Thursday, October 16, 2014

Wednesday in Leogane 2014

Wednesday I walked over to the Children’s Nutrition Program of Haiti (CNP) – Kore Timoun de Ayiti – to meet up with Tarin the director. I had met her the prior night because Dustin (Engineering 2 Empower) has a girlfriend who is a CNP intern. Tarin offered to bring me up to speed regarding the program’s development since 2009 and show me their malnutrition identification clinic/outpost on Wednesday. (I was familiar with CNP’s “hearth” community health worker model back in 2009 when I was hanging out with my friends Kara and Courtney who ran the program.) As Tarin explained, their programs have effectively knocked severe malnutrition out in the rural mountainous divisions of the arrondissement of Leogane. Now they are now looking to address the urban severe malnutrition issues in the town. Part of their outreach is a referral site where those mothers and babies identified as malnourished can come for follow up. –Plumpy nut peanut butter/Medika Mamba, weight, arm circumference, basic triage assessment. Those with severe acute malnutrition get a dose of amoxicillin, medika mamba if they can eat it or a special milk enriched feeding formula if they can’t, and a referral to a medical clinic in Ti Grove. The program is as fantastic as it was in 2009. It is too bad that the Haitian government does not have the funds or resources to replicate their system on a national scale.

My first real case as a doctor in Haiti came at the CNP outpost while Tarin was explaining their system to me. (during my time at Hospital Universitie Mirabalais, the ER director asked that I would just shadow/accompany during my time there and make suggestions so technically this baby was my first... but who's keeping record anyway? no pun intended) A mother arrived from the mountains, referred by one of the community health workers (aka Monatrices) who determined that the baby had malnutrition. This baby girl was about 4 months old 15lbs with no obvious signs of acute malnutrition (no redish tinged hair, edema, underweight, glassy non-focusing eyes) but had a case of impetigo around her mouth and cheeks and a nasty fungal infection in the folds of her neck. Mom wasn’t sure exactly what her baby girls name was which was sad but often the case with rural Haitian families who wait to name their children. We explained that these infections were likely because she was drooling and spitting up all over herself with no one to dry her. When she said she pa gen lajan – didn’t have money for the trip to Ti Grove, the time for the wait, or the consultation fee, or to actually purchase the medicine that they would prescribe….everyone looked to me………doctor? Which medicines? What dosages? I recognized quickly that she should get an antibiotic and some miconazole antifungal powder. CNP had plenty of amoxacillin so we gave her a first dose and a 5 day supply, then walked her down the road to some pharmacies looking for miconazole powder. After the third pharmacy only sold miconazole crème I settled for clotramizole powder. I gave her 100 goude (about 2 dollars) for her moto back to her mountain town, reiterated my instructions for when to take the amox etc...and she left.

I reflected during my sweaty half mile walk back through town to the residence - curbside consult, compromised treatment plan, tenuous follow up. Grateful for whatever, no HIPPA violation or lawsuit threat- type of patient. Part of me enjoyed it. Part of me didn’t feel good. I would have felt better if I had had my smart phone to check the mg/kg dosage of Amoxacillin, or if I had thought to give her Augmentin instead, or had known for sure that clotramizole would suffice for miconazole. However, I am confident that had we not intervened the mother would not have taken the baby to a doctor as recommended and consequently not received any medicine. At some point when I am more confident these encounters will be easier. In the mean time the ethics of sending inexperienced doctors to Haiti to face these “sink or swim”/”now or never” moments ought to be considered. Are these encounters Win/Win situations or singly profitable for those gaining valuable medical experience. If they are Win/Win scenarios why not encourage medical residents to spend large quantities of time in the developing world?

Tuesday in Leogane 2014

Jean Marc encouraged me to spend some of my brief visit here working in the lymphedema clinic that Notre Dame and Hospital St. Croix jointly run as an outreach to those already permanently disfigured by lymphatic filariasis. In many ways these are the patients who Notre Dame, CDC, and IMA World Health, couldn’t get to in time. Lymphedema develops after years of chronic filarial infection.

Eradicating the transmissible blood borne microscopic filarial worms is one matter (Diethylcarbamazine aka DEC is being distributed to kill the worms), while tending to those who are irreversibly suffering from damaged lymphatic valves (lymphatic system works like the arterial and venous blood systems but pumps serous lymph instead of blood) is a practical matter of providing compassion, hope, and engendering good will in the community. Once the body’s immune system reacts to the worms and attacks/damages the lymphatic vessels there is no cure. Lymphedema from venous insufficiency and other causes is common in the United States. Lymphedema from lymphatic filariasis can be controlled in the same way - with pressure stockings and close attention to skin folds which are high risk spaces for fungal infections. Notre Dame (in addition to preventative measures with DEC distribution and symptomatic control with the lymphedema clinic) brings down urologists to operate on those with filariasis induced hydroceles (scrotal swelling). Hydrocele is the only component of Lymphatic Filariasis/elephantiasis that can be surgically reversed.

Last week a group of lymphedema experts and doctors from Nova Southestern University in Florida (Osteopathic medical school) came down to Hospital St. Croix to teach several Haiti Program staff osteopathic lymphatic pump techniques that have been shown to reduce lymphedema over time if performed on a regular basis. Additionally, they set a system in place for monitoring the size and progression of the disease with circumference measurements in 5 locations on the legs each time the patient comes in for treatment. One of the staff who was selected for training happens to suffer from a tremendous “gwo pie” – big foot/elphantiasis himself and is especially pleased to have received this new skill.  I encouraged him to become further trained if possible. It must be therapeutic for him to see so many of his fellow countrymen suffering from his same condition pull up their pant legs on a daily basis and look to him for guidance.  While I saw an incurable and grotesque disease, he saw a unique opportunity to empathize and give hope. He was treating the person and not the disease.  I personally felt out of place in the clinic, unable to find the same hope and optimism necessary treat these patients. The smells, the incurability, and the seeming futility of the techniques, left me feeling that with only 1 week’s training he was the “real doctor” in this situation. I was just a machine going through the lymphatic pump motions.

Tuesday, October 14, 2014

Mirabalais to Leogane

When I got picked up in Mirabalais Monday morning I was greeted by the familiar face of Roosevelt the carpenter who works just outside the gates of the CDC/Notre Dame Residence Filarose in Leogane. Jean Marc Brissau the director of the Notre Dame Haiti Program sent his driver to come pick me up in Mirabalais and Roosevelt had joined just for the hell of it. He had once cut his finger on a wood lathe/saw and sought my help when it got infected. I had gotten my first aid kit and helped some of the nursing students I lived near clean it out for him. It’s a little crooked looking now but he told me it’s fine. He had made the journey roundtrip to Mirabalias from Leogane in the passenger seat just to see me. He was excited that I remembered his name and the cut. This was great. It addressed my biggest insecurity about returning to Leogane. He reminded me that despite my 5 year absence, I still had friends who missed me and were excited that I had returned.

The journey was a long one. We passed through Port au Prince on our way through Leogane. We drove through Champs de Mars where I had been stuck in traffic when the earthquake had hit. I tried to recall which exact tree I had hugged that night but we zipped by without any significant traffic this time. The country’s White House is still in ruins. The national cathedral ruble is still being removed. The part of PAP that we drove through had less garbage and better roads then I remember however. We continued down Route Nacional #2 where Jean Marc and I had hitchhiked and walked on our way back to Leogane the night of the quake. I saw the UN base, still there, where I had tried to gather information from a Brazilian who had been just as shocked and confused as me. We drove past a newly rebuilt and improved Anacaona high-school, which had collapsed in a pancake fashion and killed many of the students, on our way into Leogane.

Leogane was more or less just as I had remembered it prior to the earthquake. It was hard to find any rubble that hadn’t been removed. Most of the streets were paved with drains. Hospital St. Croix stood in the same place with the bar, “Masaje” re-opened just across from it. Belle Negresse which had been one of the few restaurants in town was back open right where it used to be. The only startling changes were that the cathedral in the city center was gone with a crane standing in its place.  Also, the government had refurbished the town’s central square and added solar panel street lights which stood out.

The staff at the residence was the same. Max Rosemund, Ti-Gary, Carl Henry, and the cook
Janelle all pleased to see me. “konton we ou”’s and “se long tan”’s were flying with big smiles. I put my bags down and headed out to explore the city and look for my old friends on Rue la Sousse. It didn’t take me long as I recognized Ti Bouchon’s house and found Geraldi and Naldi sitting in chairs around the side. Soon I was chilling with the Zoyon club on a curb practicing kreyol and planning the evening’s street soccer game like old times.

Problem was that they didn’t have a ball. I couldn’t believe it. These guys love soccer and used to play everyday and none of them could produce a ball. So Bitten and I set out to the market in search of a ball.

We all decided that the game would start at 5:30pm because traffic would be less. Bitten explained that all their balls pop and do not last very long so they regularly wait for someone to want to play bad enough to purchase a new ball. (an organization here called “one world balls” makes Haitian Street Soccer balls that are tough enough to last I heard) Anyhow, I was just the guy. Bitten and I walked to the Residence Filarose so I could get some money and throw on some shorts. We then walked to a small confessional booth-like wooden structure down the street painted in yellow and blue called the “Bureau de Change”. We slid my 20$ US bill through a plastic barrier and received 900 goude back. I was expecting 880 at best because sometimes there’s a large fee … ( 1 US = 44goude) but Bitten explained that he wanted my business back so he gave me a full reimbursement plus 20 goude. Describing a market in Haiti requires its own blog entry…. in general they’re fascinating and chaotic. We found our way to the region of the market selling clothes, watches, and non-food related items. No soccer balls. Even Bitten said something to the effect of “mwen pa konne kote jwen yon boule, nou bezwin chache anpil” – I don’t know where to find a ball, we are going to need to look a lot” Ultimately we found a vendor who had 3 soccer ball options – small, medium, large-normal sized. We decided to pay 320goude after Bitten scolded him for asking 500 for such a shitty ball with no real seams and questionable material. He stood by his assertion throughout the game later and emphasized that it wouldn’t last the week. I got it anyway because we didn’t have time to keep looking.

Haitian street soccer games are the most exciting variety. Instead of complaining about the width of the field/street, motos and cars driving through the field/street, curbs and front yard obstacles, the guys just enjoy the leveling effect that these unpredictable obstacles have on the game’s outcome.  One cement block is stood on its side on each end of the designated playing space. There is no traditional goal or goal keeper. Walls, front porches, curbs, puddles, etc…, are in play.  In order to win you must pass/shoot the ball into the brick and knock it on its side. Our team was myself, Baby Chill, and Naldi. (yes his name is Baby Chill, and he used to be one of the best soccer players in Leogane and had a shot at the national team in his younger days I’ve heard) We played a couple of the other local guys whose names I don’t know. It was a war of attrition with both sides requiring substitutions from anxious younger neighbors so they could rehydrate. There were no injuries, car accidents, or fights. I ultimately scored the game winning goal which surprised some of the onlookers. I went home drenched in sweat to drink a liter of purified water, bath, and eat a big plate of rice with beef stew poured over it. This was pretty much my afternoon routine in 2009. It was fun to re-live it.

That night I met a 2010 Notre Dame grad and fellow student of Karen Richman – Dustin - who is working for Engineering to Empower. E2E is a new University of Notre Dame affiliated nonforprofit started by some ND engineering professors who hope to introduce a new housing alternative to Haitians and to study the current paradigm that exists between families, architects, and contractors. This is what I understood after discussing briefly, but their website would be a better resource. Dustin, Jean Marc, and I had a great conversation about the political situation in Haiti, Jean Marc and I’s experience in the Earthquake, and the distant but looming threat of Ebola.

Monday, October 13, 2014

Ebola

Haiti is at risk for Ebola. No one knows exactly what the odds of someone bringing it here are. 

Sunday, October 12, 2014

Hospital Universitie Mirabalais

Hospital Universitie Mirabalais

I met Loune Viaud at the departure terminal at JFK while watching our own airport covered by the news – “JFK begins screening passengers from West Africa for fever.” She had just come from a clean water and sanitation conference in Washington D.C.. I asked her what Haiti was doing to prepare for Ebola. She looked at me, paused, and said, “Haiti is still figuring out how to deal with Cholera.”

The flight was seamless. The cloud cover was minimal as we descended over the Northern portion of Haiti. My left sided window seat afforded me an arial view of Cap Haitian, impressive mountains, and Mirabalais (which I had been checking out on google earth last week) and what appeared to be the Hospital Universitie Mirabalias.

I sat next to Amos Joseph an accountant returning from Quebec. I asked him if he thought Haiti had returned to pre-earthquake status. He said that he thought things had improved. He said the poverty and violence in Citi soleil has greatly reduced. He seemed optimistic so I decided to be too.

This landing was different then those I remember from 2009. There was no view of Citi Soleil the slum as we approached touch down. The runway was longer and perhaps oriented in a different direction. The actual airport was larger as well. The customs officer was skeptical of my passport’s lack of departure stamp and claim that I was on vacation. I of course left the country without an exit stamp in 2009. He let me by with the irritated skeptical (possibly even angry)  look of a man who had seen foreigners manipulate his country and flaunt their laws for years. I’m glad he didn’t unload any of this on me.

Loune had a driver waiting and was very approving of my lack of a checked bag. She told me there was a bus accident on Rt Nacional #3 last night that killed 33 at the scene, sent 11 critical pt’s by to Hospital Universitie Mirabalais (by truck bed or taxi) and that several of those had already died, but that it was good that I was coming. (of course at this stage in my training with no real trauma rotations under my belt I felt like I’d probably have little to contribute) She had the driver take her to her home, then sent me on toward Mirabalais.

We stopped on the road halfway through the 2 hour trip to see the overturned bus. I took a picture and jumped back in the car. Very easy to see how 33 people were dead at the scene. I arrived at the Hospital and met the ER director Shada who is an american ER doc who splits time between Brigham in Boston and HUM in Haiti. She gave me a tour of the considerable only 1.5 yr old hospital and its facilities: CT scanner with PACS online system, 2 –xray machines, Peds ward, Internal Med ward, outpatient primary care clinic, Oncology, 6 room surgical suite, ICU, and 8 private beds for especially contagious pt’s, and an administrative department with offices for all of the chiefs. Pt’s are charged about 1.25$ US to get a membership card to the hospital and then subsequent care is free explained Shada. I was told that the hospital is officially a MSPP (Haitian Government Hospital) Hospital which runs mainly on donations Partners in Health and the Clinton Foundation donate to the Haitian Government. The hospital hires almost exclusively Haitian docs and buys its own meds and supplies from US vendors (no second hand stuff more or less). I did bring a pack of 50 sutures to donate as a good faith gesture :) which apparently they were open to accepting after last night’s bus accident.

I met some of the ED residents – Jimmy, Brezil, and some of the GP’s Linda, Oxana, and Daniel the pediatrician. Everyone was very nice to me and pleased with my broken Kreyol…. which is returning a bit! Some of them are headed to ACEP in Chicago in 2 weeks which I’m excited about. Email addresses were exchanged.

I met Luther the American general surgeon from Arizona today. He has been living and working here for 1 year now. He was consulted on 2 pts… 1 with appendicitis vs appendiceal abscess… the other with cholecystitis vs obstructive choledocolithiasis. I joined him on his lunch break. We walked from the hospital to his house where his wife and 4 kids live and then on to the town market. His wife teaches at the local school where his kids attend. He responded to the hospital’s need for an experienced general surgeon and committed to living here for 2 years with his young family. Adorable kids. I admire families like Luther’s (My uncle Mike and aunt Nora’s too) who live abroad. What an experience for his little kids… chickens to chase, an abundance of outgoing Haitian kids as playmates, fluency at a young age.

I met Maxi the medical director of the hospital as well. He’s an OB/Gyn doctor who started working with Paul Farmer 20 or more years ago. He was pleased to meet me and chat about the state of healthcare in Haiti. He emphasized that they are looking to the next generation of young doctors to help support what they started in Haiti. Fundraising, training/expertise for their residency programs, and doctors willing to commit months at a time to work in Mirabalais. He gave me one of the hospital’s new English brochures advertising their training programs in IM, Peds, OB/GYN, family medicine, general surgery, and ER. He also mentioned the ER residency’s month long “visiting professor” program. Currently there are two American ED doctors here lecturing to the residents daily for this month and living at a guesthouse 500 yards from the hospital. I can think of a few ER attendings who would be perfect for such a month.

Tomorrow I’m told I’ll get to see the chaos of HUM on a Monday before I get picked up by a driver from the Notre Dame Haiti Lymphatic Filariasis Program and head to Leogane. It was an honor to be invited to visit Mirabalais in this fashion (especially as a D.O. from a non-Harvard affiliated institution) for which I’m grateful to Loune, Maxi, and Dr. Farmer. Perhaps I’ll be able to come back and do an elective rotation here.  Perhaps I’ll just be accompanying and be accompanied by the emergency medicine residents of Hospital Universitie Mirabalais over the next four years from afar while I’m in Chicago.

Friday, October 10, 2014

Heading back to Haiti

 All packed. I’ve had as little time to prepare for my return trip to Haiti as I had to contemplate leaving. I just finished working 3 consecutive overnight “house officer”-like shifts 7pm – 9am. 22 H&P’s (History and Physicals), a case presentation to the IM program, and an aggregate 18 hours of daytime sleep later….. I’m ready to return to Haiti in true ER doctor form– sleep deprived.

Hitching a jeep ride to the US embassy in Port au Prince after spending a day helping provide emergency care in Leogane was the last glimpse I had of the town I lived in for almost 6 months. Evacuated on Jan 15th 2010 in a C130 military transport exhausted and terrified that a poorly timed aftershock would crash our plane during takeoff was where I left off. After several failed attempts to get LECOM to approve a medical rotation in Haiti, and several failed attempts to protect my Haiti return trip fund from the nostalgic allure of family reunions and expensive weddings, I have managed to accumulate the time off from work and the money. Here I go.

After a layover in NYC tonight, I’ll fly to Port au Prince tomorrow. I planned to meet the director of Zanmi Lasante at the airport, but she just emailed me to say that we are on the same flight tomorrow from JFK?! The plan is to meet some of the first intern class of Haitian emergency medicine residents of Partner’s in Health’s new residency program tomorrow and Monday in Mirabalais. I hope to tour the Hospital University Mirabalais learn a bit about the local healthcare needs then return to Leogane where I lived in 2009 for the rest of the week.