November 5, 2008

Lightening flashes outside our window.  Thunder rumbles somewhere beyond these concrete walls.  Patrick and I just returned from a venture out of our room to observe our first Haitian storm—mild in comparison to what Haiti has recently survived.  The air smells like rain on dry earth.  Finally, at least for tonight, the dust settles.

I’ve needed a few hours to unwind tonight.  Today was one of those days that takes a while to digest. 

Yesterday proved to be a fruitful day.  We ran errands in the morning doing such things as replacing tires on our car, getting insurance, exchanging money and finding the office that will hold our mail (so send away!). In the midst of errands, Patrick Villier got a call that I had a patient waiting for me in the clinic.

My first patient and her daughter waited patiently for me to drive down the mountain and stroll in the clinic.  When I finally arrived, I had to hunt down the head nurse, who had no idea that the patient had been there for the last 30 minutes.  We then had to dust off the chair in the clinic, and Madam Fano shuffled through some papers and found the one for an exam.  In the mean time, I went hunting for someone who could help me translate. 

The patient had heard me on the radio show, and luckily she was the one with “back ache”—simple enough.  After everyone I needed was in the room, I was impressed to see Madam Fano taking all appropriate vital signs, asking a brief history, and offering me a nice summary in a mix of her best English and slow Creole.  The woman wasn’t too sick, just in need of a really good massage.  Her daughter had a little skin condition that we ordered some cream for.  All in all, it was a nice experience.  More importantly it clued me in to the state of the clinic.  Filthy.  Empty.  I had a gem with Madam Fano—that was apparent, but there was work to be done.

Francois found a suitcase full of over-the-counter medicine that had been donated by a church group.  I decided that it was time to take charge, at risk of stepping on some toes.  I went about starting to organize and log the medicines, clean off the shelves, and start our own mini pharmacy.  Madam Fano followed suit, and soon we were sweating along together, transferring the dirt from the cupboards to our washcloths and ourselves.  I moved on from medicines to diving into some cabinets that hadn’t been organized in a long, long while.  Suture, still good, but covered with a fine layer of dust, and other such supplies were stuffed into corners and nooks as if by a dirty pack rat.  I started to fall into a rhythm—pulling everything out from their hiding place, cleaning, organizing things into category.  I could see Madam Fano looking a little overwhelmed.  I was in heaven.  Finally something concrete I could do that I could do well.  Organization.J  I could have worked there all night, but the nurses needed to go at 3pm, so my momentum was cut short. 

All in all, yesterday was a satisfying day.  We accomplished a lot of little tasks, I took a little ownership of the clinic and it was seemingly well received, and I finally had in my mind a to-do list to get the clinic up and running: 1. Clean 2. Organize 3. Re-stock 4. Discuss clinic flow and documentation 5. Start seeing patients.  I figured we could get most things done in a week or so (Haitian time), and could have an honest-to-goodness clinic running in no time.  But preparation first.  I canceled my trip to Karfou for the next day thinking I would stay on task at CONASPEH.

So last night I went to sleep happily tired, ready to have a big, dirty day in the Clinic getting it patient ready.  But Haiti had other plans for me.

This morning started like every other morning.  Sleepy shuffle to the bathroom, cold abrasive shower leaving me awake and refreshed, strong hot Haitian coffee jump-starting my brain.  Today over breakfast of sweet grapefruit and bananas, I met a Haitian man, now an American, who shared with me his life story. His mother had died when he was only ten, so he had grown up an orphan in Haiti.  He was taken in by a good boys group home, sponsored by a kind American benefactor, and he eventually graduated from college in the US.  Now he is a successful engineer in the states, and looking to buy his first home.  He was back in Port Au Prince in hopes of finding a job so he could move his family back home—it was his dream. He was a success story of a boy rising out of the dust and despair.  His outlook was bright, and he fostered a love for Haiti that sparkled from his brown eyes.  He was an example that there are reasons to hope here.

Once back at the school, Patrick busied himself with preparing for his English class, and I went to work straight away in the clinic.  I met a little more resistance this morning.  I’m not entirely sure, but I think that the CONASPEH staff thought that wiping down surfaces and cleaning was a little beneath me (if only they knew).  As much as I reassured them that I was happy to do it, they insisted that I wait for the proper cleaning man to come.  He did come and pushed around some dirt with a dirty, dry washcloth and left.  Mmm no.  Not so much clean, much less sterile.  So I pushed on ahead much to the staff’s dismay. Madam Fano joined me, pulling out stacks of paper pushed into drawers, throwing some away, organizing others.  The morning was going just as planned.  It was only 8:30 and my hands were good and dirty.

Suddenly, the Pastor from the Karfou clinic showed up.  Ready to go.  Apparently he had not got the message and there was a clinic of patients waiting for me across town.   With a shake of the head, a shrug of the shoulders, we dropped what we were doing, grabbed our bags and hopped in the car.  Our team: myself, the pastor, Patrick and Madam Fano headed across the city to the neighborhood of Karfou.

Our drive took us through a different part of Port Au Prince.  We passed a landscape that looked like more of the same.  Concrete buildings, most in a state of mid-construction or post destruction lined the road. Deep trenches ran along the pock-marked road serving as a makeshift sewer, with stagnant water full of trash filling the depths.  We passed the town’s main market—a huge square full of people selling fruits and vegetables, artwork and household goods.  Mountains of clothes were scattered around the ground with people sorting through the piles like shoppers going through a sales bin. 

We passed a huge shanty tow. Patchwork tin lean-tos held up by long sticks made up a neighborhood of one-room “homes” along the side of a bustling street.  Smoke snaked out of several shacks indicating a meal being cooked within.  Naked children stood outside the walls, watching the traffic pass them by.  One little girl, a braid sticking comically straight up in the air, gave me a grin and a wave as we passed, oblivious to her nakedness.  Mounds of trash lined the roadside, partly charred from being burned.  Pigs and goats and dogs shuffled through looking for something to eat.  Waterways held more trash than cloudy water.  Tap-taps, brightly painted with “Love Jesus” passed our truck with a cheerful honk; people were packed into every inch of the truck bed, their belongings teetering on the rooftop.

For a moment on the drive, we realized we were only yards away from the ocean, but only brief glimpses of the cool blue horizon were offered to us as we bustled along.  Largely the view was blocked by concrete and barbed-wire.

The pastor indicated our turn into a narrow, muddy alleyway between rows of cinder-block homes. Clothing was hung out on lines zig-zagging over the alley creating a colorful canopy.  Children's' curious faces filled the windows as our truck rattled by.  We parked precariously wedged in a tight little alley, and filed into the clinic.  The Karfou staff was waiting for us.   A Haitian doctor greeted me in Creole.  He had kind eyes and a warm smile.  His nurse, dressed in white, sat at a little desk in the entry way ready to start bringing in patients.  They had a small, simple pharmacy, and a separate room.  The doctor lead me to a desk, offered me a chair, and started bringing patients in before I could ask a single question.  Madam Fano wedged herself behind the desk with me, and a translator who spoke thick broken English sat with each patient as they came for “consultation.” 

Patrick spent the day mixing among the crowd, trying out his Creole on the little old women and children waiting so patiently in the hot afternoon sun.  He had one woman laughing out loud when he told her in Creole, “I HAVE your dress” confusing the word for “have” and “like” accidently.  The children and teens encircled him, teaching him Creole words, quickly figuring out he was easy to tease and delighted when he teased back.  Patrick had a wonderful time and felt that the experience was as pastoral as he has had thus far.  He turned a waiting line into smiles.

In a period of 4 hours, I saw over 30 patients.  We started slowly, not having had a chance to work out our game plan.  Uncomfortable with a desk separating me from my patient, I was constantly sqeezing around it in order to exam, clarify and communicate.  Madam Fano, quickly seeing the inefficiencies in the system (as we caught glimpses of the line forming outside) reorganized immediately so a better triage system was in the works.  Men, women and children sat in the chair on the other side of the table.  All complained of a stomachache.  Some also had fevers, headaches, backaches, and two with whole body pain.  The few tools I had in my bag were the only things I had to work with.  I brought patients to the small exam table around the corner to poke, peer and prod, hoping something would clue me in to whether this was a serious condition, or simply a need to be touched, to be listened to.  One patient came in with a complaint, “I vomited on Saturday, and now I feel fine.”  He then proceeded to tell me about the choir he was in, and proudly showed me pictures.  I had to smile. I couldn’t figure out why one young woman was sitting across from me as she had no real complaint.  Finally wise Madam Fano leaned over and whispered, “vitamin—she wants vitamin.”  

I couldn’t help wondering if all the stomachaches were from hunger, from parasites, from gastritis or from stress.  I wrote for some labs for women in whom I was worried about malaria, wrote for medications for infections that needed to be treated all the while wondering if any of these orders would be filled.  They were seeing me because they had no money.  I doubted much would happen after they left the stuffy exam room.  I struggled with not feeling defeated and instead dove into a happy rhythm of meeting my first full clinic day of Haitian patients.  Again, the language barrier was frustrating.  I imagine I was more efficient with less information.  It would be easy to sit down and ask a million question about these people's lives.  

Many were women were anemic—it was clear by physical exam.  Some I worried about early HIV infection.  A pregnant woman came in for routine ob care.  I attempted to find a fetal heart tone with my stethoscope—no luck—but the baby obliged and gave me a healthy kick that reassured me that even though measuring small, it was alive and well.  My knee-jerk reaction was to set her down and commence with the “initial OB” visit we did in residency, ordering extensive labs, getting her pap smear done, ordering an ultrasound and ensuring she was on prenatal vitamins.  I could only do a fraction of such a work-up as I had no supplies and she had no money.  I asked her to come back so I could monitor her as best as I can, to ensure that at least she gains weight and that the baby still kicks at me with gentle prodding.

I am coming to realize that the Haitian woman is a uniquely tough breed.  Stoic and strong, they handle their lot with pride and determination.  Last week I watched a teacher in our school suffer from an infected tooth, have two teeth pulled without anesthesia, and was sent out of the dentist's office with Ibuprofen.  I saw her shed only a single tear.  She had to be in misery, but her only sign was that she was quiet, head bowed, with a bag of water on her face.  Her normal chatty nature was subdued.  But she handled it with grace, sitting in the hot sun until her ride came, refusing an earlier ride that Patrick and I could have easily given her.  “No, no—I have to pick up my child from school” she spoke clearly as if her mouth was in perfect condition. 

Today a woman came in with an extensive abrasion down the length of her leg, caused by falling on some tin.  I looked in my medical bag, and the only thing I had to clean it with (since this clinic also had no water) was alcohol and wet wipes.  Warning her this was going to hurt, I gently cleaned her long wound as best as I could, knowing that the sting had to be severe.  After dressing the wound, and letting her sit up, beads of sweat covered her forehead.  They stood as the only witness to the pain she was feeling. 

It is because of these women that I find myself blinking back tears.  I want to mirror their strength even when simply driving down the road, watching the naked children play in trash makes my insides crumble.  I blink back tears of my frustration today of not being able to talk to my patients, to offer them the complete medical care that they deserve.  I do my best to hide my lack of confidence at being thrown in before I feel ready, before things are organized like I’d like them to be.  I leave my tears to the comforts of our small room when I reflect on the hungry children coming to school eager to learn, knowing that I myself have never known real hunger. 

The line trailing outside the clinic kept getting longer rather than shorter.  No matter how fast I worked, more people came.  Finally, Madam Fano signaled that it was time to quit.  The staff had to get home to tend to their own families, and the patients who lined up outside would return in a week for me to see them.   I pushed down the worry that somewhere in the line was someone who needed quick attention, that wouldn’t be able to wait.  

The drive back home was quiet and bumpy.  We were all hot and tired.  Patrick has come to humming songs when traffic is particularly precarious, and was doing so as he weaved through the maze of Port-Au-Prince streets.  Madam Fano insisted on riding with us to our Guest House, even though we passed her own house miles back.  She wanted to ensure we got to our destination safely.  And she wasn’t taking no for an answer.  I look forward to one day being able to talk to Madam Fano.  She has been my silent partner thus far, and has created a little order to the chaos.  Despite language barriers, her spirit is shining through, and she gives me hope that we’ll make a fine team, when its all said and done.

So tonight the rain outside washes the dirt out of the air.  I’ve had time to sink into a Creole lesson; the fact THIS I can control, that I can organize vocabulary into categories and fall into the rhythm of memorization gives me comfort and calm.  I am reminded daily that I live here not on my terms, but on the terms of people here.   And when they ask me to go, to work, I can’t say “wait,” because they’ve waited long enough.  The need is critical.  And having to do “the best I can do” when I want to bring the care that is needed will be my biggest hurdle to jump.  

Good night, my friends.  Time for a snooze to recharge for a new day.