Blan

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

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

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

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

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

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

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

Death Summary

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

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

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

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

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

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

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

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

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

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

2016

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

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

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

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

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

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

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

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

Spectrum

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

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

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

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

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

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

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

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

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

Promise

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

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

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

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

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

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

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

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

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

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

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

I did it.

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

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

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

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

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

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

Koupe

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

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

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

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

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

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