It's becoming a tradition to spend on night enjoying the art and music of the Oloffson.
Friday, December 30, 2011
Our group
-Sarah
-Kari
I love being here, every bit. We have a wonderfully balanced group. My father, a pathologist by trade, has been working in Haiti for the past 25 years and can be effective in multiple ways. He's our ace in the hole. Ally is an ER/ICU nurse and the acute needs of emergency medicine are especially needed. Sarah and Kari are physical therapy doctoral students at USC. Since the earthquake in January 2010, the abundance of amputations and chronic injuries has left an enormous need for PTs. The remainder of us are post-bac, pre-med students, Chris, Christian, and myself. Sarah and Kari start each day doing hands-on teaching with the two staff PTs. I spent this afternoon shadowing them and it was awesome. The dedication, appreciation, and skill level of the local staff was incredible. Both have been working with different PT volunteers, especially from Italy and the Mayo clinic. Sarah and Kari also were a joy to watch, excellent teaching, enthusiasm, and patient. Wow!
M'ap rive
M'ap rive.
Arriving in Haiti is more than just a cultural transition. The difference at times for a first time foreigner can feel as if the internal system must shut down in order to reboot as they acclimate to Haitian culture. Stepping out of the airport, one is approached by dozens of baggage porters all wearing bright red shirts and their aggressive pursuit can feel as if one is being pulled in all directions. The amalgam of sleepiness with a history of news coverage highlighting the disasters and poverty in Haiti can be jarring. We all arrived at the airport at different times. In the past we have all been on the same flight, but because of the holidays, we were scattered all around the country and the cost was too high to be on a specific flight. The airport is chaotic, but it is perfectly safe. Everyone had the number of our driver from the hospital who I had worked with before; he spoke English, and was waiting just outside to pick us up with a sign with our name on it. It was only 100 feet distance, but it's an intense stretch and can't really be described – it must be experienced. In part, it is the confusion of starting again, when the old system crashes, our perception must grow and learn anew. Our previous experiences can't analyze the input. We must leave the predictable and familiar and enter into a culturally diametric paradigm. In the end, our capacity to function in the unfamiliar, when we are naïve and groping in the dark, is expanded. We become more capable, not in any specific skill, but deeper down at the level where the system itself operates.
Day 1 – August 2011
I descended into the Caribbean's tropical, humid heat that had a density like we were walking under water without the weightlessness. Haitian Kompas music, as part of the welcome wagon, displaced through the disembarking passengers in a raw, acoustic simplicity – four guys, a few instruments all awkwardly hand painted with Western Union advertisements. I couldn't help but smile, in fact I couldn't stop smiling. I was home to a certain degree and there was a familiar nervousness and excitement rumbling below the surface. The excitement was that I was returning to Haiti. A country inextricably woven into who I am, a relationship that began at such a young age (14) that it is impossible to say which parts of myself it impacted. Yet this time, after months of preparation, planning, cajoling, and convincing I was leading a group of my peers. It was a bit like being 8 years old and showing someone for the first time the contents of my super-secret box that I kept tucked in the deepest shadows beneath my bed, not quite that personal but personal none the less. It was exhilarating and the Haitian airport didn't disappoint. Haitians have never had lines especially, not like our omnipresent social, line etiquette. We all just piled into the immigrations room and milled about until we miraculously were shuttled forward. The official customs business is simple and fairly easy, but a simple thing like the baggage carousel breaking down produced, with only slight hyperbole, a total breakdown in social order. In a mob-like fashion though without violence or malice that the term mob conjures, the passengers swarmed the 4 square foot hole as our baggage was being fed through by hand from the tarmac. This hap-hazard method would get the job done, but what irked me, what I could feel erupting in with such vehement ire was just how completely illogical it all was. Yet I also loved it, in fact, I could have cheered them on for the same reason and to watch this inveterately American side of me baulk and insist that this way of dispersing bags was the wrong way to disperse bags was equally amusing. I had stepped out side my comfort-zone enough to hear but not take too seriously my cultural expectations of how things ought to happen. Granted most would agree that it's inappropriate to hurt yourself or others, but nothing like that was going down hear. This was luggage and there was no real hurry.
There are only a few situations where you can see how cultures and common laws cultivate social norms, which are then re-enforced by varying levels of social etiquette. Some may believe that certain social behaviors are rigid, stuffy, and de-humanizing while others just down the street will see them as indications of classiness, sophistication, and appropriate public decorum. Yet standing in the unvetted Haitian chaos as everyone grabs, tosses, stacks bags unceremoniously throughout the terminal, and in such stark relief to Newark International airport where I had just come, the scene read like a glaring neon sign that said "appropriateness is cultural" and that often we unconsciously believe that our appropriate behavior is the appropriate behavior. What makes it so hard is that when the underlying rules shift so dramatically, the anxiety is real, and it feels as if the plane is coming in for a landing and the control tower has suddenly gone silent, or it feels genuinely disrespectful when we don't receive thank you cards or a nod of appreciation when holding open the door for someone. What I have learned is that I'm too mired in my cultural up bringing to see things clearly. Something's will always feel off and yet not be in any way disrespectful, and so I feebly try to shift my attention toward people's intention rather than their behavior. Here in Haiti, in the apparent chaos, at least from my frame of reference, it seemed as if the rules of the game had changed radically and I loved it! Nothing like spending time on Mars to see the Earth that before had been too close and too consistent to reveal how profoundly it had shaped me and how naïve was my sense of volition. Welcome to Haiti!
Gerome
I wanted to begin by posting something that I wrote exactly a year ago. It gets at the profound difficulty and adjustment of providing really high quality healthcare in resource poor environments. It's something we all experience at different times and in different ways. To some degree, we begin by becoming aware of our own preconceived beliefs and expectations.
The photos are of Father Rick, a doctor as well, and the director of the hospital where we are working. He is an amazing individual. The story below describes a patient who passed away. I've included some photos of Father Rick, one where he's saying prayers at a mass grave just after the earthquake. It's a harsh photo, so I cropped out the majority of it, but it demonstrates the deep respect for the dead and grieving that I've seen in him time and time again and it is no less for his living patients. Even on a weekly basis, on Thursday morning, he goes to the mass burial by the government of all those who remained unclaimed because no one had the money to pay for their proper burial.
This organization is more than just a hospital. There are orphanages, employment development projects, job training, and much more. One of the most famous chef's in Italy recently helped them set up a pasta factory, an addition to the existing bakery. They're building a fish farm that will feed the orphanage, provide fertilizer for the garden, and employment for others. The hospital which he helped build provides long-term care to critically ill children and outpatient services to more than 40,000 children and adults each year. Amazing!
Gerome – December 2010
I had been working as a translator (Haitian Creole to English) for the past week at a cholera treatment center in Port-au-Prince, yet this morning started like no other. The night before Gerome, a patient, had a common cholera complication of an intestinal obstruction. We lacked the facilities to treat him and had just gotten word that the government run General Hospital would admit him. Even within the medical community, a cholera contamination stigma persisted and we had spent the night hearing rejection after rejection from other hospitals. It is difficult to imagine a more calamitous year for any people than 2010 in Haiti. The earthquake in January killed a conservative 200,000 people, which was followed by a cholera epidemic that began in October. It was now the end of December and only 5% of the earthquakes rubble had been cleared. Gerome was as familiar to tragedy as most of the Haitian people. He had lost his two children in the earthquake and his wife had passed a few years prior.
Daniel, an Italian nurse, and I road with Gerome in the back of the ambulance. The experience of driving in Haiti is akin to riding a roller coaster without a safety harness. With one hand firmly grasping a rail, I steadied Gerome's head with the other. Occasionally he would vomit intestinal fluid and in an effort to preserve his dignity more than any good it did, I'd braise my legs beneath the stretcher and gently lift his head to clean what I could. As we weaved through the cacophony of street vendors, the onslaught, the dense sensorial experience of Haiti's poverty pored through the windows in a chaotic blur. The streets were lined by refuse filled canals, black with industrial soot and mounds plastic bottles floating in stagnant piles. The smells, thick and heavy in the tropical sun, of coal-fired ash, diesel smog, composting waste, and roaming livestock filtered in.
I had been to General Hospital many times before with bad memories. In fact, in the late 90's when I worked with Mother Theresa's organization, we would pick up the poorest and severest of patients literally discarded on the street by the hospital. When you'd enter, patients would be lying on the floor with filthy bandages, partly unraveled and a smell that I'll refrain from describing. The feeling of the place is captured by the iconic photo by the British photojournalist W. Eugene Smith called "Madness, 1959" taken in Haiti. It had been ten years since I had been there and I hoped that the presence of the UN and recent events had transformed it into an institution that truly served its people.
The most immediate, but temporary, intervention for Gerome would be to give him a nasogastrial tube to suction the intestinal fluid from his lungs and stomach. His stomach was swollen and it was possible the intestine had hemorrhaged. I held his head steady as we barreled down the road. We arrived at the hospital, a gated compound near the now collapse palace. Six, white, concrete buildings that had almost a communistic homogeneity were organized in three rows. We pulled up to the door where a small crowd huddled beneath an awning. With due prudence we brought our patient on a stretcher to the entrance. Gerome was unresponsive, but continued to breath in slow, effortful gasps as air percolated through the fluid. Conan went to the window and told them our situation. I could hear him relaying that Gerome could die at any minute if action wasn't taken immediately; and this is the incredible part – they told us to take a number and they would get to us when it was our turn.
There were four of us, Conan, a young Haitian man who assisted at our hospital, Daniel one of the Italian nurses who I had been translating for, and myself. We stood, surrounding Gerome's stretcher who lied at our feet, and waited in the heat of the late morning sun. Our frustration and impatience was apparent in our lack of conversation. The emotion was most palpable in Conan who seemed restless and on the verge of an expletive but at a loss of where to aim it. Then suddenly he seemed to calm down some and said, "This is poverty. This situation is poverty."
Over time, this struck me as so perceptive. Haiti's poverty was not just a lack of resources. The poverty of Haiti was infinitely more complex and it would be a gross simplification to place blame solely on the hospital, the greed of the administrators who had received lots of money from the UN and Red Cross, or the ambivalent staff. I don't mean to discount their responsibility, but the destitution within Haiti has been so chronic, so pervasive, that it has become inextricably woven into Haiti's social, psychological, educational paradigm. What we saw as repulsive apathy toward Gerome's suffering was for them normal and how things had always been done. On a daily basis they had to decide who would live and died because there was nowhere near the resources for everyone. The staff went months without getting paid, and most of the staff had never been properly trained. The complexity of the situation reminded me of the most recent educational reform 'No Child Left Behind', where schools were financially punished for when their students under-performed on a standardized test. The argument was that this held the teachers accountable. Yet the true cause of under-performance was so radically more complex. Students do poorly because they live in violent neighborhoods and deal with detrimental levels of fear, because both of their parents work 60 hours a week and aren't there to support them through homework, because 20% of the children in our country go to bed hungry and this nutritional deficit impacts cognitive functioning. It was like doing surgery with an eight-inch chef knife.
Haiti's own histories that lead to our circumstance at General Hospital was the culmination of hundreds of years of individual desperation and self-focused survival. Without the model of another way, there was no way the current system could change. And change if it could, would have to happen individually, collectively, and with an equal intensity and persistence as the suffering that preceded it.
Eventually, they lead us into a small room where because of a lack of an examining bed, we pushed a tall bench against the counter and laid Gerome there. The hospital itself was cleaner than I had seen it before and more organized. With trepidation we left. Later that day Conan, and Father Rick (the director of the hospital) went back to check on Gerome; and there he was propped up on the counter and the bench, untouched. Conan and Father Rick brought him back and later that night we were able to insert the nasogastrial tube.
The next day we found a surgeon who would admit Gerome. Here he stayed under observation. The following morning, Conan came around asking for volunteers to give blood. I agreed with two others (two women, Swiss and German) and we were off to General Hospital again. There's a funny way that patients receive blood from the blood bank in Haiti. Because blood drives aren't really a social responsibility, the blood bank requires that you give blood in order to receive it and it's kind of a three pints to two ratio. Our blood donation was fairly routine, and immediately we went with our cooler carrying two pints of blood to the surgeon's office. We arrived and were told that Gerome had died one hour ago.
We brought Gerome back to our small chapel where our patients who had passed away awaited cremation. That night Conan told me that he was going to spend sometime in the chapel with Gerome and another young woman that had also passed earlier. I mentioned this to others who had worked with Gerome and the word spread. Conan had found a surprisingly elaborate coffin for Gerome that had been left by another family who decided on cremation. As I approached the small chapel, more than just those who had worked with Gerome were there. Incense had been lit and the chapel had been swept. The melancholic, nasal drawl of Bob Dylan played in the background. Father Rick sat with us and I wondered what he thought of this less than ceremonial wake, but he sat humbly, with a gentle grin, possibly even enjoying the irreverence of our gathering. I think that Gerome's story, for those who had known him through the death of his children in the earthquake, and his own in the cholera epidemic represented the grief we all experienced through our work in Haiti. As I sat on a pew against one wall, I could see the others who quietly, vulnerably sat with these emotions which had not had the time to be addressed and for this tender moment we opened ourselves to the sadness the Haitians experienced everyday.
Father Rick and ConanChallenges of nursing in Haiti
After three days working here at St. Luc ER I finally feel like I have settled into a routine. The first day was both exhausting and overwhelming. I was asked to take on a management position with the nursing staff as well as present a series of lectures for nurses. I feel very honored to have the privilege of working with my fellow nurses as well as sharing my knowledge with them. I also feel a tremendous amount of pressure to give them so much information in such a short amount of time. Yesterday I gave a lecture on triage and emergency nursing assessment of patients. I am so grateful for my translator Jean, for none of this would be possible! I am currently working on the next lecture which will cover hypertension and stroke, as well as ACLS protocol with the hopes of running a mock code next week.
One of the most frustrating things so far about working in Haiti is the lack of resources. As a health care provider nothing is more difficult to deal with then having a patient who is sick and suffering and you are unable to provide proper treatment for that patient. It is heartbreaking to have to stand back and not be able to do anything. I have learned that I must focus on the things that can be done and not the things that cannot. Often the simplest task becomes complex when you have to take time to stop and figure out how to adapt your care related to the resources that are available.
One of the most frustrating things so far about working in Haiti is the lack of resources. As a health care provider nothing is more difficult to deal with then having a patient who is sick and suffering and you are unable to provide proper treatment for that patient. It is heartbreaking to have to stand back and not be able to do anything. I have learned that I must focus on the things that can be done and not the things that cannot. Often the simplest task becomes complex when you have to take time to stop and figure out how to adapt your care related to the resources that are available.
Everyday presents a new challenge, and I feel very grateful for the opportunity to be here in Haiti, and hopeful that the work I do will impact the lives of many.
Thursday, December 29, 2011
A Whole Lot of "Differ"
"Different", "differential", "difference." One root--"differ" (which is French, of course)--with multiple implications.
Different:
After only one day of shadowing Dr. Boyce in the outpatient clinic, it is quite evident that Haitian patients, culture, and medicine are different from what is found in the US. First, patient treatment is performed at a slower pace and in a more relaxed manner; I was very impressed with the amount of time that Dr. Boyce was willing and able to spend with each patient. Due to various bureaucratic pressures in the US, patients are bounced around between office staff and various allied health care professionals, and face time with a physician is minimized in order to maximize profit. Continuity of care is a low priority, which leads to a lower standard of care. In contrast, Dr. Boyce had the freedom to manage the doctor-patient relationship from beginning to end; patient history, examination, diagnosis, and treatment plan were executed in the same room and by the same health care professional ... and without pressure to see "x" many of patients in "y minutes." Each patient benefited from outstanding continuity of care.
As for the patients and culture, I have never before seen such a humble, thankful, polite, and respectful patient population. The women showed up in their "Sunday dresses" (for lack of a better phrase) and what had to be their nicest shoes. They were simultaneously brave yet modest, and exuded an uncanny gracefulness. The men--most of whom were escorting the women--were surprisingly proper and courteous; a stark juxtaposition to their demeanor while competing for business on the streets of Haiti.
Differential:
"Differential" as in "differential diagnosis." I have heard the phrase so many times, yet never fully understood what it meant. As I observed Dr. Boyce, I was awed ... no, overwhelmed ... by his ability to look at a chart, discuss the chief complaint(s) with the patient, rule in/out various afflictions, and devise a treatment plan. With so many variables and so many possibilities, I thought, "How can one come to a concrete diagnosis, and by what method is such a diagnosis reached?" The answer is "differential diagnosis." The methods are taught in medical school, however, only a lifetime of application can turn book knowledge into second-hand nature. Therein lies the secret to Dr. Boyce's talent; while his bedside manner and patient care are first-rate, his abilities to diagnose are beyond reproach. One day, I hope to emulate all three.
Difference:
Though a mountain of work looms in front of us, a trail of successful patient care follows closely behind. Let me offer some perspective: patients literally line up at the clinic in the cold, dark, wee hours of the morning and stand in line, hoping to see a health care professional before the clinic closes. Sometimes, after waiting all day, patients are turned away due to staff shortages. Patients then return the next day with the same hope, but also with a tinge of fear that they might not receive care. On this particular day, Dr. Boyce was able to see over 20 patients that would otherwise have been turned away. Therein lies the ultimate metric for our collectuve success: making a difference in patient lives, one patient at a time.
First Few Days
Chris and Jean
Dr. B and "H"
Will
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