by their standards.  But for people who have visited, and especially those that have had the fortune to visit more than once, they can speak positive about the situation.  They can speak about change.

Change is quite possibly the most important characteristic of disease that physicians use for diagnoses and managements.  The natural progression can help differentiate a virus and bacterial respiratory infection.  It’s been a week and suddenly it’s getting worse?  Then maybe we should start an antibiotic.  You’ve had intermittent back pain for 4 months that hasn’t gotten better, but hasn’t gotten worse?  Sounds musculoskeletal and I don’t want to rock the boat with a bunch of costly tests right now.  Even with patients that are extremely sick, in critical care units, many times doctors treat just to prevent a change for the worse.  Vitals are the same from one day to the next?  Good, let’s keep everything the same.  The patient may not be closer to getting better, but step one is to prevent a chanje mal.

Change impacts so many decisions in our lives.  Don’t like the status of the country?  Vote for a “Change You Can Believe In.”  That’s a change that the U.S. and Haiti share.  Haiti actually had to prepare for their election cycle in the aftermath of the earthquake.  Due to the types of delays one can expect when a natural disaster kills over a quarter of the public servants in a country, the election ended up being delayed until approximately the one year anniversary of the earthquake.  By this time the Haitian people had felt that there wasn’t enough change in their country, so they decided to change the head of state.  In walked Michele Martelly - former musician whose music is more Eminem than Bono.

Now whether the change in President truly had an impact or not is a matter of debate, but I believe that Haiti has been able to avoid a chanje mal, and in many instances experienced chanje bien.  And I do not think that I am alone.  People who are more Haiti-experienced than I can attest: It looks cleaner.  People appear happier.  More services are available.  Driving through Port-au-Prince you can see parks.  Like recreation parks.  With landscaping, slides, basketball courts, etc.  I saw more construction equipment in action than ever before.  More housing projects to help people move out of the tent cities.  Don’t get me wrong.  There are a ton of the shanty communities where I am sure that disease still rages, but I’m talking about change.  Improvement.  It’s there.

Change doesn't end there.  This most recent trip to Haiti featured 5 newbies.  Everyone reacts differently to their first time working a CHI clinic in Haiti.  Some have a deeply spiritual reaction and find themselves pursuing God more upon their return.  Some respond with visceral anger to the inequities they witness firsthand.  Trivial tasks such as opening a refrigerator can evoke tears.  And there are some who don’t really know how to respond.  Maybe the trip wasn’t quite what they were expecting.  They were disappointed in the food and accommodations.  Perhaps they see so many problems in Haiti that they aren’t able to see the changes that are happening.  But it’s to these people that I say, come back.  Wait about 6 months and come back.  You will see changes.  You will notice the spirit of the people more.  You will feel connected.  Come back and realize that you too have been changed. 

Sis San

I’d seen this story before.  The eighteen year old girl was carried to our clinic by her loved ones.  Rigan, a Haitian nurse who has been with CHI since before the beginning, took note of her sickly appearance and quickly ushered her back towards my room.  Why me?  She looked like death.  Or at least like death was on its way.  There was a gurney in my “office” – still in disarray because I hadn’t fully set up yet – so we laid her down.  Fortunately, we have two amazing nurses on our team that both are used to taking care of sick patients.  One rolls through a peds floor that manages CF kids with a pCO2 of over 100 (that’s not compatible with life in most instances) and the other is adult critical care trained.  Why am I the one in some semblance of charge again?  Maybe my memorization of the krebs cycle will allow me to outrank their years of practice.  #OrNot

We got vitals.  First step, easy peasy.  HR?  150ish.  I grab a manual sphygmanometer and register a BP of 90s/60s.  I was expecting lower.  She’s clearly tachypneic and is flaring, retracting…the whole bit.  In other words, she’d be using her toes if her body thought that it would help her get more oxygen in her body; she was giving it all she had.  I grab the thermometer and try to communicate to her to place it under her tongue.  I’m not sure if she’s not mentating well enough to follow commands or just doesn’t have the ability to execute.  It shows 35.8.  Not a fever.  She’s sweating.  Shivering.  And feels hot as an iron.  Let’s have another go.  Rectal?  Eh, let’s not ruin the thermometer.  Axillary it is. 

I turn my head and see Shandy, the critical care nurse, walking in with an IV starter kit.  This is why nurses rule.  I glance back and the thermometer is already to 39.  And there it is. 

I grab my stethoscope and quickly realize that I can’t clearly hear her heart sounds because of the crackles and rales in her lungs.    She’s septic.  I have a source.  But what I don’t have is everything in the “Clinical Guide to Sepsis Management”.  Should have ordered a central line with mean arterial pressure monitoring, blood cultures followed by broad spectrum IV antibiotics, and oxygen supplementation.  Instead I’m left thinking how to adjust those protocols to Haiti medicine.  Janice (peds nurse) makes short work of the shrunken veins in this girl and the fluid is flying in. 

Thankfully, Dr. Abby, the only real physician showed up to get a feel for what was going on.  I gave her the rundown, she verified the source of infection, and we started basically every antimicrobial we had.  We injected ceftriaxone and administered Bactrim and Hydroxychloroquine. Janice rigs up our nebulizer to see if we can’t get her to breathe a little better.  We check her O2 saturation and it’s 77%. 

At this point we think we ought to test for a couple of the infections we can, so run an HIV and TB test.  The HIV test is negative, but I later find out that her TB test is positive.  The breathing treatments start working and her lungs are able to open up a little more as we also give her some steroids.  All of a sudden she starts coughing up a mix of white, yellow, green and pink sputum into a plastic cup.  It honestly looked like a bunch of cake frostings layered together.  #NeverEatingCakeAgain #LiesWeTellOurselves.

We had to go about our clinic as the patients outside were piling up.  Thankfully I was just getting in the way in the patient’s room, so I had plenty reason to get out.  I popped in to get updates.  Her saturations, after 2 more breathing treatments and another dose of rocephin, climb to 80%.  She still looks like death.

Patients come and go, including some other real sickies, but our teenager is still in the room next to me.  Dr. Abby stops by my room to tell me that the decision was made to transfer her to a local hospital.  I agree with it being the best course of action.  Neither one of us are sure that she will be alive when she arrives at the hospital over an hour away.  I stare out the window as the truck pulls away, hoping that I’m wrong in thinking that I’ll never see her again. 

We completed the clinic including working through another septic pati*nt who showed the initial improvement with IV fluids and antibiotics that we never saw in our first patient.  The clinic ran us haggard and through all the struggles we still were left wondering about our patient.  The answer came later as we were all sharing a cold Prestige back at the hotel, trying to salvage such a brutally exhausting day.  Physical exhaustion and spiritual exhaustion.  Hyppolite received the phone call bearing the news we knew was coming.  Our patient was no longer alive.  We don’t know if she made it to the hospital or not before passing. 

If the history given to us by her caretakers was correct then her death was nearly two months in the making.  I didn’t learn this until later, but before sending her Dr. Abby asked if she was scared.  The patient, only an 18 year old girl, very calmly responded with, “No.  I am at peace.”  Dr. Abby said it best when she pointed out that this young girl probably had few opportunities to feel loved and cared for like she did when our entire team worked like dogs to save her.  I only hope that she saw the spiritual drive and power from a higher power working through us in our efforts. 

The phone call was not only about the loss of our patient.  Her body was now in a foreign town and the driver had felt no obligation to return her back to Les Anglais.  Apparently a two month’s salary doesn’t cover the extra hour for a round trip anymore.  And then the family was concerned about burial costs…A very important tradition in Haiti.

I’ve never discussed the passion the Haitians have for the deceased before, but it is evident by the quality of the funeral homes in every town.  If you want to find a funeral home, just look for the nicest building in the town.  Multiple stories.  Air conditioning.  Landscaping.  Any amenity that one can have in a Haitian building can be found in the funeral homes.  Tombstones and crypts are ornate expensive.  The quality of the burial situation signifies the respect and love you earned as a living individual.  Funeral processions often feature parades with music and celebration.  And without refrigeration the entire process must take place as quickly as possible #DecompositionIsNotFestive. 

The anticipated price tag for such a proceeding and burial?  Six hundred dollars.  Death is the only time a Haitian can expect to live like a king.  Seems like a cruel joke.

Blesi

I'm watching Wreck It Ralph on my computer tonight and it is one of the best animated movies I think I've ever seen.  I kinda want to adopt Vanellope.  Anyways, today we saw an older gentleman today who had had a surgery on his right flank.  I'm assuming it was an appendix, but it could have just as easily been a hernia repair.  I'm not sure when it was done (he was not my patient), but it looked bad.  I could only see muscle, but whatever deep stitches he had placed were being forced out by his immune system.  I was concerned about us cutting them out as I've heard horror stories of removing stitches and all of a sudden you're staring at intestines because those stitches were the last thing holding together the fascia.

So that's what was going through my mind as we proceeded to clean and dress this wound. But that's typical of most medical minds, "What's the worst possible thing that can happen when I start doing this."  It's a destructive line of thinking if you let it hinder your actions.  However, it can cause you to think about disastrous, but preventable outcomes.  Careless scissor work can result in lost nerves, damaged blood vessels, increased risk of infection, and super long surgeries.  It's this neurotic thinking that has been drilled into our minds on the wards and in the operating rooms.  Pimping regularly features surgeons asking medical students questions like, "What happens if I cut this?  What major structure is beneath this tissue plane?"  Annoying questions, but the end product is a well-trained physician.

But this story is not about medical thinking.  That would be boring.  This story is about my own Blesi, or "wound/cut".  Kind of a weird translation, right?  Blesi, so close to blessing, is Creole for wound.  #Irony.  Anyways, a few translators and I decided to venture out and play a game of soccer with the local Les Anglaisians.  I'm terrible at "football".  Never played before.  I just want to grab it and throw it.  Shoot it.  Anything but kick it.  It's rather embarrassing how bad I am.  But, I'm done to embarrass myself when I'm in a foreign country, because who is going to judge me?  Anyways, it was a game of 6 on 6 and I offered my services for the defensive end of the field.  My size would be able to serve me well, right?  Just knock over the little kids and take the ball from them.

We scored quickly and all of a sudden the other team started taking their shirts off.  Can you say freaked out?  Did I just sign up for a game of strip soccer?  Nothing but dudes on the field...not my kind of stakes.  This was not a blessing.  This was an anxiety attack.  A wound on my psyche.  "Rigan, why is everyone taking their shirts off?????"  "To identify the teams from each other."  Whew.  That was really weird.  I mean, I know I need to get some sun on my pasty skin, but not because I got involved in an all-dude game of strip soccer.

Our team was significantly bigger.  But bigger also meant a little slower, and we didn't pass too well.  Actually I just tried to not touch the ball (a partially inflated basketball).  It didn't take long for me to draw a lot of attention.  Suddenly it became the object to fake out the blan.  I'm not quick, but I'm big and have no problems standing and letting a smaller dude run into me.  That ball is mine.

This worked well for a bit, until I started to dribble.  And by dribble I mean not with my hands which would be much easier, but with my feet.  I quickly got tangled up with an opposing player.  Apparently it's the norm in soccer for two players to basically kick at a ball wedged between people's feet.  The ball was lost.  As I braced for one last swipe to knock it from the opposing player's feet he had the same idea and our feet collided.  I dropped.  And the deed was done.  My years and years of scrapes and scratches on my knees opened up like they always do.  The blood oozed through the dirt that I had decided was as good a band-aid as any.  Not sterile, but at least it provided a little barrier.

If a white person on a soccer field full of Haitians didn't attract enough attention, then throw a little blood on them and suddenly it's a major event.  Yes, everyone, I'm okay.  It's a little scratch.  White people bleed.  And we are not babies.  I can make it through this!

So I played on.  But not well.  I'm old and running in my hiking shoes.  Do I need any more excuses?  We ended up getting beat 5-2.  It was clear who was used to playing together and who was older and slower...  So we walked back to our hotel with everyone trying to throw the blame around.  I participated when I could get them to speak in English.  It was fun and no one cared about my blesi anymore.  We are all haggard old men who got beat by the young guns on the field. #Beaten  #Broken  #Wounded  #Together  #Blessed

Turbulence

                I had just landed in Miami Airport a little over four hours ago, and it felt like mere minutes.  The few winks of sleep I was able to get were quickly disrupted by janitors, PA announcements, or even other anxious travelers.  I was boarding the last leg of my most recent return trip to Haiti – the 90 minute flight from Miami to Port-au-Prince.  I found my seat square in between two patrons who did not share a primary language with me.  The safety demonstration whizzed by.  I found myself drifting asleep to the soothing tunes of my hangover cure playlist. 

                I was so tired that I’m not so sure that I was ever actually asleep.  Eyes closed?  Check.  Slowed respirations?  Check.  Rapid eye movements?  Probably.  Brain in shutdown mode?  Nope.  Not sure what was going on.  The track playing was Chromeo’s “Don’t Turn the Lights On.”  Pretty sure that it’s a pretty obscure song.  That’s right.  I’m a hipster.  And my brain started noticing that it seemed like the airplane was being jolted to the rhythm of the song.  It was nuts.  The chorus kicked in and all of a sudden my plain was bouncing up and down.  Each down stroke matched with a drop in altitude.  The high hat with a bump to the right or left.  It almost seemed too perfect to be true, and it only lasted for two eight counts, but I swear it happened.

                The turbulence kinda reminded me of what can happen when a totally new group of people get pushed together in a small setting like we are in.  I’m currently in Les Anglais, Haiti.  If you look at Haiti as a giant ‘C’ facing the opposite direction then we would be at the tip of the bottom tail.  Gorgeous views of the coastline along the whole drive.  Beautiful surroundings notwithstanding I have to say that I’m not worried about turbulence with this group.  We are small in number, only 13, but we are an experienced lot.  I think efficiency will be our strength.  This is shaping up to be a new experience for me.  Brand new location and I can finally spend some time learning about organizing a clinic.  I think Dr. Abby will be a great mentor as I look to start organizing our trip to La Fite.  I hope to be able to continue to have inspiration to blog about, but if not then that probably means that we’re kicking ass in the clinic and I’m just too tired!