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!

Getting to Work

It’s the end of Day 3, and I’m exhausted. By then end, I mean 8:30 pm. This morning, instead of walking out of breakfast to 7 or 8 people wanting to be seen, there were nearly 40.  Word had spread that the white people where here. Matt and I had to wait for our interpreters to arrive, who planned to arrive at 8. In the meantime, Matt told me to start sorting out people by who looked the sickest. Kids get priority.  One lady is lying on the ground, one lady is plumb pregnant, and many are looking wide-eyed patiently waiting to be chosen. Eventually we get a system. The community health workers begin handing cards with numbers to the patients we prioritized, and start a line to take their vitals. Pretty slick. Matt is seeing patients out on the sidewalk, and I took some back into the clinic room. We keep going back and forth to get each other’s opinions and show interesting findings. Matt directs me to a girl who is 17 and never had her period. She came down from the mountains, which means it’s a several hours of travel. She stayed nearby last night to arrive early today. I start chatting with her, and try to get to the bottom of it. Just by looking at her, she has well-developed secondary sexual characteristics (body shape, breast, etc), so she should be menstruating. “Any chance you could be pregnant?” “No” she bashfully says. I ask my interpreter, John – “Do you believe her?” “Well, she’s from the mountains, so it difficult to make sex”. Ok, fair enough. I explain to John that I believe no one, and got a urine sample. It was negative.  Next test is to take a look. We don’t exactly have any privacy in this two-roomed concrete schoolroom, and I’m not going to lay her on the ground, so I grabbed a sheet and took her to my bedroom. The community health workers have never done a vaginal exam or seen a cervix, so they want to come along. The patient said two of them could come along. I talk with Angie, who is a family medicine resident that worked with Matt back in Jan, she arrived late last night with her husband, about 5 hours later than planned due to a bridge collapsing. After telling her about the patient, she agrees and we head upstairs to my bedroom for the exam. I am not exactly sure what I am looking for, but one thought is that she has an imperforate hymen and she is menstruating normally but the blood is building up. Which would explain the abdominal pain that comes and goes. This poor girl is terrified. We’re in a concrete room with two open windows, a white girl telling her to drop her pants and spread her legs while she puts on a headlamp and cracks open a bottle of lube and a speculum – which is something that has never been used in this area before.  Before even using the speculum, I use my gloved hands and examine the external anatomy. This isn’t normal. Where her vaginal opening is supposed to be, there is a rubbery mass protruding. It is round, and almost looks like a cervix. Could her uterus be so full of blood that it is pushing her cervix outside her body? I try to push it in or move it around, this is very painful to the girl. I obviously can’t do a speculum exam at this point, and tell her to get dressed. I grab the phone and call Dr. Ryan, who luckily answers and is as puzzled as I am. Fortunately, an Ob-gyn surgical team is coming in January and will be equipped to offer proper evaluation and treatment. In the meantime, she suggests using hormonal suppression to prevent blood production, which is painful. Matt hops on the motorcycle with one of the translators to go to the pharmacy, and comes back with a depo provera shot to hold her over until Jan.

            Clinic resumes with a severely malnourished child, scabies, some usual aches and pains, and several women with dizziness and likely anemia. All three of them had recent pregnancy losses where they lost God-knows how much blood and managed it at home. Iron pills and close follow-up is all we can do.

            The real plan for the day was to teach the community health workers. I printed Creole books called “Where Women Have No Doctor”, yesterday when we had no interpreter I just instructed them to read the pages out loud and stop and discuss. I just sat by watching. These students are something, yesterday we went until about 7pm…they just want to keep learning! They could be talking about whatever they want or quitting at anytime, I am just following their fingers on the paper and trying to monitor their discussion – they really are into this. This group of students is interesting. There were 5 community health workers that I knew about from prior, but there is now a group of 12 – 11 girls aged 21-30 and one male.  Mahalia, the wonderful woman runs this mission, “rescued” them from the streets of Port-au-Prince to come live here. They help with chores, and she gives them food and faith. And has instructed me to teach them health and English, and to learn Creole. Yes mam.

            Today, the students are patiently waiting while I’ve been running back and forth with the impromptu patient clinic. They have their books, and are opened to Chapter 4 as instructed the day before. “Understanding your bodies”. Always a fun lecture. We covered everything from anatomy to periods and then finally to my favorite – pregnancy. Along the way, there were many questions and myths. Angie brought me some colored felt, so I had cut out the female organs to use in quizzing and demonstrating. They just couldn’t believe that women don’t make any new eggs, yet men make 10 million sperm every time they ejaculate. Still crazy to me too.  One interesting myth that we kept getting stuck on, is that women can be pregnant for years. Years. The call it Perdicion, and have heard all kinds of stories of this happening. Alright enough here-say – “Ok, who has actually seen this?”. Two girls slowly raise their hand. “Tell me about it”. One girls cousin was pregnant, and after 5 months of pregnancy she started to bleed, and she got her monthly cycle back and but she still hasn’t had the baby so she is still pregnant. Ouch. The concept of abortion and miscarriage is difficult to explain. Without ultrasound or prenatal checks, and if you never actually see a baby leaving your vagina, it’s tough to swallow that your baby is gone. I’m guessing this “disease” they are speaking of, is a product of women getting pregnant with sequential miscarriages, or even just that they don’t get periods due to malnourishment. I think we talked enough to maybe dispel some myths by focusing on the biology of the phenomenon, but science doesn’t always win. Consistence and persistence, I am learning are the key.

            Class kept getting interrupted by yet more people turning up to be seen in clinic. I wasn’t expecting this. How did they even know we were here? It wasn’t a health worker clinic day, they were here to see the “blan”. Matt and I stayed busy, never left the compound to fix our internet or go to market as we planned. At sunset, we were feeling pretty energized with the reward of patient flow and teaching. The last discussion we had was with one of the health workers who was a little chubby and asked how to be skinny. We tried to show her some easy stuff like jumping jacks, but Matt surprised the heck out of me by giving a clap and saying – “Let’s go for a run”. This led to quite a commotion among some of the kids whose parents work here, as well as a few community health workers. “Tennies?” Nods of “Wee!” get your tennies kids, Blan going running. We have about 5 women, 2 girls, and the cutest 6-year-old boy, just beaming with excitement to run with us. After jog down the gravel road into the community and back, the party kept going at home with different exercises and hurdles. Matt grabbed a stick for limbo and ran to get music. This limbo challenged turned into a dance party – and DJ Protégé brought out his mixing skills.  Keep in mind there are still only about 8 of us. We just had a blast into the nighttime, with the workers and kids coming out to join the commotion. Love Shack even made the playlist, and I’m brainstorming how this playlist can be utilized in English class…

            The fun ended for me a short while into dancing with Liza – the 3 month old baby I befriended the night before when painting a room with her smarty pants 10 year old sister. Well, she and I were mostly just talking while Matt painted. In fact, she make the remark “The boy like work. It dark, we no like work in dark”. Ha. Yes, the boy like work.  Anyways, Liza cozied right up into my arms and neck, and became so relaxed that warmth ran down my abdomen. I knew I was sweaty, but this was a bit much. I suppose diapers are expensive. I handed her off, and decided to hit the shower. When I was in the shower, I saw I left my watch from the night before and realized I had zero idea what time it was throughout the day. Just nutso busy from sun up to sun down, and it left me feeling refreshed and joyful. 

Perspective

            It’s Monday, my first full day of waking up and withdrawing to sleep here, and I can’t help but compare how different life was just on Friday. Friday I woke up to my iHome singing my favorite “Good Morning” jam at 5:30am. Today, despite the night sky telling me to sleep, I laid in bed listening to a battle over who-ruled-the-roost coming from all windows rafters and doors. Cock-a-freaking-doodle-do. Get ahold of your circadian rhythms!  Needless to say, the chicken for lunch today was delicious.   

         

            For a Coralville breakfast, I’d grab a quick protein bar or oatmeal for the road. Today, Matt and I sat at the same table with no tv, computer, or test quizzing, and actually ate breakfast together.  It was warm cornmeal with chicken stock and some other seasoning. Mmm, warms the soul. Might take some getting used to.

            Then-off to work! Walking just downstairs resides the clinic room, which is run by the 5 community health workers whose training consists of 3 months of classes with Dr. Angie, Dr. Matt, and Dr. Mike last Jan. They are supposed to follow-up with patients who are seen by the visiting Iowan doctor teams. So I bring Charles to translate, and am hoping just to observe this first day, and see how things run.

            There are two rooms, one where people walk in and take a seat, waiting to be called. The next room has three desks, each with a health worker and an open seat in front of them. The wall is lined with shelves of medications. They are eager to start, and begin calling names back.  First patient is a 1.5 year old boy. Alright, kids are easy, I can do this – mostly education, developmental milestones, and vaccines, right?  His mom says he’s more tired than usual and has diarrhea for a day. Temperature – 104. The boy is very lethargic in his mom’s arms. I am pretty wide eyed at this point and can’t help but intervene with questions. “Is he eating?” “Not really, some breast milk but won’t take anything else”. “How long has he had runny stools?” “3 months.” I show Widlyne how to check for signs of dehydration, his pulse is 160, but he still has moist mucous membranes and good capillary refill. His mom also points to a bump in his groin. It looks like his inguinal lymph node. It is hard as a rock, and bilateral. Checking the baby’s other lymph nodes, it was apparent that he was fighting off some massive infection. Shit shit shit. So much for easy patient follow-ups. I should have paid more attention to infectious diseases when I was on my peds rotation – oh wait…I never saw anything remotely close to this. At this point, all eyes are on “Dr. Rachelle”, and my conclusion of how to fix this baby. I have no idea, without tests or imaging, I just have no idea how to diagnose the cause of this ongoing diarrhea and fever and am slightly panicking on the inside. I ask Wyndline “What is your diagnosis and plan?” I mean, she would be the one calling the shots if I weren’t here, right? She says, “Belly infection, I’d give amoxicillin”. Wrong answer. I teach her that amoxicillin does not help abdominal infection, and can even make it worse. We give the mom a home recipe for oral rehydration therapy, a prescription for children’s Tylenol (which we are out of in clinic-so lame), and albendazole for a probable worm infection. Not likely the primary etiology of her illness, but could lead to further problems. We instructed her to bring the baby back to the big clinic on Friday if he’s not eating. I’m not feeling good about this. No real diagnosis or treatment, just shots in the dark. The interpreter sees my despaired look and says, “Welcome to Haiti”.

            Among the next few patients, I see a 17-year-old boy who is hear to bring in his blind grandma. After we work-up his grandma’s pain and eye troubles, he tells us he is sick too. He has sharp belly pain daily immediately upon awakening, and some previous diarrhea, now with constipation. After an array of questioning and no specific idea of what’s going on, I took Matt’s advice from January and asked, “When’s the last time you had a good meal?” “About 22 days”.  But who’s counting, right?  Wow. I’d be counting the minutes, and started whining about 21 days ago. He also reported blood in his stool, weight loss, fever, and no appetite. All the things you don’t want to hear from a patient.  The differential for infectious causes of bloody diarrhea includes about 15 microbes – some of which get better with antibiotics, some of which get worse. What would I have done in the states? An abdominal x-ray, CT, colonoscopy, and stool sample to nail the responsible microbe. What can I do here? Give him tums, vitamins, and ORS, and tell him to come to the big clinic in a few days if he doesn’t feel better.

            The next case brings me a little more joy to tell you about, for the selfish reason that I could actually diagnose and treat. He is a 23-year-old male, complains of an “empty head” and “pressure” in his chest. Again, on the list of things you don’t want to hear from a patient – at least without an ECG machine and cardiologist on staff. Empty head – hmm. I decided to go for the depression screening. “Appetite?” “Not really”. “Sleeping?” “Not well”. “Losing interest in everyday things?” – “yes”. “Feeling guilty?” “Yes”. I probed. “Guilty about what?” Then flows the dirty love triangle. He loves a woman who is with his friend and on and on. Suddenly, giving a pick-me-up pep talk to a broken hearted man sounds pretty damn easy. We talked about his life, love, and Jesus. Pretty soon two other women workers nearby join in the questioning and counseling. He left looking a little lighter, with instructions to return as often as needed until his heart and head didn’t hurt so bad.

            Just last Friday, I was working in the surgical ICU and was also unable to communicate directly with my patients.  I experienced similar frustrations as now; the face-to-face exchange of words and emotions is what drives my investigations in medicine. In the SICU, I have interpreters as well: machines. My patients have several tubes in their body, with things going in and out every which way and screens like a NASA piolet that honestly still confuse the hell out of me – but can offer information as detailed as their lung capacity, ventilation rates, blood pressure by the second, fluid level in their veins/arteries, and the amount of carbon dioxide, oxygen, acid, base, and every other element possible – it’s all in the numbers. We can analyze and adjust treatments based entirely on these interpreters. As a side note, these interpreters cost near $10,000 a day to utilize. My interpreters in clinic this Monday are costing me $10 a day. They are able to convey the words while I study the patients’ expressions and responses to my touch. I’m grateful for their assistance, but I sure hope the Creole comes easy and I can ditch the dependence on a third party.

            On normal days, like Friday, I usually have some errands to run. So I drive my car when I want to, where I want to, and park at the store that I know will be selling my product of offering my service. Today, I trust my interpreter, (and new buddy) John, to get me to the bank and to market for some razor blades (to cut umbilical cords), bars of soap (my shower last night just wasn’t the same without any soap or shampoo), pick up a cell phone, and to exchange some money into Haitian Goude. So we walk. John hails down a friend with a motorcycle – and we both hop on the back. We’re whizzing around potholes, donkeys, and naked children like some crazy Batman finale scene.  Everyone we pass, stares. Some kids yell “Blan” at the white girl, but most people are just confused. It makes me laugh. I get confusing looks when traveling at home too, but that’s because I drive a car designed for an 80 year old euchre-playing, red hat lady. I am so much cooler now! No speed limits, no rules!             We then transfer from the moto to the “tap-tap”. The famous Haitian “tap-tap”, where there is always room for 1 more. Or when it’s completely full: 6 more.  John pushes me inside to a seat underneath the wooden cover, where speakers are blaring full blast. Again – huge improvement, the speakers in my Buick have been blown for awhile, and I haven’t been able to truly rock out in years. I’m in heaven - Minus the stench of BO and sweat mixing with my neighbors. We finally arrive at the market, where it’s just straight chaos and LOUD NOISES. We bustle from stand to stand looking for our goods. Traffic is whizzing in the middle of it all, and I think John had enough of my small town girl wide-eyed looking around, and just grabbed my hand to pull me along. Too much stimulation for a distractible girl – look! Bird! A few hours and dollars later, we were victorious and hopped on the back of another moto to take us home.  

Warm Welcome

Welcome to Haiti! We safely landed and I already feel at home. Dr. Matt left a mark here in January that contributed to a warm reception. After 2 unsuccessful attempts to pass through customs with 200+ lbs of baggage, we were finally unleashed into the chaos of grabby Haitian hagglers and the beating sunshine. Before we even have time to confront a plan of action, I hear “Dr. Matt! I think I know you!”  Our friends and interpreters, Charles and Peter fended off hagglers, loaded us up, took us to exchange money and purchase a cell phone. We headed north past Arcahaie towards the mountains where our new home, Mission Matana, was nestled.  The scenery on the drive reveals a countryside in a better state than I anticipated. Being the rainy season, the green abounds. We drive by a few “tent cities” and mounds of rubble, but all in all the place looks better than I expected from all the presentations, books, and accounts of those who have come before me.

            An inspiring Haitian woman named Mahalia founded the compound we now call home. Her impressive history includes working as an international diplomat, managing banks, airlines, and getting her masters at Harvard. Her husband Raymond is a brilliant engineer, designing solar panels for use in the Caribbean. The two of them are quite the team, both very committed to improving this community. They could live in the U.S. if they chose, but their hearts are here in this community to serve God through tending to the poor and in need. They have housing, food, and employment for people on their grounds, and take in young women with nowhere else to turn. As Mahalia put it – “We tell them, if you must sell their body for food, come and be safe here.” Construction is currently underway for more housing and a large kitchen to host international teams to have clinics, help with agriculture, construction, etc. Big goals for the future here include a women's and children's hospital as well as a nursing school.

            They are devout Christians, and have daily services open to whomever. Each evening we fall asleep to the children singing their hymns and are awoken around 5am with the men starting their day with songs of praise. It is interesting and honestly refreshing to see bright faces embracing Christianity here at the compound. We are nestled in the “voodoo” capital of Haiti, which is a mix of Catholicism and saint worshiping as well as priestly witchcraft, bad spirits causing diseases and good spirits bringing healing (for a steep price to the “priest”). It will be interesting to see how this plays out in medical practice – may be hard to treat people for diseases that they believe a spirit caused and only a priest can fix.

            The real stars of the show around the compound are the animals. Goats nibble anything and everything, sheep stand wide eyed in the roads, chickens peck near our feet with their babies close behind, mangy mutts have no shame in begging, and the roosters just don’t shut up. Eating dinner our first evening, Matt wolfed down his first chicken leg so I offered him mine too – feeling a little guilty with Mr Chicken’s cousin pecking around my feet. He promised it wouldn’t take long for me to get over the guilt, and in fact the chicken would taste better than Kalmus’ after a few too many rooster awakenings.

            The highlight of my first day was walking around the community. It is just beautiful. So lush, palm trees and greenery all around – not what I expected. I briskly followed Matt as he led me on dirt paths following the canal system traversing many backyards. At one part of the canal, you see three little kids playing naked, splashing and giggling enjoying their baths. Just downstream, sits a young girl with buckets to fill and carry back to her house for drinking and cooking. This is possibly the simplist explanation for the stomach aches and diarrhea to be seen in the future…

            When walking, kids and adults alike line the streets and shout “Blan!”, because yes, we are white. In fact, I haven’t seen another white face yet in our several trips to town and back.  On the exploration, one young girl is extra friendly, waves at us and is motioning with her hands in her hair, and waving for us to follow her. It looks like she is asking me to come back and have my hair braided or something, what is she doing? She leads us back into the homes, where the celebrity of Matt’s blogs was sitting and getting a bath from her mother. Turns out the girl’s motions with her hands on her head, really meant “come see the little girl with the big head!”. The little girl with hydrocephalus had seen by local specialists, thanks to Matt’s persistence, including a neurosurgeon who told her that since she had made it to age 5 (which most don’t), she would be able to live with the condition and not need a surgery.  The moment she set eyes on Matt, she burst into clapping and giggling, never had I seen such excitement in another being. She was just shrieking, and her mother followed suit.  The little girl’s head is still too big for her to balance on two feet, so her mother picked her up to place in Matt’s arms, where she began rubbing his hair and touching his face with glee. I lost it, and was fumbling through tears to get out the camera and try and capture it. Keep in mind the language barrier - no one is really speaking, but we stayed there for about 15 minutes just laughing and hugging. Her mother immediately brought us chairs to sit in out in the yard, and went inside to retrieve two cds with images of the CTs that were done on the last trip to the hospital. She had saved them this whole time, waiting for him to come back. The blan had arrived.