Numbers and Diseases(Matt's Blog): Hypothermia part 1

Numbers and Diseases: Hypothermia part 1

The Climb

            No, this post isn’t going to be about a cheesy Hillary Duff song.  More like a bonus level of Mario Kart that is only unleashed only by double lapping Wario on the Chocolate Mountain. Or perhaps like Freaky Friday-ing with a stud motorcross athlete on a quicksand pile of rubble, sans helmet and neon leather jumpsuit.

            As alluded to yesterday, I promised to follow-up with the 23 day old baby who had been eating cookies and shitting bricks. Not funny, she was actually pretty sick looking. And the conversation with the parents revealed a lack of education that begged for a community visit. If this mother doesn’t understand newborn nutrition, she likely isn’t alone. Guilene and I plan to travel early in the morning. She has never been to this town, and I sure as heck don’t have a clue where I am going. I pack up a backpack of children’s and prenatal vitamins and a couple protein bars and Gatorade packets. In hindsight wish I would have packed bubble wrap and vacillated gauze. Or a helicopter.

            The trip starts smooth, the usual moto ride into town, dropped at the riverbank to walk across because the bridge collapsed. Hop on a taptap for a good 30 minute drive. Piece of cake. Then another motorcycle. At this point we meet up with my interpreter Smith who agreed to come along. I am not, ahem, sufficiently  “equipped” to do the proper breastfeeding education with body language alone. This moto takes us back down a dirt road with large loose stones. These drivers are impressive, sharing the road with mules, horses, and sometimes two other motos alongside. I prefer to sit on the back of our threesome, so I have any easy exit. You also get more air in the back, which makes the ride a little more exciting.

            As a preface, I took a moto expedition last week up a nearby mountain to talk with some women, and the ride home was horrifying.

As a preface, a couple weeks ago we took a nearby mountain by foot.  This proved a wise choice as those of us hiking watched two of our friends flip off the back of a moto trying to take on a steep climb; one whose spine was saved by her backpack, and the other who suffered a severe calf burn.  The following week I repeated the expedition on moto to go talk with some women (business and family planning). The ride back home was horrifying.  The feeling of “freefall” is not something you necessarily want to experience while attached to a motorcycle painting the edge of steep drop offs.  Freefall is an amazing feeling when, say, plunging into a Jamaican cove or off the back of a boat with a scuba tank. Must say my body is still a bit cautious from the most recent feeling of freefall in rollerblades down Dr. Freund’s hill. The wound on my knee is currently opened and being whipped we fly by weeds and thorns, reminding me of the bad decision. We are entering the mountainous ravines. I ask where we are going. The drive points up, where I see nothing but mountains beyond mountains”. Ok. “How much longer?” “One hour”. Alright, hold on kids. Let’s do this.

            Things are going, so-so. The steep drops are short-lived, and the hiking path is just generous enough for the narrow wheels of the bike. Things get worse quickly. The steep ravines expand beyond view of a flattening point. I really have no road vocabulary to describe the path – Level B is the worst we have at home. This is like level B with large, loose stones loosely piled on top of each other and steep cuts within the dirt road from the recent rushing waters of Hurricane Sandy. Combine this terrain with the steep climbs and drops, and you have one heck of a widow maker.  One slip of the back tire on a loose stone, and my calf is sandwiched between a muffler and gravel.  The further we drive; I am realizing the closest thing to a hospital is probably trapped trembling in my muddy shoes.  This was so stupid of me. The revving motor and tires peeling out below me in the rubble pushes my threshold. “Mache!” I say. I’d rather stop and walk than jostle on the back of this moto with a back wheel swaying back and forth to the rhythm of my funeral procession. Which is stuck in my head at the time. He says it is better for him to have more weight on the bike for downhills. I say it is better to not have dead weight for the way home. He agrees, and at the bottom of the cliff we resume positions on the bike. This trend ensues, we ride until the terrain is too nuts, and Guillene and I hop of to hike up or slide down the mountainous hills. Two hours of this later, we arrive to a slew of families. Asking around for our patient, we hike another 20 minutes straight up, and there sits the baby daddy we’ve been looking for.

            I still don’t see the baby, and begin to worry. I get up from the conversation centered on the moto driver’s plights (including him reminding me to pay him well for taking “hell road”).  I peek into the mud hut of a home, and see the mother on the bed holding the baby. She sees me and hands her to me.  Mom looks bashful, and almost ashamed to see me. I feel bad, I was probably too stern with her and should have been a little more gentle with the counseling. The baby looks the same. Doesn’t squirm or make a peep when in my arms, just stares past me. Her belly is swollen sounds like an inflated bongo. I asked mom when she last fed her. “Yesterday afternoon, when I was with you at clinic.” “How often do you feed her in one day?” “Twice.” I am frustrated. We come out into the sunlight to join the small circle of friends and family. Lecturing her clearly didn’t stick yesterday; let’s try another method. I ask the older woman, “What should new babies be eating?”  “Breast milk for the first 6 months” she astutely replies. I’m impressed, yet angry. “Do you share this information with new mothers? How did you learn that?”  “She didn’t ask the elders. She wanted to feed the baby her way.” Life advice people – ask your elders.  (sorry mom and dad)  More counseling ensues, with the elder peer pressure on my side. She wasn’t happy with me when I said the feeding schedule might require waking up in the middle of the night.  Upon request, she began breastfeeding the baby. The baby took like a champ. We sat and watched for about 15 minutes, and I was reassured that 1) mother could produce and 2) baby could suck. Was the 3 hours horrendous journey worth it for those 15 minutes of monitored suckling? I hope yes, but the whole ride back I had myself convinced the answer was no.

            The ride home went a little faster, but still involved hopping off the moto to “mache” when the inclines and terrain were too much. Nearly three hours of intense Haitian sun later, I had never been so relieved to see the paved road. The ride back I stopped focusing my energy on whining in my head and realized – she just made this trek with a 23-day-old baby. She walked for hours and hours just to come see us, to come get lectured, and to not have her baby “healed”.  I hoped that at least by going out there it instilled faith in her and her community that we care. Sure, it wasn’t too exciting – no lifesaving mission or emergency intervention where I can see a positive outcome. But that’s just selfish. What God packed into each breast lobule is 100% goodness, nature’s finest remedy.  What is my job if not to match resources and needs? I am beginning to embrace the simplicity and huge impact of basic education.  

24 day old baby girl with a belly full of air. Baby guts are lined with cells that love human milk and aren't able to digest much more...thus gas and mush build up to make a huge belly.

Checkin out the goods. Honestly, handing out the pack of vitamins was probably more for my benefit than theirs. Sucked to drive all the way there without "giving" something. Sorry kid, they taste pretty nasty. 

This is my attempt to create a fashion blog and bring back the overalls.
 When did they become uncool? Kipp, help me out here... 

Dear Danielle

Dear Danielle,

I am writing this to you today, because I have been thinking of you all day. I know it is your big opportunity to shine at state volleyball, and it hurts my heart thinking I won’t be there to cheer you on and watch your talent and leadership in action.  I know it’s lame, but this blog entry about my day isn’t meant to be an excuse for not being there or even calling you, but I hope by reading it you realize you were with me the whole time. Every day I can’t help but put on my big-sister pants and think of how I can teach you and guide you with little life lessons… this was especially true the last 24 hours.

The morning started with goodbyes. The Bellevue team of the beloved neighbor ladies Emily and Julie, and many more good friends, headed back down the mountain. With a 3-4 hour grueling drive ahead of them, I wasn’t envious. We had just made it up the mountain just two nights earlier, traveling on motorcycles as a last ditch effort to complete the long journey. We weren’t giving up. We left the house at 8:00 am on Tuesday morning, after having one driver bail on us that morning. We hit the road, dropped off a 2 year old and her parents in Port-Au-Prince to see an eye doctor for a surgery to correct her congenital cataracts and give her vision. VISION. Yea, that’s a big deal. Try closing your eyes for a minute, and tell me it’s not. She’s gone her whole live with her vision getting worse and worse, woth little understanding of what’s going on. Nice work Tyler for finding and diagnosing her.  Dani – never take that for granted. Try serving your zones blind. That should be easy. Now try blocking the middle blocker you just played against. Grateful now? And don’t forget that vision is more than just what’s in front of your face.

After sending her to the hospital, Matt and I had a mission of finding an orphanage that is looking for medical teams to come check on their kids. We didn’t really know the name of the place or where it was, so we picked up a passerby on the street who thought he had heard of it. He used Matt’s phone to communicate with the orphanage’s manager, and 10 minutes after he left the car we realize Matt’s phone (with all of our contact information for the week’s journey ahead) was missing. We turned that taptap around to find the punk responsible. We caused a near riot in this small town, with the town on our side yelling at the group of guys who were potentially guilty. I was ticked. Enough talk – I lined up the 4 guiltiest parties and gave them the full pat down. No luck though. It was gone. Lesson for the baby sister: don’t invest too much of your life in a cell phone. Or any material item for that matter. These things are transient and can’t be counted on.  Also – just because you get burned once doesn’t mean you lose faith in humanity. People do bad things for reasons we can’t always explain.  We have been blessed to never have lived in poverty or desperation where stealing is a means to eat dinner.

Once we reached the orphanage, we felt instantly energized and relieved. Connie (new friend) received us with open arms, and showed us around the grounds. Over 150 kids call this place home. Kids who were left on the doorstep by their parents, or found sick and dirty in the streets. (Check out Imagine Missions - http://www.imaginemissions.com/index.html) 

We were only there a few minutes and in walks two Canadian family physicians and their 3 daughters, here to do a clinic with the orphans. They visit twice a year to do check-ups, and their girls help with giving vitamins, paperwork, and reading/playing with the kids.  (Ready to sign-up Dani?) This trip, they had missed a flight or two and were behind schedule; so immediately upon arriving they were ready to get to work. Connie introduced Matt and I as health providers. They said – great! If we have 4 providers we might be able to get through all the kids’ exams today! Let’s get to work! We looked at each other with raised eyebrows… this was only supposed to be an hour pit stop to check out the location and see if it would be a good spot for our team. But are we going to turn down the offer to examine a bunch of energetic orphans in their Sunday best school uniforms? Heck no. In a matter of seconds we responded “Yea!” and got to work examining kids right there on the spot. Scalps, heart murmurs, ears, throats, and bellies were examined, and albendazole was force fed to the masses. In talking with one of the interpreters – we learned that our final destination was still quite a trek away – about 4-5 hours on a terrible road. It was 2:30 now, we had no choice but to get moving. We thanked the gracious Canadians for letting us join, and we hopped back into the back of the truck to finish our journey. Lesson here little miss Dani? Go through life with an open heart. You are very open-minded individual – continue to keep your eyes peeled for opportunities to learn from other people and share your gifts. Some of your gifts: encouragement, optimism, enthusiasm, leadership – use these gifts every chance you get! You never know what kind of difference you can make until you try your best to share what you’ve got.

Matt examining some kiddos 

Awesome Canadian FP doc 

 Two hours into the journey, we arrive at the base of the mountain.  Our driver stops for gas, and begins chatting with the locals. He returns with bad news – he’s not taking us any further. This road is too rough for his car. “What!?” We specifically asked him before leaving if this truck was 4 wheel drive and 4x4 (even though I still don’t know what that means), and he say yes. Now he sheepishy admits he lied, but thought it would be fine because it “has a really strong engine”. Yeah, well so does my mouth but I don’t have a balloon to fill with my hot air and land us at our target. Only option to make it to the top is on motorcycles. I asked a truck at the gas station if we could rent it from them, they said heck no. Soon word had spread that the “blan” needed motos, and about 15 guys were behind our truck begging for the job. Big job – 3 hours each way would earn them about $20. In the midst of al this I realize it’s going to be a long ride in a skirt. I’d learned that the hard way previously. I change into my cargos in the midst of the chaos. Lesson here? It’s coming…

Crazy moto driver

Gorgeous views, less scary looking from bottom up. No photos were taken from the top for fear of my life.
Yes, I am being dramatic. 

There she goes. 

Three and a half hours into the dark later, we have climbed and coasted through several mountains and arrived safely. Keep in mind these roads are unpaved, without street lights, without a middle line dividing traffic, and without a separate "animal crossing" lane. Upon arrival, Matt is bruised from colliding with a mule, I'm muddy from getting stuck in mud and feces, and we're all sore from holding our months worth of luggage strapped behind us. The crazy moto drivers are grinning like kids on Christmas - this challenge of speed on rough terrain with a girl screaming on the back is a teenage boy's dream. 

The exhaustion wears off immediately in hearing a familiar voice - "Rach! Rach! OMGGGG!" Emily and Julie come running down the stairs with open arms. The hugs are energizing. I can't stop smiling, and am so grateful for the hospitality of Cindy, Julie, Emily, John, Toby, Andy, and the whole gang. 

The little sister lesson here: 1) For all activities that thrill you to the point of terror, loosing your voice, and wetting your pants: you’re only allowed to do once, the second time will probably kill you.  Do this with prayers and for good reason. Doing it for the thrill or to test your luck isn’t a good reason. 2) Friends make bruises go away. Friends with licorice and beer waiting deserve payback in tenfold. Always strive to be that friend who gives hugs, licorice, shampoo, and clean sheets. Be that friend to everyone, not just your bestie snuggle bums honey lover (whatever other weird nicknames you guys have for each other). Got it? 

Bellevue reunion. Can't help but bust out the Girl Scout's theme song:
"Make new friends but keep the old, one is silver and the other gold"

            Today the awesome group left, and Matt and I needed to finish our mission, which involved a 5-hour hike even higher into the mountains. The remote town of La Fite had build a clinic building, but had no one to work it. Our group has many doctors, nurses, pharmacists, ect who are super gung ho and awesome about helping in new places. We are hoping to match the services, so Dr. Chris told Matt to check it out. We pack up our sleeping bags, protein bars, and half-clean underwear. Lace up the hiking shoes, fill the water bottles, and do some deep lunges and raises to warm the calves. Kidding about that last part – these calves were born hot.

            Only problem with leaving for our journey – there are about 60 patients downstairs waiting to be seen. Awesome, except our interpreters left. Dr. Leo (Haitian doctor who works/lives at the mission) told us to get to work so we could get on the road. We each have a clinic room and nurses leading patients in. Once I get past “How are you” “Does your head/stomach/back hurt?” “Do you have acid” and “Youre blood pressure is high”… I’m out of phrases.  I am running back and forth from my room to Dr. Leo’s, who is laughing at me saying “You’re fine just do what you think the patient needs!” Not okay. I bail on my room at join Matt’s. His Creole is better, and two heads are better than one. Matt led the way with his Creole and I did my best in talking with my hands (life skill I know you have mastered!). Eventually I was again frustrated. Communication is everything, especially in medicine. When a mother has a sick kid on her lap, traveled for hours to get here, and is going on and on about when it started, what symptoms she’s noticed, and what her concerns are – I need to hear what she is saying. Sure, I can garner a lot of information from listening to heart/lungs/belly, assessing their weight for age, and taking their vitals. Heck, just by looking closely at a person you can usually label them as sick or not. But when a patient just traveled for hours and spent a day’s wage to see a doctor, you damn well better give them the best care you can.  I sort of turned into a brat and told Matt this is dumb, we are better off letting these people just wait for Dr. Leo. I leave the room, Matt’s continues on and feels more confident about the situation. I went to check on the inpatients – there are 4 people staying the night here in a room with curtains between them. They are told to bring their own food, but 3 of these are kids who are staying here alone. They have no food; they are sick, and looking pathetically weak. One of the patient’s is a girl we admitted the day before who stepped on a rusty nail a week ago and was now septic. Another was a 7 year old boy with Typhoid. Another was a 22 year old male who weighed about 80 lbs and had pneumonia. The other two ladies I don’t even know what they had, but they looked ill. The good news about the Americans leaving today is it meant there was more food upstairs available to share. I know this is against hospital policy, but I’m feeling a little helpless and emotional right now. I go upstairs and load of plates of plantain, avocado, and PB&J to bring back down. All of the patients are barely strong enough to lift their head to swallow and require feeding assistance. Talk about rewarding.  Again, I think of you. Cheesy as it sounds, I am thinking about feeding you when you were a little runt. I am sorry for the times we played restaurant and I convinced you to eat my crazy creations, and for the spoonful of cinnamon. But it sure made me happy to fill your chubby little cheeks with spoonfuls of Gerber. Find a way to experience that joy. You may think there are no hungry people in Bellevue, Iowa…but there are hungry people all over Iowa and the USA. You don’t need a medical degree or even a high school diploma – you have a grocery store and a big heart – go feed someone. 

Snapping out of it, I resume to the clinic room with Matt, who has intelligently opened a Creole dictionary program on his computer. We are able to succeed in seeing a handful more of patients, and around 3:00 we are finally ready to get on the road. We buckle up our packs, knowing we need to hustle before dark sets in. As we are just two feet from the door, commotion abounds.

8 men are carrying a stretcher, followed by 15-20 other community members reeking of emotional havoc. We immediately drop our packs, and usher the patient to a bed around the corner. He is filthy dirty, shivering, and not responding. There are 12 people in my way, and my angst causes me to angrily point them out the door and shut the door in their faces. This guy is sick. Matt is already at the bedside doing ABCs. He yells – “No breath sounds on the right”. I yell “Oxygen!”. No one moves. Dr. Leo yells “Oxygen!”  The nurse scrambles to find the O2 machine and oximeter. He is satting at 82%. Matt is still assessing the patient's neuro and cardiovascular status. I begin tearing off his muddy, soiled clothes. The smell is horrible. We start to get the story: He is a friend of Dr. Leos, works in his garden. He has been missing for 2 days, and his friends just found him in a 70 ft hole. He has wounds on his hands indicating he was defending himself. Exam of his head shows two large gashes, filled with dirt, and no longer bleeding. Not a good sign. If he has wounds this large and is no longer bleeding he is severely dehydrated and sick. Along with the gashes is a large dent, we conclude he had been beaten over the head with a machete, and his hands tied tightly. This is horrible. Gut wrenching. Things are not moving as a trauma should. “IVs!” We need two large bore IVs with fluids on wide open. We need a warming blanket. We need a chest x-ray. We need to type and screen him for blood replacement. We need cultures, labs, C-spine stability and imaging. So much we needed, yet so little we could do. Once we get the fluids, warming mechanisms, and antibiotics going, we wheeled him out for a chest x-ray. The x-ray machine rolled out of the closet, and Dr. Leo began ushering everyone out of the way for the radioactive particle release. Matt and I are holding the patient, who is flailing his hands, fighting the IVs, and struggling to breath.  Neither of us really want to be in the way of the x-ray, Dr. Leo asks me if I could be pregnant. I say no it’s fine, and begin to cringe and protect my thyroid and ovaries. This doesn’t sit well with Matt, he played the hero and kicked me out to take the beam for the team.

We suspect a tension pneumothorax, and the x-ray shows us we are right. Trachea deviated to the left with chest expansion on the right. In short – his lung deflated/leaking and air was building up in the chest cavity.  Neither of us has managed this before. We tell Dr. Leo the Step 2 CK board’s answer of what is supposed to happen – we need to insert a needle in the 2^nd intercostal space to relieve the air. It's game time.

Back in Cedar Rapids, you are probably just being announced to the crowd. Shinning red uniform, braids, and a big smile. Thinking about it now is jerking my tears a little bit.  I’m proud, and incredibly happy for you and your team’s accomplishments. Wasn’t all that long ago that y’all couldn’t get your serves over the net, and for the love of God y'all made it look difficult to pass to a setter. But look at ya now, unmatched talent and hard work has served you well.

What happens the rest of the night is more medical jargon than you care for, so I’ll do it in a separate entry not dedicated to you.  I hope you accept my apology for not calling or being present. I know how much it meant to you.  I know you understand, but still are disappointed I couldn’t be there. Remember though, this is the first of many “game times” in your life, where you will feel scared, unprepared, or nervous to participate. Your athletic challenges have prepared you to conquer scary moments in life. Be grateful for this. Standing in front of the crowd, serving game points, shooting free throws, or even just running out without tripping (harder than it looks, right!?)– these are all challenges you have already succeeded at! Cool confidence – own it. When you work hard to master a sport/job, do your best and have confidence. Stay calm. Carry on.  Remember forever how you felt on the court when you did something well, and apply this to the rest of your life – races, interviews, tests, ect.

Even more than strength inside, is the strength you can get from God. Never discount this. When you anxious and nervous – pray! Today I read Joshua 1:9 and thought of moments like this. Whether it’s a state game, or a critically ill patient counting on you to work fast. “Be strong and of good courage; be not afraid, for the Lord thy God is with thee wherever you go!”  Big sisters try to carry this protection too. You have a lot coming your way in life, and I won’t always be there. I don’t always have the right advice or the best ideas. But, keep faith in your heart, make good choices, and know that I support you and love you more than you’ll ever know! Now I will anxiously await the next time I have phone reception to find out how the game went, but no matter the outcome – I love you and you’re amazing!

           

House call in a Hurricane

The skies have opened up today and the rain won’t stop. We were forewarned that Hurricane Sandy would be paying us a visit, and I wasn’t sure exactly what to expect. I work early on to the sound of rain. Just when I thought to myself that it was the hardest I have ever seen rain pound the earth – it rained harder.

            We spent the day organizing medicines, and teaching English to the eager students. Not as easy as I thought it would be – since I know enough Creole to say please and thank you – helping them translate common phrases is not easy. I go with pictures and actions, and we had a fun morning. In the afternoon, Matt and I debated how to go about making a house call we promised a patient the day prior. A 37-year-old woman came to clinic, carried by her husband. She is unable to walk, and while the story changed several times, it is apparent this started in the last year. She also reports double vision, and leg pain. Medical professionals– help us out here.  We argued back and forth over the differential, in the end I won him over. We’re going with burst and taper of prednisone, if it MS (2 deficits separated by space and time) or polymyositis (lower extremity proximal muscle weakness was the most prominent feature), we might see some relief in a week.

            The roads were rivers, and we stopped even watching where we stepped because there was no avoiding the swampy mess. Luckily the day we left, Lynn equipped us with some rain ponchos, so at least our chests and shoulders were dry. It was actually pretty run running and sliding around. If the medicine doesn’t help her, at least she will get a kick out of us sliding into home at her doorstep. We finally get to her house, and she lives in what looks to me like a doghouse.  She’s got a straw mat on the floor, water and a candle at her side, and most importantly - shelter from the storm. Not a bad gig, all things considered. She is ecstatic to see us. Again – we have few words for communication, but she takes the 60 mg of prednisone we haggled from the nearby pharmacy. We agreed physical therapy would be important, and the only real way to teach her was to sit alongside her on the floor, in the candlelight, and teach basic strengthening for core and quads. I hope future blog posts bring good news about her prognosis, for now – we’re placing our faith in prednisone and prayers.

Food

“I’m hungry, Blan. Feed me, Blan. Give me money Blan” I’ve been hearing this a lot. Usually in Creole, sometimes in English. Yesterday a 5 year old said this to Matt and I. We said – you want to work we’ll give you money. Today he showed up ready to roll, and picked up 4 grocery sacks of trash around the compound for a whole quarter. Anytime kid. 

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            Aside from pregnancy and babies – my favorite topic is FOOD! Growing up a Bender, our work and play revolves around food. There is a special place in my heart for gardens, farmer’s market, and chopping melons in the back room of the store. Thus, I was overjoyed when the topic of nutrition came up today in class. 

            Food has a unique importance in Haiti. The obvious feature is it’s scarcity, but the behaviors that have developed from this have taken me aback. The “me me” mentality creates dichotomies even between parents and their children. This really sank in for me after my third or fourth day here, when Matt and I drug 15 of the junior league workers out into the community to see if people were using their chlorine tablets to clean the water. We walked a long ways in the hot sun, and they were sweaty and tired – so Matt and I offered to treat them to a meal and drinks by a street vendor. I was happy to reward them, and ran to buy soda and juice while Matt negotiated with the lady manning the large black pot of broth and floating fish parts. We ended up paying about $3 a person for a plateful of rice, beans, meat, and a drink, nothing right? The workers each hustled to get their own plate filled and grab their drink of choice first, with mutual disrespect for each other. They gobbled up seats, food, and drinks, and I was just standing watching in the corner, a bit flabbergasted. Not a single person said thank you. I didn’t even eat. Partly because I didn’t want to sound greedy, partly because it looked nasty, but mostly because it wasn’t offered and I didn’t know how to ask for it.

            Matt had spoken up the mentality produced by receiving handouts and having a hungry belly – but seeing it was a little bothersome. When I was a guest in different Latin American cultures, I was offered a seat, water, and food almost any place I went. This gets uncomfortable too, because you see how little people have and don’t want them to waste their chicken/mangos/rice on you – and sometimes their goat head stew just isn’t appetizing. But the theme of generous hosting had obviously spoiled me. I sort of sound like a selfish brat, but it really bothered me that there was no appreciation.

            Back to nutrition class. These ladies hand out vitamins on the reg, but it was clear they had no idea what was in them or what functions the vitamins had. They couldn’t even name a single source of protein, calcium, or iron. Rice rice and rice? No.  After a lot of guessing and discussion, we made a table of vitamins, where they come from, and how it benefits the human body. We talked about which vitamins are most important for pregnant ladies, and how all the important vitamins for babies are in breast milk.

            As usual, class and clinic sort of run together. Today is not a clinic day, but patients know they we won’t turn them away. Worked out well today, because an excellent teaching case walked in the door. Well, was carried in the door. It was a 23-day-old baby girl. She was extraordinarily calm, barely moving in fact. Mom said she had a stomach cold. Some more questioning on diet and nutrition leads to unwanted answers. She’s eating “Gerber” or mashed up foods. This includes mashed up crackers, cookies, etc. 23 days old. This baby shouldn’t have anything but a tit in her mouth. I was a little frustrated with the mother’s ignorance, in the US this would be arguably called child neglect and endangerment, and the kid would be taken away by DHS if they didn’t change their practice.  I brought the mother and baby in front of the health workers to “work-up” the baby’s “stomach cold”. They immediately got to the root of the problem and began lecturing in passionate Creole about the importance of breastfeeding. Made me proud, but didn’t solve the problem.  Angie left us a few bottles of formula, so Mahalia (who has a baby girl of her own and is furious about this situation) mixed up a bottle and I tried to feed the baby. She wasn’t taking. She is probably so backed up from all the crap in her stomach, and hasn’t been strengthening her sucking muscles. I’m hoping she hasn’t forgotten how to squeeze those cheeks. I told mom to go sit in my room, and they aren’t leaving until I see that baby sucking a tit. An hour later, they were released, with about 15 seconds of successful feeding. Mom still just didn’t get it. We are going to visit them tomorrow, and hold an education session within her community on breastfeeding and children nutrition. I unfortunately agreed to this before asking where they live – sounds like we will be leaving at 5am to catch a moto, then a tap tap, then a moto, then walk an hour to get to their mountain village. Damn.

            Matt had the idea of creating a survey for parents on what they feed their kids at different ages, as well as measuring babies arm circumferences to assess malnutrition.  I’d been wanting to survey more women about birth control (what they’ve tried, how well it worked, and if they’d like an IUD/tubal ligation). One paper with some questions Sharpied on, and a couple hundred copies later, and we have a survey for the community. We teach the girls how to measure kids’ arms, and incentivize them with some sodas. Half of the group goes to the market to teach about nutrition and take blood pressures, and half of the group breaks into pairs to go house to house with our questions. Ready...  break!  

The junior leaguers hitting the streets for community surveys

Community health workers teaching women about different forms of birth control we have available. Visual aids of the mysterious uterus and cervix are money.  

See Matt's post "Fracture" to explain the sling

    















          I stayed back with the interpreter Smith to help me translate some recordings from some women’s “focus groups” I taught the girls to conduct. It’s fun to hear the information that comes from a bunch of women sitting around talking about pregnancy, disease, babies, etc. I’ll share some of that once I have it more digested. For now a summary looks like – “We need food, jobs and schools, kids are expensive, and men don’t help”.  Speaking of food – its about 2:30 and lunch still isn’t ready. I’m not too disappointed; I can do without the usual buttered noodles and will hold out for the good stuff at dinner – rice and beans. Mmmm.  One of the younger girls runs into the kitchen and says –“You have a patient!” Smith says “Tell them to come back, we don’t have clinic”. I give him an expression saying otherwise, and we both head over to clinic. The man looks an aged 65 years old, and complains of pain in his throat. He said he was eating lunch, and can’t swallow his food. Feels like it’s stuck in his throat.

            He looks in a bit of distress, but not bad enough for me to be too worried about aspiration. His lung sounds were beautiful. If there was food, it was in his esophagus. Uncomfortable, but not going to kill him. Next I want to see him swallow. He’s handling his spit pretty well, but I’m curious to see more.  Now I should give him a little water or liquid first, but we are currently out of water at the compound (yeah - no drinking, showering, or flushing…Matt’s toilet is still full from this morning). The last bit of water I know to exist is in my water bottle, and the selfish Haitian survival instinct kicks in. I’m keeping it for myself. Let’s move on to solids. I grab a couple Tums from the medicine shelf and instruct him to chew and swallow. This is very uncomfortable for him, and he is nearly gagging trying to get it down. My brain says that gagging means Heimlich.  I have never done the Heimlich before, and imagined it going down around a big dinner table, with an emergent gasp from across the table as someone turned blue and brought their hands to their neck. This was a bit odd for me to do such a harsh maneuver on a man just sitting comfortably, but I shrugged; What the heck, let’s give it a try. I awkwardly stand behind the man, bear hugging him. He’s gotta be slightly confused as to why the white girl is seemingly trying to pick him up or crack his back or God knows what. At this point the two little girls (enduringly annoying little sisters by now), are peeking around the corner watching what’s going on. I position my right hand into a fist, just under his rib cage with my left on top for power. I swiftly supinate my right wrist, plunging into his stomach. He gags. Uncomfortably.   Other than that, nothing happens. I keep at it. Two pumps, three pumps, four… blaaaaaah. Out it comes. A huge rubbery chunk of meat. And every thing else in his lime green lunch stew. This dude had a good lunch. Carrots, spinach, rice, and stew meat. I felt bad making him loose all those calories. Even more sorry it happened in the middle of the clinic floor and I didn’t have more insight to take you outside! I was as giddy as a freshman getting asked to prom. It worked! Holy shit! Ha! Did I mention I have never done that before? Or seen it! It really does work. Thank you Carole Schafer and all the CPR/First Aid teachers of the world!

            He looked at me with a wide-eyed grin of relief, and reached readily to shake my hand. The looks on the faces of my interpreter and the two girls were just priceless. So disgusted.

Awesome. 

           He immediately feels bad and wants to clean it up. I am still laughing and motioning to him not to worry about it. One of the girls brings him a piece of cardboard and a small jug, still disgusted, and motioning that he better get to work cleaning it up. Did I mention we were out of water?  He was just overwhelmed with joy, and kept saying “Merci Ampill”! The pleasure was all mine. As he left, I finally saw the culprit as he opened his mouth in a gaping toothless smile. I’m still shaking my head laughing.

For your food viewing pleasure: a few photos from the nearby bi-weekly farmers market.

The market continues to impress me, love the colors and sounds - not so much the smells....scroll down to see why.

Fresh meat from the market.

Tasty, eh?

Baby David

The day began as every other – roosters and goats calling “Ma-a-a-a-a-a-a-t” until we all wake up and feed them mango peels. Patients were lined up outside before breakfast was on the table, including some of the women who followed instructions to come back one week after their speculum exam to see if the medication had improved their symptoms.

“Is your discharge better?”

“Well, I won’t know until my period.”

“Did your discharge get better from the day you were here in clinic?”

“I didn’t have it that day.”

What? Oh boy. The “buffet phenomenon” is a term coined (today by Matt) to descrive patient behavior at our big clinics. They see a doctors once every who-knows-how-long, so they complain of every symptom they may have experienced in the last year. Get their plateful since they paid their 50 cents for the medical buffet.

“Ok, did you take all of your medicine?” Yesterday should have been the last day of Flagyl 500mg BID treatment for the Bacterial Vaginosis we diagnosed per microscopic exam.

“Oh I still have a few left, I take it ever morning and when I have a headache”.

Fail.

Next patient – here for follow-up to enroll in our contraception project. Any woman interested in long term contraception – IUD or tubal ligation – was to follow-up with a pink id card so we can give them a progesterone shot now to ensure they are not pregnant when the surgical team from Iowa comes in January. We want as many women as possible informed and consented for procedures so we can have them roll in and out efficiently, and provide the service to as many women as possible.

The patient sitting before me has had 8 pregnancies and 6 children, and she is 33 years old. She is wisely inquiring about obtaining a tubal ligation.

“What form of birth control are you currently utilizing”

“None, God is protecting me”

“Ok. Do you use condoms, pills, shots, or anything at all?”

“My partner drinks Toro energy drinks and takes my birth control pills sometimes. It has worked well so far.”

Wow. Please don’t tell your friends about this method. And please tell your partner not to be alarmed when he develops breast tissue and emotional labiality.

The next few patients are my least favorite – kids under 2 who are lethargic, not eating, and parents complain of fever and diarrhea. So hard to watch sick babies lying on their mothers bony lap. They hate me for poking them to draw blood for malaria tests, sticking scopes in their ears, and forcing grape goo in their mouth. All that pissing them off, and I still feel helpless. I have finally become competent at peds dosing of antibiotics, but to say I am confident that they will help is a long shot. The need clean water, a steady supply of food, and DEET. So simple, yet so far fetched.

In the midst of clinic, a woman was brought to my attention. She was a referral from Dr. Matt who was currently in a nearby town talking to people about their need for a bridge vs road. She was pregnant and uncomfortably laboring. My bedroom has several unused extra beds and is located right next to our clinic room. We made her comfortable on the bed, gave her some Tylenol and a cold washrag. The health workers were too excited about delivering a baby to tend to the patients who were building up in clinic, and I’d be lying if I said I didn’t want to blow off every other patient to sit here by her, time contractions, and remind her to breath. Nola is one of the community health workers who has had some training as a midwife, and is also a neighbor to this lady. She gets a free pass to tend to her laboring needs, and the rest of us go back to work to finish up the patients.

            When I return an hour later, she is just miserable. She got up to squat out the back door, walked a bit, and regressed to writhing on her back. She was moaning about a “cesarean”. Sounds like she was begging for one. Sorry lady, you’re rocking this and there’s no way I’m touching a scapel to that firm belly.  Only one way out of this, and it involves stretching the most sensitive part of your body 1000x its original size. Doesn’t seem like a perfect design when you put it that way. But I must say, the natural progression of the labor was just beautiful. When contractions were only a minute or two apart, she was alternating between wailing and exhaustion. Even lower back pressure and sips of water weren’t of interest anymore.

            The younger girls I have been spending a good deal of time with are asking about class today. They have notebooks and eager faces, ready to scribble in whatever English or health lessons I can muster up. “Today we will talk about labor and delivery!” They head into the room with the laboring lady, and before too long, they begin doing what they do best (besides learn English). They begin singing at the top of their lungs, clapping, and swaying to the beat. “Jesus loves us, oh yes he does!” “Praise God!” and many other combinations of that sentiment. Nola takes off her gloves to join in the clapping. The laboring woman throws her hands in the air to clap and sing along between contractions. This is so much more fun than an epidural. Finally – I see a big thick head of hair peaking into the sunlight. “Puse!!!!!!” The room echoes “Puse!” And the singing continues. In about 10 more strong pushes, the head of a perfect baby boy emerges. He is not yet crying, but I grab him from Nola and begin warming and stimulating, suctioning his mouth and nose. Just a few days ago we reviewed in class the basics of a clean birth and neonatal resuscitation. I was happy to see the other health workers in the room, with faces glowing and cheering along. The baby let out a wail that was barely audible in all the singing. Mom was exhausted, and finally released the tension in her neck by collapsing on the bed.

            We got to use our first “Clean birthing kit” which were just decorating our small Coralville apartment. The sterile string which had been baked in our oven was tied on the cord, and the clean razor blade purchased down the street at the market effortlessly sliced through the cord. Placenta came out in no time. Mom and baby were both too tired to feed, but they snuggled and warmed each other’s shivers. While cleaning mom up, we took the baby for a little teaching on the newborn exam.  Matt drew up a modified Ballard exam, complete with pictures of baby nipples and testicles. It was perfect to have the universal pictures. For non-medical people, the Ballard exam was designed to estimate the gestational age of the baby at time of birth.  There are certain features in the baby’s position, skin texture, etc that can indicate if the baby is preterm or not.  We are hoping to get a good exam of all the newborns that the health workers provide prenatal care to so that we can see how accurate the fundal height measurements are. It is difficult to ever know for sure how far along a mother is without ultrasound, especially when all the women seem to measure so small when they are undernourished.

The girls assessed the baby’s posture, skin, vitals, and anatomy to determine he was of full gestational age and healthy. All of the attention must have finally made him hungry; his lips began puckering with intention. Time to put mom back to work. Baby rested on mom’s chest as he took he first ex-utero gulps. Remarkable instincts. Yup, back to accepting this as perfect design. I quizzed the girls on benefits of breastfeeding.

“It makes a healthy baby.” Absolutely right. Breast is best, tough to convince everyone of that, seems that kids get fed crackers, cheetos, rice, and other foods at much too early of an age. Matt informed me it is easier to feed babies a few little crackers than to buy mom an extra couple thousand calories so she can keep producing milk.

I explained that milk passes immunities, offers some birth control, and helps the uterus shrink back to size. We felt her uterus together, and as predicted it was firm and remarkably shrunken down.

The lesson was going so well until my stupid statement “Another benefit of breastfeeding is it helps mom loose baby fat” Blank stares. “Scratch that. I mean mom needs as much calories and nutrition as possible. Kill a chicken, figure out a way to get her some meat every day.”

I should have heeded that last statement more seriously. A few hours after delivery, things were calming down, and mom wanted to go home. Dad was nowhere in sight, and a friend had come with some baby clothes and a change of clothes for mom. She was sitting up, talking, and happy. Matt and I said we would help her get home. We packed up her goods, included the sterile sheet we used (she wanted to wash and reuse it) and the placenta (to bury at home). After walking a short distance at a rather slow pace, I graciously offered her Matt’s services. “He can carry you!” To all the readers -  next time you see Matt remind him how strong and brave he is.

We walk about 100 yards from our compound, and we need to stop and let him rest and give her a shot to take a few steps. Matt just barely gets her hands off of her, and she begins to wobble. Not in an organized dance kind of way. She slumped into matt and onto her knees, with a classic myotonic jerk as she went down in the gravel. We both swept under her as best as we could, her friend still walking off into the distance with baby David without a clue. I don’t think we even exchanged words, just knew we had to get her back to the compound. I boosted her up as Matt lugged her back into his arms. We got her snuggled back in my room, and to be honest I was pretty thrilled to keep an eye on her and the baby for the night. Once she was snuggled and they were both sleeping, Matt and I hopped on a Moto to quickly go into town and get some “fastfood” on the side of the road. Mmmm, rice and beans. She gobbled it up while we took turns goo-ing at the baby. Dad is here now, and they are all happily relaxing in my room.

Special birthday, and a wonderful day to be born! Gets to share with my favorite godfather/uncle Rick Fury. If this baby is anything like uncle Rick, Haiti needs a fair warning when David puts those feet to the floor with some Bachman-Turner Overdrive. Happy birthday to all who are blessed to share this day with David and Rick!

I admit, the recent “discharge study” was enough to make me question why I wanted to get my face between the legs of complaints of “itchy, smelly, thick discharge” every day for the rest of my life. I owe baby David a big thank you for reinstating my love of obstetrics and excitement for my future in Ob-gyn. What a joyful day!

Birthing kit finally put to use! It contains a bar of soap and gloves for the deliverer, sterile string and a razor to cut the cord, a sterile blue blanket for mother to lie on and to warm the baby if necessary, and some alcohol wipes to keep the cord clean in the weeks to come. Thanks Nurse Sue for the head start on the project!

The "Discharge Station" Begins

The big team arrived yesterday afternoon, and is prepared to see the hundreds of patients headed our way. Matt and I will have a unique role, introducing the speculum exam into the crazy clinic flow.

Today started with mixed expectations. The day prior, my goal among many others, was to get my hands on a microscope. Matt designed an awesome study identify and treat vaginal discharge. Sounds exciting right? It’s actually a pretty big deal. In prior clinics, the majority of women complain of some type of vaginal discharge. White, yellow, thick, painful, etc… a variety of complaints make this a colorful category with many possible etiologies. It is difficult to pin down the cause of discharge without a speculum exam of their vagina and cervix, as well as a microscopic exam of the discharge. It is also very time consuming for a provider to find a private area to take their patient, perform and exam, and establish a better diagnosis that history alone could have, all the while patients are getting backed up and pushing their way to the front.

            At home, we’d send specimens to the lab where a tech will grow the bugs in culture media or run a rapid screening test, and all I’d have to do is wait for the result to pop up on my computer screen.  Yes, these simple tests exist, but when it comes down to it you really just need able hands, observative eyes, and a microscope. Back to the microscope escapades. One belongs to CHI, but it is currently missing with an unknown location. (what?) We developed a couple of leads, and were waiting on phone calls from a Dr. Mark and a Miss Phyllis (no idea how the phone trail lead us to them, don’t even care to ask). We finally touched base, and they had one but we could not take it from their premise, as they needed it for a busy clinic as well. Matt and I resolved to take our slides to them at the end of the day. Would it work? Probably not. Would we know without trying? Heck no. We’re doing it.

The only exam table of the clinic -we did our best to maintain sanitation and privacy,
but it was a little more difficult that back home. 

Working under Dr. Bybee to remove a lipoma.

            The microscope was the first of many challenges; to keep this simple I’ll just name the biggest hurdles. 1) we needed a way to clean the used speculums, we had soap, but really needed some bleach water. No bleach. No water. Luckily it rained last night and it ain’t someone’s first rodeo.  For the bleach, I delegated someone who delegated someone who went to a nearby house and bought a baggie of bleach. Just in time for our first string of patients. We had the only actual exam table in the whole clinic, so Matt and I also got the fun job of minor procedures. This includes removing sebacoue cysts from skulls, lipomas from arms and legs, keloids on earlobes, and stitching up machete bites. You really can fix a lot of the world with some lidocaine, a razor blade, and thread – right Dr. Bybee? Dr. Bybee was my first mentor on clinical rotations in his rural practice of Maquoketa, Iowa. He taught me resourcefulness and procedural confidence. On that rotation (summer of 2011), he told me of his many medical travels to Haiti, and I said, “Let’s do that someday, K?”. Well, we’re here, and I couldn’t be more grateful for his mentorship.

            Unfortunately, these simple tools can’t fix it all. In the middle of slicing through a 6 year old girls earlobe keloid the size of a plum (pierced ears + African skin = angry scarring), two of the nurses on the team are carrying a patient slumped between them.  She looks to be about 30, and is gasping for breaths. They act quicker than I can digest the situation, starting an IV and nebulizer within minutes. I refocus back to the bloody mess I am working on fixing up, and keep my attention on my patient in the midst of their controlled chaos. It’s only a matter of minutes when the gasps stop. Before I even complete my stitching, the woman has demised on the table next to us. Time of death – 9:54 am. On the first day of clinic.

            We soon learn that the male that brought her in is in fact a voodoo priest, and she had been staying with him the last several nights, but it was “never this bad”. We will probably never know what she died from or how it could have been prevented. But for now, I am embarrassed to say I felt too busy enough to feel sad or sympathetic towards the life of the unknown woman. At the time I was just frustrated, because it put our working space out of commission and we had patients backing up.

            Despite the hurdles of the morning, we performed 16 speculum exams. We saw several acute inflamed cervicitis, consistent with STDs, as well as some plain old bacterial vaginosis and some completely normal. To all you ladies who may be a future patient complaining of discharge to me - some clear/white discharge is normal!  After we finished up the last patient – Matt and I were excited to head out and check our slides. We hopped on a moto and headed out to a compound where an American doctor had us a microscope. Only one moto wipeout later, we arrived. Dr. Mark is a gracious man from Indiana who spends a couple weeks several times throughout the year to hold clinic, teach local docs, This compound is huge, and quite fancy by our standards. It is funded by Dr. Mark and his wife, through the support of their church. They boast an orphanage, hospital, lab, and even have a fancy operating room.  Matt and I were in awe. We got the microscope set up, and they even had an extra laid out for us to snag. We pulled out the day’s slides, and Dr. Mark hooked me up with a Coke – which made for an excellent dinner at 8:30pm. Deliciously refreshing. We again got busy, but weren’t too successful with identifying live bacteria on our dried up slides. Made for some comic relief and opportunity to work out the kinks of the the experiment's methods and protocol - which I had apparently been wrong for the majority of the time.  From slide prep to timing of manual exams and when to require patients follow up – we had discrepancies between each patient we saw. “Research protocol says do it this (my) way every time”, says Dr. Matt. Fine, you win. Even though I (still) think some of the rules are dumb, I know he’s right. If we want results, we gotta be tight with the protocols.  The first day of clinic was successfully under wraps – with over 200 patients seen and treated, and tomorrow would only be better!