Haiti Day 10 - If You Are Squeamish...

Today I got up and went to the clinic and what started off as a typical primary care day changed fairly quickly. I had a man come in after having a fight with his wife during which she bit his lip...last week. Now he had a very large infected wound instead of a lip. He was laughing about the fight but I couldn't laugh about the wound. Yikes. Hello antibiotics. 

Another man, drove his motorcycle while intoxicated. He crashed with the motorcycle landing on top of him, passed out and burned a large part of his right lower leg...last week. Now, I had to debride a dirty burn wound with bits of God knows what inside. He was in severe pain, but I managed to get it done. He'll be back tomorrow for a dressing change. 

An elderly gentleman came in with a lesion on his knee growing for "a long time". He has had nightly fevers/sweats for "awhile". I asked about tuberculosis but he didn't think he had it. Take a gander at the picture and let me know what you think. I even tried to lance it but nothing came out. He was sent to the health department for tuberculosis testing.

Seriously, one weird case after another came in today. Just when you think you got your groove on as a provider, something stumps you. Today, it must have been stump the PA day. 

After work, I had an early dinner and Edelin and I took a walk to see the progress on one of the homes being built and swung past one of the water tanks sponsored by Peacework Medical. It reminded me of a baby brought in today by her mother. She had white watery diarrhea (rice-water stools anyone?). We've had a lot of rain lately and this can increase the risk of a cholera outbreak. During the previous cholera epidemic in this area, Peacework worked to install 30 water treatment tanks around the village which stopped the epidemic in it's tracks. There are still occasional cases as people can use other water sources but I am unaware of any recent deaths due to cholera and those cases that crop up now have a chance at early intervention due to the clinic. As Pam Burwell, Peacework's Director and Founder, explained to me, those tanks are just as important in preventing death and disease as the clinic. I see the tanks on my hikes and the life-giving water they provide and am in awe of how much we can do as individuals. Pam's vision for improving Ranquitte's health has saved countless lives.

Summing up Day 10: I have seen so many new things on this trip but one thing is universal: Men wait until a limb is falling off before they admit that it hurts. Why??????

Haiti Day 9 - The Moment

I went to bed last night with the funeral home across the street overflowing into the streets with the biggest party I have ever seen outside of Solomon's Island Tiki Bar Opening (cheers St Mary's friends). It was a wake for a 90yo woman, a distant family member of Edelin. Haitians know how to celebrate life even in it's passing. Edelin explained that "We are born. We live. We die. It's just how it goes." In medicine, I spend so much time fearing death, afraid I won't halt it's grasp on the living that I forget that I really don't get a say in when that moment happens, not really.

Waking this morning was like any other day in Haiti, the roosters crowing, breakfast being made with the utmost care in the kitchen below me, and those mountains calling to me. I also heard a six hour Catholic mass (it is broadcast across town on loud speaker). When you feel tired after 45 minutes next Sunday, think of that. It was immediately followed by the funeral mass for the 90yo woman. Standing room only, out the door, into the streets with a small marching band (a la New Orleans style). How often do we celebrate our elders in this way?

During the morning mass, I went for a walk with Edelin and had the opportunity to see some of the other homes he is working on building for the poor. When does this guy sleep? Apparently never, because after the funeral we took a moto taxi out into the country to an area called Bas Pinal. He originally started a food program to feed the poor but realized the desperate need for an orphanage. He teamed up with a church in Georgia to build a dormitory and school and he just completed a stall for a goat to get the children fresh milk. When I arrived and saw those beautiful children and adults (Edelin doesn't discriminate, if there are homeless starving adults, he helps them too) I just melted. We went into the spotless schoolhouse and they waited one by one to be seen. I saw the sick and Edelin helped by removing a very large thorn from a child's foot. The first child had a loud murmur but exhibited no symptoms. The next child had fever and likely pneumonia in his right lower lung. An adult had had a stroke in her 30s with pain along bilateral temporal arteries. Another child with fever, murmur and possible pneumonia and several children with mild colds.

It was sometime as I listened to another little chest that I realized I was having one of the most perfect moments in my life. I know this seems a bit crazy but it felt like I had waited my entire life for that schoolhouse, those children, and my dreams to converge. It was incredible. I belonged there. I felt like I grasped a piece of joy in that moment that is rare, perhaps never to be repeated. Don't get me wrong, there are personal moments (weddings, babies, etc) that outweigh everything but this was something mystical. All I can say is, if I hadn't gone to PA school, hadn't met Pam Burwell, hadn't come to Haiti, I never would have had that moment.

Summing up Day 9: I am so thankful for all of the pieces that fell into place so that I could experience that moment today.

Haiti Day 8 - A Day of Rest

Today I did something I rarely do, I rested. Usually, if I "rest" I have at least three pieces of technology (phone, TV, iPad) or a book to read. There is no electricity here except two hours per day during which I charge my phones, ophthalmoscope, etc. My battery for my iPhone wasn't working for some reason, I left my iPad at home (i.e. no books, games or emails), no TV. It was a strange disconnected feeling. I honestly didn't know what to do. I wasn't well enough to venture away from the house. So I sat in quiet or played with the kids, or rubbed the dogs' bellies and tried to just be present. Meditation and quiet reflection are actually hard (for me) to do. I'm always thinking ahead a few steps, and spend very little time in the "now".

I used to watch my dad fishing. Sometimes he would cast a line into the water and only touch the reel now and again out of habit. He would sit like that for hours. My dad is a seriously hard-working guy but he also knows how to be still. I have always admired that about him, but could never understand how he does it.

So, I broke new ground today. I was able to sleep/nap without thinking of the things I "had" to do because technically I couldn't do anything. I wanted to go to an orphanage today to check out the children as a lot of them have cough and fever, but my stomach bug even nixed that idea. I felt that even this experience, or lack thereof, was something I needed to learn while in Haiti.

Summing up Day 8: I always tell my patients to rest, and yet, I don't take days off for rest myself. Physician (or PA), heal thyself...

Haiti Day 7 - The Kindness of Strangers

Today I don't have a lot to tell about the clinic but a little more about the Haitian people I've come to know. 

Sometime in the wee hours of the morning my stomach started hurting with wicked nausea. I tossed and turned but no sleep for me. I got up and got ready for the clinic but could barely eat my favorite Haitian oatmeal (think oatmeal mixed with warm tapioca pudding--awesome). I'm also a coffee addict and couldn't drink more than a few sips. My body was achy but I've been pushing through that my whole life so I thought I would be okay. I rode again on a moto with my compadres, one of which was also not feeling well with nausea. 

When I got to the clinic, the hours seemed to go so slow. I got shaky and was feeling quite ill by 12:00. The moto driver came to pick us up and I had to be sandwiched in between to stay up on the bike. When I got back, my host family gave me 7-Up and rubbed some type of oil on my arms and legs which relieved a lot of the pain. I took Tylenol and slept all afternoon. On occasion I would wake up to find one of Edelin's sisters checking on me. For dinner, they made me soup. Michael, my translator, was supposed to go his home in a nearby town but stayed to make sure I was alright. Edelin was out-of-town but called twice to make sure I had everything I needed. I thanked them all profusely, but the translator said "You left your home, your family, your job to take care of us, now we can take care of you." Kinder words have never been spoken. 


Summing up Day 7: In my vulnerability, I found the strength of those around me.

Haiti Day 6 - Little Victories

I started the day on a hike with Edelin. He wanted to show me the progress on the home I had first seen last weekend (look at Day 1 photos). It now has most of the roof beams in place and the family even had a pot on a fire in a cinder block room which will someday be a kitchen. An old woman was sweeping the dirt around the house. Starting to make the structure into a home. 

On the way back, I realized I was keeping pace with Edelin with only minor effort. It was amazing to think that only one year ago I struggled to walk a mile.

When I returned, I had about 10 minutes to eat and hop on a motorcycle...with three other people. (I'm sure there is a joke there somewhere.) Four people on a moto on unpaved bumpy roads, it was terrifying and hilarious at the same time. By the time we reached the clinic, my legs were shaking and I was nearly hysterical laughing.

I saw 50 patients today in a very busy clinic. It started with a woman who was "about 8 months" pregnant (not sure) appearing for "cramps" that came and went over the past 1-2 days. No regular contractions. She had no other complaints. We discussed Braxton-Hicks versus early labor. I advised her to drink plenty of water (in the event of preterm?? labor from dehydration) and see her midwife ASAP. The baby seemed low and ready to go.

I saw a baby with croup. You never realize how you rely on modern conveniences like nebulizers, liquid prednisone, a refrigerator or hot steamy showers until you realize the sick baby in front of you has to tough out an illness or go to a hospital if it worsens because you don't have those conveniences.

I also saw a baby with chicken pox and a bacterial superinfection on the face. Poor little cutie was only 1.5 months old. Her mom had gotten chicken pox approx 1-2 weeks after giving birth. Despite the way it looks, the baby was as happy as can be.

On the way home, we all piled on the moto. We even passed another moto with four people on it. I guess it wasn't such a bad idea after all.

Summing up Day 6: I felt capable of climbing mountains, taking risks and being the person we are all meant to be...happy.

Haiti Day 5 - The Other Path

Today seemed to move slowly. As Edelin's truck needed repairs, the staff and I took a taxi to the clinic. On the way the staff told me that sometimes they cannot afford the taxi to go to Gard Hiram ($5) so they walk 1-1.5 hours there and again on the way home. The taxi driver also uses his car as an ambulance when needed. He drove slowly and carefully allowing me to see things I have missed over the past few days. There was a woman and two children sitting in a square outlined by two layers of cinder block...the beginning of their home. They were going about their activities as though the roof were simply lifted off so I could see inside. Children along the way said "Good Morning" trying out a phrase on perhaps the only "Blan" person they had met. One little entrepreneur told me I should give him $1 for attempting English.

The clinic went easily enough with a few interesting cases. A woman stating she was 50yo (more like 70yo) came in with stomach pain, severe bloat, headache, and weakness. She reported painless hematuria (blood in urine) x 1 year. I treated her for possible UTI but am suspicious for malignancy. She agreed to follow-up next week. If no improvement, I will send her for further evaluation with a specialist.

Also, a 6yo boy came in with multiple bug bites on his arms. He was mildly tachycardic, febrile, and ill-appearing without further findings on exam. This is one of those times when the illness must declare itself. It is possible mosquito-borne illness (Chikungunya, Dengue, malaria...) versus any number of childhood illnesses. He did have report of joint pain, fever and stomach pain. Dengue and Chikingunya present similarly with exception of type of joint pain (asymmetric vs symmetric) and when the fever stops in Chikungunya the illness slowly resolves with exception of some residual joint pain. In Dengue, when the fever stops, the worry starts. It is during this time that patients may begin to hemorrhage. Luckily the family lives fairly close to the clinic and will follow-up tomorrow.

After work I went on a hike and finally made it up one of the mountains. It was worth the huffing and puffing. I had the most amazing view and met a lovely family at the top. When I got back to town a girl no more than 2-2.5yo stood in front of me with her hands on her hips and asked "Why are you white?" in Kreyol. I had to laugh. I had no good answer for her.

Summing up Day 5: I felt like I took off some training wheels today. It was as Robert Frost wrote: "Two paths diverged in the woods, and I, I took the one less traveled by, And that has made all the difference."

Haiti Day 4 - Market Day

Today on the way to the clinic there were a lot of people, a few donkeys and one horse crowding the road. Everyone seemed to be in good spirits despite the loads they carried. They walked together laughing and socializing along the way. (It made me sad to think I don't even know some of my neighbor's names.) We have had a lot of rain over the past few days and the muddy hills were difficult to climb. Edelin stopped his SUV to pick up people along the way. I lost count of how many people ended up loading into the vehicle. Even the hatchback was full. In Haiti, it seems they always make room for one more.

When we reached the clinic, the crowd was much smaller than the day before. I still saw 22 patients in 2.5 hours but it seemed much more manageable. I saw a variety of cases including a large neck mass on an 80yo man. He reported it had been present for 15 days, but in Haiti I have found "15 days" to mean anything from days to months. It's like saying you are 50yo regardless of your actual age. The mass was not red, warm, fluctuant. It was 6cm in diameter inferior to his ear running along his jaw and anterior cervical region. It was firm and fixed. I know some will disagree but although unlikely to be an infection, I prescribed an antibiotic in hopes that it was not as sinister as it seemed. He agreed to follow up next week. If no improvement, he will be sent to the hospital for further testing.

On a more humorous note, I had an elderly gentleman report "loss of energy" (i.e. erectile dysfunction). He asked for Viagra by name. The Viagra marketing department should be proud.

The clinic closed early so staff could go to the market and Edelin drove the little girl with the eye condition (from yesterday) two hours north to Cap Hatien. She was found to have a small piece of gravel lodged in her cornea (if you zoom in on her picture you can see it in her right eye). The doctor removed it and prescribed cipro drops. He said she would have gone completely blind in that eye had she not had treatment. On the way back Edelin had to cross several streams that run across the road. Unfortunately, due to the heavy rain, Edelin's vehicle was overcome by water while attempting to cross a stream. Everyone managed to escape without harm but they had to get a taxi home.

I spent the rest of my day with the kids and learning Kreyol with Jean Francois. M' wè ou! 

Summary Day 4: All-in-all it was an amazing day and so much fun to see that community spirit everywhere from the marketplace to Edelin picking up people along the road and then driving a child two hours, in a flood, to save her eye.

Haiti Day 3 - The Patients of Haiti

Today I woke early in anticipation of seeing patients in the new clinic. Pam Burwell, PA-C (CEO of Peaceworks Medical, humanitarian, and all around amazing human) came to Haiti after the 2010 earthquake and brought teams to facilitate clinics in Ranquitte ever since. In March of this year, she made a more permanent commitment by building a free-standing clinic in nearby Gard Hiram. I am staffing this clinic with a Haitian nurse practitioner, Colleen, for the next two weeks.

This morning, Edelin drove Colleen, Michael (pharmacy tech and translator) and myself to the clinic. When we arrived, the courtyard and porch was already full of patients. I took a few moments to familiarize myself with the medications available and then went to a large exam room with a single shelf, square table, and three chairs. The patients came in twos and sometimes three at a time usually mother with one or two children all wishing to be seen. Before today, I was worried about not knowing how to treat tropical diseases but it turned out to be good old fashioned primary care mixed with a few cases that still have me puzzled. 

The most common maladies were stomach ache, colds, joint pain and a few sinus and ear infections. Taking a history was challenging as most people do not know or admit their age. Everyone was "cinquante" (50) even when they are really about 80yrs old. They all reported chest pain and fever regardless of complaint. There is a lot of poorly controlled hypertension, so taking this lightly was not an option. 

The most difficult case logistically was a 10yo girl with right eye tearing and "white spot" on her cornea x 2 months. Her mother reported it had turned red initially but then pain and redness resolved. She had a steady stream of tears and a white 1mm rough exudate/lesion in her cornea with surrounding hazy circle approximately 3mm in diameter. Foreign body? Fungal keratitis? Any guesses would be welcome. My host recommended she see an ophthalmologist in Cap Haitien but travel alone is too expensive for the family much less the cost of a specialist and possible procedure. We will likely send her by moto to Cap Haitien tomorrow for the consult and go from there.

Another woman in her ?20s had a sore throat for 15 days with abdominal pain and vomiting blood for one day at onset if illness. She was treated for an unknown disease at a hospital at the time. No other URI symptoms, GI issues resolved. She had a fiery red patch on her soft palate with mild ulceration noted. She also had BP 164/112 with normal rate and rhythm. I am still searching for a good diagnosis. I treated her hypertension, gave acetaminophen for pain and rinses for her mouth. I asked her to return in a few days to follow up. 

There were many others that I could not treat due to lack of medications or testing but it was still was a good first day in the clinic and a great day to be a PA.

Haiti Day 2 - Learning the Area

I woke up, literally, to hundreds of roosters crowing in the middle of the night. After wrestling with my mosquito net, I fell back asleep and awoke later to a much better sound...children laughing.

I went for walk around Ranquitte with a 5yr old as my tour guide. We went to his friends' houses. Unbeknownst to me, there is a town center not far from where we walked but this was not on Dawins list of things to do (LOL!).

I came back and had a great Haitian breakfast of spaghetti, avocados, and boiled egg. My little companions joined me and we laughed until spaghetti was flying out of our mouths.

I then went on a hike with my host, Edelin Phillipe. He is only 29yrs old and has done more to help his town than I could imagine doing in a lifetime. He has learned four languages and with the help of a sponsoring church in Georgia, attended University in Port au Prince to learn International Diplomacy. Even when at University, Ranquitte never was far from his heart. He dreamt of making his town better for everyone in it. He is currently working with 38 women to develop businesses to sustain their families. He has organized a project with the church in Georgia to put roofs on homes for widows with children. As Edelin says, "You never know what these things will do in the future." He knows that giving children a roof to keep out disease and their mothers having jobs is not so much charity as building a future. He also spear-headed a project along with Peacework Medical and other organizations to provide clean drinking water after a recent cholera epidemic. He also acted as Peacework's in-country partner to build the clinic where I will be working tomorrow. If that wasn't keeping him busy enough, he plans to run for mayor next election. I'm in awe of his leadership and passion for his community.

Today I was also fortunate to meet Jean Francois who is a 24yr old man who wants to be a doctor. He brought a book to teach me medical Kreyol and I taught him the English equivalent term. He wants to return to Ranquitte after medical school and serve in his community. 

Day 2 Summary:
I learned so much about the people if Ranquitte and the community I am blessed to serve in. They are resilient, strong and dreaming of a better future.

Haiti Day 1 - Arriving in Haiti

I started my first day at Reagan National Airport at 3:45 am and am still going strong. I stopped briefly in Miami and landed in Cap Haitien shortly after noon. I love hot weather and at 90 degrees and 83% humidity, I had my share. My host picked me up from the airport and we drove the 30 miles (2+ hour journey costing only $75 - I've paid that much to get around New York before). Along the drive I witnessed the unfathomable poverty of Haiti but little of the sorrow we normally associate with it. People were smiling and happy. It reminded me of a trip to Mexico when my own children were playing electronic games and unhappy about our trip and we happened to pass children playing kick-the-can that were simply laughing and living in the moment. 

As we drove into the mountains, I finally understood the phrase "mountains beyond mountains". In Haiti, there is always another hill to climb or an obstacle to overcome. I marveled at mothers and young children climbing hills with buckets full of water on their heads. Where do they get their strength?

After we arrived at Ranquitte, I settled  in and found that my biggest obstacle was trying to understand what I should do versus being what could be perceived as a bad guest. A table with a lot of food was set up outside of my room. I wasn't sure how much to eat, if I should clear the dishes, etc. I learned I was supposed to eat by myself (still not clear on how much) and even the offer of help was considered a faux pas. 

I spent the rest of the day meeting family, friends and playing with the children (who are adorable beyond belief). I even treated a scraped knee for a neighbor boy who was hiding from his family. The boy was 10yo and completely enamored with his yellow Crayon bandage which led to other children requesting the same.

It is now late evening and the generator is running as planned for two hours of power to get things charged up for tomorrow.

To sum up Day 1: Wow. I still can't believe I'm here. I expected to feel like a stranger in a strange land. Instead, I feel an odd sense of familiarity almost like déjà vu. It couldn't be less like my normal life and yet I couldn't be happier and comfortable if I tried.