Teen Pregnancy

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

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

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

story is duplicated every day in Haiti.

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

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

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

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

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

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

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

Jean working for HandsUp!

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

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

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

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

Gwo Tet De

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

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

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

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

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

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

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

You can see the bruise.

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

#WardrobeFail x 2

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

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

#NewbornSelfie

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

Gwo Tet Un

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

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

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

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

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

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

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

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

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

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

He doesn’t look good.  

Takotsubo

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

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

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

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

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

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

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

Breech

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

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

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

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

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

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

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

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

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

Boule Un

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

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

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

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

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

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

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

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

Frèt

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

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

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

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

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

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

Amnesia

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

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

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

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

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

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

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

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

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

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