Cheers

As my time in Haiti has come to an end, I assure those who have been following my blog:  I have not forgotten.  In the midst of all the craziness that has consumed my final weeks, I felt I did not have adequate time to attempt to give you the blog you all deserve.  Therefore, I have decided to combine my last weeks into one very long post.  In keeping with my efforts to pretend that I am a writer, I have decided to break this post up into chapters.  Enjoy . . . .

‘The Honeymoon is over’

So . . . there I was, the start of my final week at OSAPO . . . and my concerns began resurfacing.  I know that I may seem like somewhat of a, well, complainer . . . perfectionist . . . negative Nancy . . . glass half empty . . . you take your pick.  The thing about work in areas like this, if you aren’t trying to encourage people to make things better (specifically, if there is nothing to make better), then your work really isn’t needed. 

The weekend before, Judy had come up and had a repeat in service on instrument cleaning.  It turns out that the solution being used is way too harsh on the instruments, something she had taught the previous time she had been there.  Unfortunately, it was a little too late as two of our coated speculums had already been destroyed; a couple days into the week, essential screws to another coated speculum had been lost in the cleaning process, leaving us with only 2 usable speculums for performing LEEPs.

One afternoon, as I was working with my two assigned nurses, one of them got board as we were counseling a patient, so she blew up her glove and accidently popped it.  I’m not one for scolding, but I could not believe the inaptness of the matter . . . I told her it was extremely inappropriate to do that in a professional setting, especially when you are in a room with a patient. 

All of these things, any time I try to give ideas, counseling, advice, etc, I feel goes in one ear and out the other.  I know I keep on saying that at least I’m helping the people I’ve seen in my short time here, but the whole idea was to create something life long . . . something that could continue working even when I’m gone.  Four months may not be long enough to change the ways people have spent a lifetime learning. 

The Haitians I’ve worked with have a tendency of anti-preparation . . . wait until you are completely out of something, then scramble to get what your out of, creating a daily struggle to just to have the essentials.  What’s going to happen when they run out of the things you can’t get in Haiti . . . LEEP loops, coated speculums, monsels . . . our essential list that is attainable, but it will end up taking several weeks to get ordered, shipped, and through customs . . . I would start thinking about it, and wonder:  What’s going to come of all of this?   Honestly, in that final week, I still didn’t know.

‘And the band played on’

[Just to clarify, I did not come up with this name all by myself.]  In keeping with my goal of reading more than just medical related topics, I decided to do a little recreational reading during this stint in Haiti.  I have always found HIV an interesting topic . . . a disease still so much in its infancy, but has come so far in treatments.  During residency, my first big publication was all about HIV prevention, a topic that I also lectured on for my grand rounds.  As I was researching the disease, a friend recommended that I watch the movie ‘And the Band Played On,’ as it illustrated the surfacing of AIDS in the 1980s, and focused on the many mistakes that were made in controlling the epidemic.  Although I never had time to watch the movie, in searching for a decent piece of literature, the book (aka, what comes before the movie) popped up, so I decided to give it a whirl.  What I didn’t consider . . . It may not be the smartest idea to read about the AIDS epidemic when you are working as a physician in an AIDS endemic area.

My first weeks working at Pierre Payan, there was some viral ailment that was striking many of my team members.  I had gotten a little sick in my first few days visiting the states, so I was hopeful that I had built up some type of immunity.  As I started developing symptoms, I was deep into the book, which follows multiple characters from the start of their acute retroviral symptoms to full blown AIDS.  Suddenly, I was starting to identify with those symptoms . . . I had swollen lymph nodes, fatigue, myalgias . . . just like the characters in the book.  All of the sudden, I was identifying with the characters, I was even writing my own story in my head.  I was convinced that I had somehow contracted HIV.

Now, I realize at this point, I probably sound crazy.  I am very well aware of how you can contract HIV [and just for the record, I have not been participating in any ‘high risk’ sexual behavior down here in Haiti].  Hospitals in Haiti do not operate under the same ‘cleanliness’ guidelines that they do in the states . . . and I have never been convinced that everything in my gyne room is 100% clean.  I was paranoid . . . what if the speculums weren’t adequately sterilized and I held one I though was clean with my bare hand that had a paper cut?  All the dirty instruments are brought upstairs to be cleaned . . . what if I picked something up off the ground that had a microscopic amount of blood on it, and then I put my contacts on with that same hand.  What if I had a hang nail that time my glove ripped during surgery, and the patient’s HIV test was falsely negative? . . . I had become your typical medical student hypochondriac.

I was so paranoid, that one day, I actually mad my interpreter go with me to an HIV clinic down the mountain to get an HIV test.  Suddenly, going down the mountain on a moto was not so scary (the last time I had gone down the mountain on a moto, I continuously though . . . if we hit just one big rock the wrong way, hello brain injury, goodbye career).  So . . . the test was negative, and in case if you were wondering, I don’t have syphilis either.

The next time any of you think you are being a hypochondriac, you can just think of this experience I’m sharing to remind yourself that you are nowhere near as paranoid as I was! 

‘Angels and Demons’

In keeping with the trend of book tittles, I assure this again is an appropriate one.  I know I have alluded to the fact that this time around has been very different than my first couple months in Haiti.  The one thing that has made the biggest difference is the fact that there have been so many missionaries/volunteers here.  It seems that the winter months are the trendy times to come to Haiti.  I can’t imagine why no one would want to come work in the blistering heat of August and September.  There are some people who just come for a couple weeks with medical teams, and there are some people who come for a more permanent 6-7 months, and I have had the pleasure of meeting and spending time with two such people:  Annie (from Michigan), who runs an orphanage for handicapped children, and Judy (from BC), who I don’t think I can adequately summarize everything that she does (running of ORs, organizing, providing sanitary products to young girls).  It has been so nice having the two of them around . . . definitely takes out the loneliness aspect. 

Of the many projects Judy has been involved in, one big one is called ‘Days for Girls.’  In many developing countries, girls don’t have access to sanitary products, so they just use washcloths.  Many girls will skip school, and wont go out and work while they are on their periods because they are embarrassed.  It is my understanding that the organization’s first project started in Uganda, where disposable sanitary products were provided for all the young girls . . . it didn’t take long for people to realize what a strain this was no the sewage system.  Disposable products would not work, so they developed reusable sanitary kits.  Each kit comes with to ‘shields’ that have water proof lining, with 8 reusable pads, made out of flannel.  When the kits are distributed, the girls are taught how to care for them, clean them, and how to properly dispose of the water that is used to clean. 

These kits are being made and distributed in many different countries . . . now including Haiti.  During my second week here, one of Judy’s friends, Linda, came to join us in Haiti with the many kits that had been made in Canada.  In my final week here, several more Canadian nurses joined us with more kits. 

Obviously, this was a project I found quite intriguing, given my interest in public and community health.  I also just happened to have an interpreter working with me who was a young female who is now very knowledgeable about the female body.  It turned out that OSAPO had just started doing youth sexual education on Saturday mornings, for the adolescents of surrounding villages.  We had a perfect set up for success, and it was.  Marceline, my interpreter, interpreted, Linda and Judy gave the lecture, the girls were behaved, asked appropriate questions, couldn’t have asked for anything better.  I wasn’t aware as to how much I appreciated this crowd until the following Friday. 

Thursday was my final day at OSAPO.  We completed clinic, I deemed Ernot capable of VIA and LEEP on her own, and I headed back to Annie’s to be welcomed by a full house.  Four more Canadian nurse friends of Judy, Linda, Annie and myself, all laid out on blow up beds made for an adult sleep over, although the extreme heat and lack of circulation in the rooms made it a little less fun.  We all attempted to get our beauty sleep in preparation for the adventures we had planned the next day. 

We were taking the kits to La Grange . . . I community in the middle of nowhere in which Annie had been affiliated with.  We had a ‘church’ reserved as our community center for education and distribution, and we brought lunch for the girls, at the pastor’s request.  I honestly think the place should be renamed la Grunge.  After a 2-3 hour drive down windy ‘roads’ (and by roads, I mean dirt path which may or may not be able to accommodate the big blue truck that carried us all), we were in the middle of the dirty desert village, where it was uncomfortable just standing because of the heat. 

Just to clarify, my feelings for this place have nothing to do with the heat, the dirt, the lack of air circulation . . . it was the people.  The minute we got there, people were rood, grabbing us, the boys were trying to get inside this church (none of the windows were glass, and there were holes big enough for people to get in) . . . and it only got worse.  We had thought that things had maybe settled down when we initiated the lecture, but things escalated to an unbelievable extent.  Initially . . . all the boys were just sitting outside, banging on the doors, trying to sneak in, and by the end, they were grabbing at me through the windows, trying to steal the food, trying to steal the hockey bags full of the feminine products . . . it was ridiculous.  And, unfortunately, they were not the only ones who were inexcusably poorly behaved.  Once the kits were distributed, the women and girls became monsters . . . we had unleashed a beast that was uncontrollable.  They were taking extra kits and handing them out the window, trying to hide the ones they received so they could get two, and they were extremely unappreciative of any of the work that went into making them.  The only thing that provided me with some hope in humanity in this place were the very young girls.  We allowed them to come in and listen to the lecture, but decided they were too young to give a kit to.  When the kits were handed out, they were instructed to go to the back of the room, and they were the last ones to receive lunch.  These little girls were so well behaved . . . not once did I see them try to steal or cut in line . . . they just sat patiently waiting to be allowed to get their food. 

By the time we got back to the truck (which was a little walk as the roads got to be so bad we could not take the truck further into the village), I think we were all ready to get the f*** out of there.  I road in the back of the truck on the way back, which was actually quite pleasant . . . we had little chairs, all I needed was a nattie light in my hand and you had a redneck Christmas card. 

The following day, we wend up to OSAPO, and unfortunately did not have enough kits for the EXTREMELY well behaved young girls.  Their behavior was like night and day in comparison to the previous day.  On the bright side, we were even more able to appreciate how lucky we were to work with such nice young girls.

 

My Legacy

I’m 28.  I’ve still got many years of my career ahead of me . . . in fact, it is really just beginning.  I don’t want to give the impression that I’m this phenomenal, amazing person, nor that I see myself in that manner.  I’m just a person who saw an opportunity to possibly make the world a better place, and took it.  Now, whether or not I’ve made a huge dent, only time will tell, at least I’ve maybe made a small dent.

To different degrees, I think we all have a fear of failure.  To be completely honest, I’m worried that these past several months will be considered a failure.  Things did not go as planned, and the thought of going back for an extended amount of time is exhausting for me (especially seeing as I’ve come to realize how much I hate hot weather).  I think there is always more that can be done, and you start asking yourself, ‘am I a failure, because I could have done more?’  If I decide I want to go to an orphanage in Liberia, or work in a clinic in Nepal instead of go back to Haiti, does that make me a quitter?  All of these questions have been going through my head a lot these past several days.

When I look back on my experiences, I don’t regret going.  That being said, words can not express how happy I am to be home.

B-E A-G-G-R-E-S-S-I-V-E

[What I really mean is be assertive, but there is no cheer that goes with that.]  First off, I need to apologize for how badly I’ve been keeping up with my blog . . . here I am, two weeks in, and this is only my second blog.  This country has been keeping me more than busy.  By the end of the day, I barely have time to reflect on the occurances, let alone make attempts to create a whitty recap for my blog.  Any thing I may have been able to piece together would have been worse than having a discussion with me off my ADD medication . . . disorganized and maybe half way make sense.

I’m honestly not sure where I should start in my attempts to update all of you as to what I’ve been doing these past couple weeks . . . there have definitely been some memorable moments . . . singing ‘It’s a hard knock life,’ as I cleaned the OR floors; the chicken who scared the crap out of one of our team members in the work room (who we later found out was waiting for her chicks to hatch); my first ride on a tap tap; further getting to know some great Canadians who, as it turns out, came to Haiti to work on a project that is right up my alley; . . . the list goes on. 

If I did not say it earlier, I have been truly blessed with the people I have had the privilege to work with during my time here.  Our entire team at Pierre Payan was better than anything I could have asked for.  [I don’t want anyone to feel left out . . . but I feel it necessary to say that Judy Douglas, you are a saint . . . you seem to have twice the stamina of someone half your age . . . your kindness, generosity, positive attitude and work ethic astounds me . . . you inspire me.]  When multiple people of different ages, locations and backgrounds come together to do work in Haiti, one may think there is only one common denominator (whether it be medicine, religion, etc).  My experiences have proven that theory FALSE.  [A friend once told me he couldn’t believe that most of my closest friends were also doctors . . . how boring, right . . . but medicine is not the reason we are friends, it’s just the thing that brought us together prior to realizing we had so much more in common.]  I found out that one of the general surgeons on the team (Dr. John Reidell) had pitched in the minor leagues while he was in medical school.  His father, brother, and nephew were also major league pitchers for the Yankees and Reds.  [Although I was unable to watch the games with my favorite fans, watching with him, with his commentary, was definitely the next best thing . . . those moments are something that I’ll never forget.] 

The second week I worked at Pierre Payan, I operated with Dr. Reidell.  Very much a gentleman, he asked my permission to assist me in my surgeries.  What I did not realize was that he literally meant assist.  He wanted me to do the entire hysterectomy (for those of you who don’t frequently watch abdominal hysterectomies, you usually have a surgeon on each side, taking turns ligating vessels and pedicals).  I told him that one of my mentors use to make residents operate the same way . . . so if there was a complication, you have no doubt who is responsible.  His response . . . ‘Sounds like a very wise man.’  [I never had the chance to do any major surgeries with Dr. Griffin, but I almost felt that I was this past week . . . an unexplainable feeling, that made my eyes smile].  On his last night in Haiti, he told me not to be afraid to be assertive [among some other personable words of wisdom, which I have taken to heart].

Now, enter my last weeks at OSAPO.  I honestly did not know what I should expect.  I can’t remember how much I revealed as to the issues I’d been having here . . . specifically the lack of support, unwillingness to provide an interpreter, providing a reliable nurse to work with EVERY day, the charging for screening and treatment (and EXTREME lack of communication regarding anything relating to the program).  Issues which, after time, made me begin to feel hopeless for any long term success. 

With the help of an independent donor, we have been able to convince the powers that be at OSAPO to let us start screening people for free, and the word has spread like wild fire.  Women from all over have been coming to OSAPO for screening.  I have two new nurses I’ve been working with this past week, and we’ve already screened over 100 people, and performed 18 LEEPs (over half have been women I screened previously and was unable to treat secondary to lack of supplies).  The nurses are asking if we can start clinic earlier in the day, as they want to see as many patients as possible so that they can learn.  Another independent donor has paid for my daily interpreter for the time I’ve been here, something I felt necessary in order for me to really take control as to what’s going on here.  I don’t know what the future holds here, and I don’t want to be too optimistic, but I really feel like I’m in control, and not at the mercy of a higher up who is not listening to me.

I know that this whole blog has been slightly disorganized . . . my ‘turning life into stories,’ professor in college would probably be very disappointed in my jagged flow of events.  I hope to be more structured in future posts, but no promises!!

I'm back!!

October 26, 13

Yes folks, I’m back in Haiti . . . and what a different experience this has already been.  I’ve actually been in the country for about a week, but I have been so busy I have not had time to write.  The pure exhaustion I am experiencing may make it difficult for me to keep of this façade that I am actually capable of writing!!

About a year ago, in my second trip to Haiti, I jointed a team (whom I had never met) from the east coast, in attempts to get a little more experience being in the country prior to making this long-term journey.  For some reason, they liked me enough to request that I join them for two weeks the next year . . . so here I am.

You may ask, how is this different from what I had been doing? . . . being here with a team means having ten or so people who are probably more eager than myself to really get the work completed, 24/7 anesthesia coverage, days starting at seven am instead of 9 am . . . comparing to my recent experience, it is night and day.  This past week, we’ve done a total of 5 hysterectomies (4 abdominal and 1 vaginal), in addition to many other hernia repairs, and other minor procedures. 

I also went up to OSAPO for a day to cram as many LEEPs as possible, which unfortunately only meant about six (I pray that the twenty or so that needed the procedure will come at some point this next month).  Being there made me realize how much of a change I really needed.  Even though I’m here, MISSING THE WORLD SERRIES, I feel truly blessed that I have such a wonderful group of people to be working with. 

Being back at OSAPO brought up all of the BS and frustrations that I had left behind.  When I started this whole thing, I was so optimistic that I myself, a newly graduated gyn resident without any public health training, could successfully start a cervical cancer screening and treatment clinic in Haiti.  I really hate to admit this, but I am fearful that this whole setup will fail. 

Now, I realize my wording sounds very negative, but I think it’s healthy for me to admit my fears . . . but after this week, I have also realized that I am looking at this the wrong way.  In this situation, there is no such thing as failure.   Just preventing one person from dying a cervical cancer should be considered a success. 

I’ve been trying to think of some way to ensure that screening efforts will continue once I’m gone, but it’s not all up to me.  I’m only one person, and there is only so much I can do.  Over the last few months, I felt myself slowly loosing faith in people (I need to emphasize that there were definitely some phenomenal people at OSAPO, and if it weren’t for them, it would have been difficult for me to have the stamina to keep going).  Being with these people for just a week has rejuvenated my spirit and faith in humanity.

So . . . I’m going to take all of my negative thoughts away; I will continue working my big butt off for the next week; I will continue to resurrect my stamina and faith; I will continue listening to every cards game (as our wifi connection is not strong enough to stream), praying that the internet does not go out; and I will pray that I will at least screen as many people as possible in my time remaining at OSAPO.  I will say au revoir for now (and will hope that it will be less than a week before I have time to blog agai

A final night at the round table

10/3/2013

[Disclosure . . . the table at OSAPO is not round, it’s long and rectangular.]

I’m currently sitting in the airport, enduring the beginnings of a VERY long day of travel.  I’ve been in Haiti for two months . . . it’s time for a little vacation (and by vacation, I mean 2 weeks in the great city of St. Louis . . . more importantly 2 weeks of experiencing the post season for the greatest team in baseball!).  On the long ride from OSAPO to the airport, I couldn’t help but smile as I reminisced over the way I spent the previous day . . .

I was finally able to have another day in the OR.  I don’t think words can express how stressful operating here actually is.  [Don’t get me wrong . . . I LOVE being a surgeon, but your talking about a completely different beast when you are in a third world country.]  To start off with . . . there really is no set schedule.  When the anesthesiologist says she will be there at seven, she really means nine, which mean your day does not start until 9:30 or 10:00.  Even though we attempt to keep a schedule of patients, they are unpredictable as to when they will actually show up.  There are some days where no one will come, and some days where many will come and you need to send them away.  Then, there is getting the equipment prepared.  Every sterilized tray is like a piñata of surgical instruments . . . you never know if you will have the instruments you actually need . . . and if you don’t, then you are scrambling to find the essential instruments you actually need, with the patient asleep on the table.  It is literally impossible to be efficient and conserve resources.  [Oh, and don’t get me started on the lack of sterile technique of everyone else in the OR, you not only have to focus on your actions, but you are also manning everyone else.]  Once you actually get to the actual operation, you are exhausted just from making sure everything is in its place. 

Last week, when I was operating on my own, I was reminded just how much I enjoyed it (both the challenges and success of knowing you did everything according to the books, and that you truly did help someone).  Yesterday, I did a hysterectomy with the assistance of one of the surgeons in Haiti, who prides himself in his speed.  I don’t want to go into too much detail, but I realized why he is so speedy yesterday.  Those steps of Identifying the ureters, double ligating all the serious vascular pedicles, assurance of a dry field, completely out the door.  I realize that I’m just out of residency, and he has been a surgeon for many years . . . so I did my best to be respectful, yet challenge things I didn’t feel appropriate.  It could have gone more smoothly.  [Janna, if you are reading this, I did not say it before, I have so much respect for everything you did the first time we came down here.  It’s a different game when you are the one in charge.]

So . . . back to my day . . . there were a couple of minor cases I had scheduled for the afternoon, but unfortunately the anesthesiologist had to leave early, and alas they were canceled.  As I was going through my ‘office,’ making sure everything was in place, Carine said there was another patient, who had just been admitted who I needed to see.  70 year old female, vaginal bleeding, hemoglobin of 7.  Carine told me she had gone to see another doctor, but they wanted me to see her, too.  My response was, not until the other physician actually does a pelvic exam, (she assured me that he did, but I’m somewhat skeptical).  [Now, just a little clarification . . . the frustration that I have with no one doing pelvic exams here is a much different type of frustration than that which I had in residency, when you would get called in the middle of the night to go perform an emergent pelvic exam on someone with vaginitis.  This roots deeper than the frustration with pure laziness of others.  At least in residency, people made sure that patients received the proper care necessary.  Here . . . when I leave . . . there is no one else to do it.  If people don’t start performing much indicated exams, no one will, and significant pathologies will continue to go undiagnosed.]  This poor old lady appeared to have dementia . . . luckily did not appear to be in too much pain.  Speculum exam:  big fungating tumor originating from the cervix.  Bimanual exam:  IIIB (at least) cervical cancer.  Just a little shout out to the powers that be . . . I get it . . . I’m still passionate about my work here . . . I don’t want any more reminders. 

So . . . up to this point, I’m sure you are wondering, what about this day made me smile . . . I’m getting to it.  My nightly schedule here is pretty much the same . . . work out, shower, eat dinner and visit with the OSAPO nurses/staff (who, for the most part are female).  It is always very entertaining for all . . . it feels so good to laugh with others.  Last night, one of the nurses (Andre . . . someone who I’ve really enjoyed working with . . . she is the one who helped me make my bat free room in the office) was asking me what my plans were in St. Louis.  I mentioned going running with my dad.  Her response:

            ‘You will not be able to run.’

            ‘And why is that?’

            ‘Because you are too fat.’

            I started laughing, ‘Andre, I am the same size now as I was when I got here.’

            ‘No, your butt and legs has become too fat.’  By this time, some of the other girls were engaged in our little conversation. 

            I chuckled even more, ‘Nope . . . they’ve always been this big, it’s just the way I am.’

            One of the other girls needed to translate this for her . . . her response with big wide eyes and a big smile on her face, ‘Ooih.’

            ‘You know, it’s not nice to call people fat.’

            ‘But I love your big fat butt.  It dances every time you walk.  I find it very sexy.’

            At this point in time, I was almost crying, I was laughing so hard.

            She continued, ‘I want your butt.  Mind, I do not like so much.’

            ‘Well, thank you.  Now, I think it’s time for bed.’

To really get (even more so) the comedy of this conversation, I’ll provide a little background information (and don’t worry, I’m not going to dive into the whole body image, insecurities, etc . . . I am by no means skinny or completely satisfied with how I look, but what woman is).  For those of you who don’t know me, I am very much pear shaped, and yes, I have a ba donka donk and thighs.  I am also very athletic, and it seems that my butt and thighs are what tend to bulk up the most.  I have ALWAYS had a complex about my lower half, but have come to find it more a topic of humor than anything else.  When I was getting measured for clothes in Vietnam, when measuring my thighs, one of the woman said, ‘hoooooaaaaa,’ in a deep voice as she widened her eyes.  Also, Andre has many a nights commented on my big butt (one night, she asked why my waist was so small, and my butt so big).  She is also one of the most lively people I’ve met . . . between her persona, the cultural differences, the literal translations and my apple bottom complex . . . I don’t think I could have engaged in a more entertaining conversation.

Now . . . time for me to relax.  For the first time in two months, I actually have goose bumps (AC in the airport).  Time to allow all my frustrations and unpleasant experiences dissolve.  Time to keep the happy memories on the surface.  Time to bring the Cardinals to the World Series!!!

[For anyone in St. Louis, you should go to Sybergs (Dorsett) tomorrow night . . . A fabulous band will be performing . . . and I’ll be there, too, hopefully celebrating after the Cards game].

The Starfish (Janna, this is different than the one we sang about in oncology years ago)

(For the record, Sandra has been an amazing voice for me here . . . she's almost loud enough to be heard here in Haiti from Missouri . . . any success can be greatly contributed to her efforts)

Is any one familiar with the little story . . . the man on the beach, and all the starfish that had been washed up on the shore.  As he walked down the beach, he would throw every starfish back into the ocean.  Another person noticed what he was doing, and forewarned him that there was no way he was going to get to every starfish . . . there were miles of shoreline, tons of starfish, and only one person.  The man picked up another starfish, threw it back into the ocean, and said ‘Well, I made a difference for that one.’  This concept is the only thing that is getting me through these past/upcoming days before I take a little break and head to St. Louis (that, and plans of Cardinals and the playoffs . . . woohoo!!).

When I was 18, I went to Hilton Head for our extended family vacation.  In July, the coast is covered with jellyfish, many of which had been washed up on the shore.  My cousins and myself performed our own little rendition of the starfish story, throwing the jellyfish back into the ocean.  Now, I’m not exactly sure the purpose of jellyfish within the animal kingdom, but at least we were maybe preventing people from stepping on them.  [I also think I created good juju for myself as there were several times I swam into jellyfish on that trip and did not get stung.  Unfortunately, my little sister was not as fortunate with the sea urchins as she was stung by a sting ray . . . a very memorable trip for us all.]

This past Thursday was by far the most exhausting day since I’ve been here (on multiple levels).  We were finally able to get the nurse anesthetist to come (a SIGNIFICANT challenge in itself . . . so frustrating that I still don’t feel like going into detail).  When she said that she would come at 7:00, she really meant 9:00; When I told her I wanted a spinal for a cervical conization, she figured I did not know what I was talking about, so she just did IV sedation.  I don’t think I have every been so frustrated with anesthesia in the OR, and trust me, there were some challenges during residency. 

Even though I was operating, they continued to allow patients to pay to see me (oh, and did I mention previously, that it was decided to charge patients more to see me . . . something I was never notified about, it was only mentioned in passing several weeks after they started doing it).  So . . . following a long frustrating day of cases, there were 14 people with pelvic pain waiting to see me.  At least we had enough speculums to screen every one of them.

By the end of the day . . . I was exhausted, however I had agreed to help the man in charge with a graduate/public health paper.  As we began discussing the program, he mentioned of plans to charge people for screening . . . a fact that I was not at all pleased to hear about.  It’s been bad enough that the person I’m teaching how to screen is maybe here 60% of the time (if that), but now charging people just for screening!  I’m starting to become skeptical as to whether or not this will be successful once I leave.  I am a person full of knowledge and ideas (especially from a public health standpoint), and at times I feel as if I have no voice here. 

Unfortunately, we are out of LEEP loops, so the LEEPS have come to a halt (I’ve done maybe 15 or 20 . . . and will be doing a lot more when I come back . . . it’s a good thing that everyone here has cell phones as we’ve been keeping track of everyone who needs to be treated).  I’ve screened nearly 250 patients.  A small number in comparison to how many people are actually in Haiti, but I’m happy with that number nonetheless.  So . . . I’ve been doing my best to lead the OSAPO hoarse to water, what if it doesn’t drink?  At least I’ve made I difference for the people I’ve seen here.

My life as a musical

A couple nights ago, I was listening to the Glee rendition of a classic ‘Annie’ song.  For those of you who are not familiar with this fabulous musical, one of the well known songs is ‘You’re never fully dressed without a smile.’  [I remember many an afternoon as a young child, my favorite thing to do was get a large cardboard box from Sam’s club, and sit in it in the family room as I watched great classics like ‘Annie’ and ‘The Little Mermaid.’] 

During residency, I worked with a great group of L&D nurses . . . one in particular who loved musicals just as much as I do.  I always loved when we worked together as it would end up being a very theatrical evening (one which tended to drive everyone else crazy).  [Nicole, I miss working with you.]  Life is so much more enjoyable when it is made up of songs . . . 

In my short time here, I have also become quite accustomed to many non-verbal forms of communication as a means to enhance any relationship I have with the people here.  Hugs, pats on the shoulder, holding the hand of a patient when I give them bad news . . . but the best (and easiest) non-verbal form has got to be a smile.

Throughout my time here, many of the employees have come to see me for various gynecologic concerns, including cancer screening.  It seems that after I have seen them as a patient, our relationship has somehow changed.  I’m no longer that odd white doctor who gets anxious when we have really sick patients, and does Zumba in her room alone . . . I am now someone they have an established connection with. 

Yesterday morning, I was sitting at the breakfast table, when one of the lab techs (whom I had just seen in clinic the previous day) walked by.  All I did was smile, and her eyes brightened up, she smiled back and said bonjour Vonde.  Then, I started singing in my head ‘Hey, hobo man; Hey, Dapper Dan’ You’ve both got your style, but brother you’re never fully dressed without a smile!’ . . . which only made me smile more.

In the afternoon, as I was seeing yet another patient who came with the false impression that the white doctor could cure every ailment in one clinic visit, I felt like I was in the temple scene of Jesus Christ Superstar . . . [see my eyes I can hardly see, see me stand, I can hardly walk, I believe you can make me whole . . . will you touch, will you mend me, Christ?]  (I am not comparing myself to Jesus by any means, but there are times where I want to scream/sing ‘There’s too many of you, don’t push me, there’s too little of me, don’t crowd me!)

So . . . I’ll admit, there are many of times that I have seemed to randomly break out into song, but I assure you that 1) I’ve probably been singing that song in my head for a while and 2) it actually does have relevance to what’s going on in life.  I also can not recall a single time where that was happened and the response of my surrounding peers was anything less than a smile.  As Buddy the elf said, ‘The best way to spread Christmas cheer is singling loud for all to hear, ‘ . . . in my opinion, it’s the best way to spread any kind of cheer.  Musicals just make life more fun.

Mother knows best

Last night, I had a nice chat with my mother via skype.  We were discussing many of the frustrations I’ve had while working here . . . specifically some aspects of patient care.  [Just a quick update, on my stage IV patient . . . we ended up finding not only fentanyl patches for her, but also Vicoden.  She went home feeling relief of pain for the first time in several months.] 

In the states, when people don’t have money, or insurance, if an operation is absolutely necessary, we work out a payment plan.  That really does not exist here.  EVERYTHING is private . . . you don’t have the money, you don’t get the surgery.  Last week, I saw a young girl with a complex adnexal mass . . . I suspect that her ovary has twisted on its blood supply, meaning that she is in a lot of pain and absolutely needs a surgery.  She still has yet to have her surgery as she has yet to pay.  I have tried to explain the situation to the folks here, but they don’t want to set a precedent of ‘not taking accountability.’ 

As I was discussing this with my mom, she asked if she could pay for the half that the patient has yet to pay for.  Now, whether or not she would be able to do that is beside the point . . . just the fact that she offered (which is not something out of character for either of my parents) made me feel less alone in my struggles here.  I am very lucky to be surrounded by such generosity.  [At this point, I also want to thank everyone . . . (especially Dan Jackson and Lindsey Smith) for your persistent comments.  You make me laugh, and you make me feel less alone in such a foreign world.]

Today, I saw two patients who had recently self-medicated to induce abortions.  Now, I do not want this blog in any way to become some kind of political or religious platform.  [I’ll save those discussions for the Howie family vacation after everyone has had a few drinks].   These two young girls had gotten the medication off the street . . . no counseling, no written instructions for expectations or reasons to see a doctor, nothing.  They both came in for ‘hemorrhage,’ which lucky for me meant they had just passed the pregnancy (the only D&C equipment they have here is a sharp curette, meaning that would be my only option if there were retained products of conception . . . meaning that I could potentially cause some type of scaring affecting future pregnancies). 

In Haiti, there is this ‘black market’ (which is really just the market) of drugs, and it’s not your typical market that you think of.  Antibiotics, cytotec, etc are all readily available for people to buy and take as they please.  The whole thing baffles me as I would say at least 75% of the patients I’ve see here have taken part in this self-medicating, when many times they don’t have the education to know exactly what they are taking or treating. 

Obviously, the culture here is quite different than what I’m used to . . . medications on demand (no need to be seen by a doctor); also scans on demand.  I cannot count the number of patients who have come to see me saying they want an ultrasound to make sure everything looks fine.  Just last week, a 28 year old actually refused to have any type of exam from me . . . she said that she just needed an ultrasound (after about 15 minutes of explaining why things don’t work that way, she finally decided that I might be correct).  The whole patient care thing is somewhat ironic here . . . on one hand you have specific things that patients make the decisions (ie, when to take antibiotics, when to have imaging studies, etc); on the other hand, you have patients who blindly follow recommendations . . . (like surgery, as I’ve discussed earlier, I don’t know that patients are actually given the option for conservative management).

Same song, different verse

Why do people go to the doctor?  They might be sick . . . they might have something broken that needs to be fixed . . . or . . . they might just want a check up to make sure that everything is okay (the latter, not very common here).  You hope that when you go see a physician for these various reasons, you will be taken care of, and obvious things will not get missed.  In residency, I remember multiple occasions on the oncology service (either a new patient in clinic or in patient consult), where patients who visited their Gynecologist regularly, had a new diagnosis of cervical cancer.   I recall two patients in particular who were diagnosed with more advanced stage cervical cancer, and had just seen their gyn within the past year (and told they were fine).  For those of you who are not familiar with cervical cancer, it is a VERY slow growing disease, taking years to develop.  These women who came with a big bulky tumor on their cervix . . . I assure you was present and ignored at their last gyn exam. 

These types of situations always got to me.  Feelings of frustration that something like this could happen in our country; sympathy for the patient who had been failed by the system; anger at the practitioner who overlooked such a glaring abnormality in the exam.  Somewhat similar feelings (albeit emotions that are focused on different causes) to everything I have been experiencing here.

Yesterday, one of the doctors asked me if I could help him with one of his patients. 

‘I have a 45 year old patient who has been treated for vaginal infection multiple times over the past 6 months.’

I glanced through her chart . . . it seemed that she had been seen by every practitioner in the clinic at least once, and was treated with the same antibiotic cocktail (Metronidazole, doxycycline, cipro) every time. 

            ‘Has anyone examined her prior to treating her?’

            ‘Oh, no.’

‘Well, it sounds like she needs to have a pelvic exam . . . do you want me to do

the exam?’

            ‘Yes, please.’

I looked past his shoulder to see a very frail woman, hunched over in pain, barely able to walk.

‘She looks really sick.  There is something more going on than a vaginal infection.’

‘Yes, she has a lot of pain.’

I invited the woman into the room, as Carine interpreted.  Recent weight loss, awful back pain, leaking of fluid from the vagina.  She took her underwear off, which were obviously soaked in urine.  The whole room smelled like death.  We helped her up on the table, and I started the exam.  Carine asked me if I wanted a mask . , , I declined.  As soon as I inserted the speculum, large amounts of urine mixed with necrotic tissue pooled into the visual field.  I removed the speculum.  My bimanual exam revealed a large fixated mass, filling the entire pelvis, most likely extending into her sacrum, obviously invading her bladder.  Stage IV.  The worst I’ve ever seen.

This poor woman walked 10 hours that morning just to get to the clinic.  She was alone.  She had been seen at 6 different hospitals for this same problem (including a PIH hospital), and I was the first person who performed a f***ing exam.  [I realize that my anger at this example of piss poor patient care isn’t going to make a difference, but you reach a point where you can’t just say . . .  ‘it is what it is.’  No one would treat someone for hypertension without obtaining a blood pressure, why is this any different.  Is it so much to ask for people to do their job . . . EXAMINE THE PATIENT . . . or refer her to someone who will.]

As we do not have any po narcotics here, we made the decision to admit her over night for pain control.  Last night, one of the doctors came to my room to ask me why I had her admitted, and why I wasn’t going to operate on her.  I explained that things were not so simplistic as ‘take out the tumor,’ it was invading too many important structures.  After what felt like a long argument, he finally succumbed to the facts provided by the specialist.  I about lost it when he told me that I needed to put her on antibiotics for the smell.  [I also think the concept of palliation is foreign to some people.  We are still trying to get some type of pain medication for the woman to go home with (while she is here, she is getting morphine), and people have been arguing that we need to send her home.  How would you feel if you had a big tumor invading your bladder, and taking over your pelvis? . . . have some damn compassion!]

Last night, Carine disappeared downstairs for a little bit.  She was bathing the patient, cleaning her clothes, and feeding her.  I almost cried.  In the midst of such a shitty situation, knowing that there are such amazing people, with so much compassion helps you see how much good is capable of existing in humanity.

The Angel of Death

My intern year, we were all required to spend a month in the SICU.  This was in the day where interns still took 24 hour call.  We were in charge of every patient from 5 pm until the next morning.  Although we had plenty of backup in house, it was still a terrifying experience (in a good way . . . I actually really enjoyed my SICU rotation).  The attending would almost always call at some point during the night, just to make sure that everything was going okay.  My first call was a Sunday . . . 2 people died.  [They were both withdrawals of care, but it still sucked].  When my attending called, and asked me how I was doing, I said ‘I feel like the Angel of Death.’ 

This past Friday, my little bat friend made another personal visit.  I’m not sure if it was mocking me . . . it could have been just saying ‘happy Haitian Friday the thirteenth’ . . . or, it could have been an omen to the upcoming events.  [I do admit that I did freak out just a tad . . . I ended up sleeping in the office, which has closed ceilings, and we stuffed any holes greater than ¼ inch with news paper].

Saturday night, well, I guess Sunday morning, one am, I heard a knock on the door.  Apparently there was a patient downstairs who had a breast abscess, and they wanted the gynecologist to take care of it.  [The other doctor who was working for the weekend is basically an intern, doing her year of service following medical school . . . I’m just going to say that it is a little terrifying how much autonomy these physicians get].  I quickly got dressed and went downstairs to see the patient. 

Now, I don’t have much experience with breast abscesses, but this looked pretty bad.  Apparently, it had been there for about a month.  I explained (through minimal interpretation) that it needed to be drained, and the patient said okay.  She freaked out quite a bit with the needle for the anesthetic; I told her she was not allowed to look when I made the incision . . . she did not flinch; When she looked and saw all of the puss coming out of the abscess, she started screaming bloody murder.  It sounded like a mix between a donkey and a bird being tortured.  I tried everything I could to get her to calm down, and nothing worked.  [On a side note, I’m sure that many of the procedures I have performed as a gynecologist have been a lot more painful than this.  Thank God the birth canal is anatomically out of personal sight.  I don’t believe people could handle have of the things we do if they could actually see it!]. 

Today’s story . . . unfortunately much more sad.  First, I get a patient who comes to see me just for a breast mass; 40 years old.  Now, luckily I yet to examine a breast mass that actually ended up being cancer, so I did not have much of a comparison, but this mass she had looked like a cancer.  After I told her she needs to have a biopsy, she shows me the results of a biopsy in PAP, +carcinoma.  She started asking all of these questions, regarding the treatment that she needed, all questions I do not know the answer to.  I had to tell her to come back on Wednesday.

My last patient of the day . . . thirty year old, who came for a second opinion.  She brought a pathology report with her, which, of course, I could not read in full . . . what I could make out . . . cervix, cancer, uterus.  I was hoping that it was just carcinoma in situ . . . wishful thinking.  I was out of speculums, so I decided to just perform a bimanual exam.  At minimal, IIIB cervical cancer.  Then, the patient told me I was the third doctor she had seen.  She started crying.  She told me that every other doctor told her she just needed to go home and die.

Carine was not here today, so I had a 19-year-old interpreter.  She had tears in her eyes as she was translating.  She said ‘I don’t like this.’  It took all the power I had not to start bawling in the room. 

The patient did not have the resources to go to the DR or Miami for radiation.  Thirty years old . . . she would have had her entire life ahead of her.  If I was capable of doing the surgery, I may have offered an exenteration . . . maybe the better of two evils . . . she will just have fistulas to deal with for the rest of her life, or she will die on the operating table.  I found the name of a doctor in port au prince who might be willing to try, but emphasized that her outcome regardless was not good.  [I had been questioning if screening starting at age 25 was too early . . . this answers that question]. 

No matter how many times you experience situations like this in your career (I hope that for most . . . it is few and far between), it never gets easier.  It’s emotionally draining . . . and however bad it is for you, it can only be a zillion times worse for the patient.  You need to maintain enough of your emotions to remain compassionate to the patient, yet be strong enough to remain ‘professional’ (whatever that means).         

The Ethics of Business

[I thought that it might be nice to follow up my previous blog with a run down of the business aspect of things down here in Haiti . . . specifically, where I am working.  However, after an incident last night, I feel it necessary to update you on the bat status.  It turns out, I’m not as over my bat phobia as I had hoped. 

The ceilings here, in the main room are quite high, and open to the outside.  I was sitting down, minding my own business, eating my dinner, and all the sudden, a bat swoops in, flies in a circle, and goes right back out.  I may have gone into Vtach just for a moment, but then it went back to a normal rhythm.  I thought to myself, that’s fine . . . if this is what everyone is talking about, I can handle it.  It was not invading my personal space.  I was fine. 

Later in the evening, I was sitting in my room (which has a ceiling that is a lot lower), reading, when all the sudden a bat flew it.  My heart stopped as I prayed that it would exit just as quickly as it had entered, but it didn’t.  It just started flying around in circles.  I nearly jumped off my bed to the floor and got the hell out of there.  I stood in the kitchen, now with heart palpitations, hoping that it would just leave and never come back (with my history, fat chance, I know).   I finally made one of the doctors come check my room to make sure it was gone.  As we exited, the damn thing flew right past my face.  Once I was assured that it was gone, I attempted to sleep with a sheet over my head.  I began having flashbacks of the night of my bat attack in Columbia . . . the palpitations, the sweating, the fear . . . not good memories.  Every time I started to uncover my head, it would fly into my room again.  At this point, I’m fairly certain it was taunting me.  I fell asleep eventually, with a towel covering the back of my head.  I hope to God that it rains tonight, with the goal of creating a bat free bedroom!]

For my entire life, my dad has been the ‘beer man.’  He worked for Anheuser Busch since before I was born up to my intern year.  This was shortly after the big Inbev takeover, an event that was very difficult for him (and many people, especially those loyal customers of St. Louis).  I wont go into too much detail here . . . but I’ve always thought of my father as an ethical man . . . in every aspect of life (one of the many reasons why the end of the Busch regime and the takeover was somewhat of a difficult point in his career). 

I always joked around with him, saying that I became a doctor in order to avoid the corruptness that he dealt with.  His response . . . ‘medicine is very much a business.’  It took me a while, but with age, I have come to realize he was correct.  Whether a large beer company monopoly, a hospital, university, NGO, or little clinic in Haiti . . . good business skills are an essential for success. 

Within any organization, there are many actions whose ethical standards can be called into question.  The problem is, there isn’t always just one right answer.  Is it appropriate for the head of an NGO to make a six figure salary?; Is it just as bad to have a similar organization run inefficiently, refusing to hire someone with business expertise?; Should all people be held accountable for their actions? [And, if so, at what point to you cross the line . . . do people who smoke not deserve treatment for their lung cancer? . . . Do the morbidly obese not deserve care for their DM II, or sleep apnea?].  You start asking yourself these questions, and it gives you a moral headache.  There isn’t one right answer.

I have always liked the concept of OSAPO . . . kind of a ‘help others, but keep them honest.’  The organization gives something to ‘the people,’ whether it’s clean water, latrines, health care . . . but the people have to give something back . . . whether it is paying a small fee to see a doctor, or building the latrines after the supplies are provided.  The first time I went to OSAPO, Dr. Gardy said that if you just gave the people everything for free, they will just take advantage of you (he went further on to explain how people do not appreciate things that are just given to them). 

In the grand scheme of things, accountability is a very good concept.  Now . . . here I am, just trying to give a little something back (to a community very far away from home).  Everything I am using here has been donated . . . the LEEP machine, the bovie pads, the LEEP loops, monsels . . . (and everything that is on it’s way here  . . . any day now, Sandra . . . was bought with the donations that many of you have kindly gifted after I graduated residency).  All donations, all equipment free, my services are free . . . I felt that the LEEPs should be free as well. 

In my first week working with Carine, she said that I really should not be performing the procedure for free, as it would cost a lot anywhere else in Haiti.  A discussion had already occurred with her and the medical director . . . patients were to be charged for a LEEP.  I don’t fully agree with charging for the procedure, but I’m just here as a volunteer, and I understand that in order to ensure that things will keep going when I’m gone, we need to meet somewhere in the middle.  When the first patient who was notified of the fee said she could not come back as she needed to pay for her kids to go to school, I asked what amount was being charged . . . the equal to fifty us dollars (which is more than what some people make in a month here).  At this point, I said that was not acceptable . . . it had to be less.  I requested it be no more than the equivalent of ten US dollars (whether or not that is the price, I’m not sure, but we have not had anyone say they can’t afford it thus far). 

In my short period of time here, I’ve been attempting to take care of the full spectrum of patient needs . . . diabetes counseling, dating ultrasounds, ward catheter placements, GYN ultrasounds, discussing the complexity of the GI system in relation to ‘pelvic pain,’ I even performed a few endometrial biopsies yesterday.  I have avoided telling people that many of these things are considered procedures, which could warrant some type of fee.  Although, as a physician, I want to take care of the patient, [and not let ‘business’ get in the way], without a good business model, the infrastructure necessary for me to practice would not exist.  

Ethics and Medicine

Throughout medical school and residency, we are constantly taught those ‘basic’ ethical principles in medicine.  Those principles of Justice, Beneficence, Nonmaleficence, and Autonomy are grinded into our head every year for our in service exam so that by the time it’s time to take your boards, you might actually remember each specific definition.  Big words, but basic principles . . . do what is best for your patient; respect their decisions for care; and most importantly EQUAL CARE TO ALL. 

I have found myself needing to approach these principles in a very different way during my time down here.  The patient care is actually quite basic.  At times I feel like I’m still in medical school, just pretending I’m a doctor as much of the care I provide necessitates some type of macgyvering capabilities.  Using foley catheters for bartholin’s abscesses (I’m not sure if that is the correct way to pluralize); cutting up gauze instead of q-tips for cancer screening; diagnosing and treating all of our different vaginal infections by smell and sight (which is also one of the great joys of being a gynecologist) . . . I think you get the point.  [Although, I still can't do a c section with a paper clip].

For the most part, the simplicity of this program has not been too challenging from an ethical standpoint.  You see something abnormal, you take it off . . . plain and simple.  [I have had some concerns regarding the business aspect of the program, but that is a completely different blog].

What is killing me is the concept of justice.  The fact that I know many of these patients could be getting better care in the United States makes me feel like I’m doing something wrong.  Today, I saw a 32 year old who I suspect may have an early cervical cancer (and her exam is somewhat skewed as we are in fibroid country).  She still wants to have children . . . so what to do?  [In case if I had not mentioned, the pathology specimens go to the patients to take to a pathologist in port au prince if they can afford it . . . thus far, no one has opted to take it to the big city].  Tell her I suspect she has cancer and needs a hysterectomy just by the appearance?  . . . Do an aggressive LEEP and just hope that everything has been removed? 

I explained to her my thoughts, gave her the option of doing either, but strongly recommended that if she has the LEEP performed, to have the specimen taken to a pathologist in port au prince.  Luckily, she agreed.  

I realize, just writing it down, the whole sequence of events seems quite easy.  But what you are forgetting is that there is no insurance here . . . the patients have to pay for everything.  You think twice before ordering a test.  If I had every patient do what is considered the standard of care in the states, they would all go bankrupt.  You need to decide what is 100% essential to taking the care of the patient.  Everything is so skewed.  Even though that in my heart, I feel that this is the right thing to do, a part of me feels guilty that it is necessary for her to pay for a pathologic evaluation.  

Although those basic principles of medical ethics are the same wherever you go, various places provide different challenges in their application.  I guess it’s good that I question myself on a daily basis as to how best to practice these concepts (much better than the alternative!)

Toto, we're not in Kansas anymore

So . . . for a change of pace this weekend, I went with Carine to Port Au Prince.  I enjoy the mountains and the little village I’ve been living in, but I think it was a much needed change of pace.  In case if my writing had not conveyed . . . the combination of the heat, and bats, and shatty, unpredictable internet were really starting to get to me. 

This is a whole different world . . . very compact crowds of people, the traffic, the extremes of poverty and wealth, just baffling.  It seems as if every place you walk into has a guard with a machine gun.  Fears of bats, lack of anesthesia, inability to get equipment to function properly, 30 week premis . . . have all been exchanged with fears of shootings, theft, and kidnappings.  Every time we get in the car with Carine’s 13 year old daughter, the first thing she says is ‘Lock the doors, momma.’  Houses are all surrounded by concrete walls lined with barbed wire, and the windows are barred up.   

I am currently staying at one of the three houses that Carine has (she said this one is usually rented out).  She very kindly arranged for her family to switch houses for the weekend in order to accommodate me (even though I’ve said I’d be more than fine sleeping on the sofa).  Last night, Carine told me that she had been very suspicious of the previous tenants of the house . . . three guys, one from Columbia who’s only form of identification was a phony Haitian driver’s license.  She said that her husband rented it out [after receiving $18,000 USD for the entire year] while she was still living in New York.  She said that they were gone at least three months before the lease was up, but there had not been any communication with the tenants for almost a year.  She and her husband re-entered the house with the police as she did not know what they would find . . . dead bodies . . . drugs . . . weapons.  She said that there was not a trace of them being here, just many old egg crates, and most of the linens were missing.  All of the locks have been changed since, but it brings a harsh reality to the world we live in.  It’s like hearing stories from ‘Weeds’ but without the comedy.

Today, Carine took me further up into the mountains into the Kenscoff area.  The weather was a bit cooler than I’m used to experiencing here (and I LOVED IT).  We went to a Haitian museum, which discussed their history, voodoo, politics, etc. . . . I had the opportunity to barter for some art work, and to see a different side of the city.  I will say there are many more white folks here than in Roussou!

On our way back, Carine we had a discussion regarding certain relationships.  Without being too specific, or being a gossip myself . . . I will say my morals or beliefs of what a relationship should be is very different than here.  I think the concept of sexual abuse and cheating are just accepted as a way of life.  The first time I came here, there was a young girl who came to be seen for bleeding.  Sandra said she looked like she was going to pass out, thought she was having a miscarriage.  When I did her exam, everything was bruised and swollen.  When I inquired more, the young girl said her boyfriend rapes and beats her almost every day.  There was basically nothing I could do for her.  The police don’t care, there are no shelters for battered women, there is no escaping . . . it is what is is. 

Today, Carine was telling me about how someone (let’s call him George), living in two places, has a fiancé (Let’s call her Michelle) in one area, and is seeing someone else in another area (let’s call her Betty).  She said that ‘Betty’ knows about ‘Michelle’ . . . and ‘George’ and ‘Betty’ were supposed to just have a casual relationship, but ‘Betty’ is in love with ‘George.’  Carine seems to feel that ‘George’ really isn’t doing anything wrong, and he was upfront with ‘Betty’ from the start.  My question . . . what about Michelle?  Carine’s response . . . well, ‘George’ is in 2 different places, so, it really doesn’t matter.  It’s CHEATING!  I’ve gotten the impression that this kind of thing is very common here . . . and I just don’t get it (I guess I don’t have to . . . I just refuse to be any part of it . . . very much don’t ask, don’t tell kind of scenario).

So . . . I shall continue this little side adventure, head back to my ‘Kansas’ of Haiti at the ass crack of dawn Monday morning, and in a little over three weeks, head back to real Missouri (Just in time to see the cards start another post season victory!).  

Bring on the heat!

Have you ever been so hot, it feels like time is standing still?  Where it feels like every moment takes forever because you are so uncomfortable?  Where even a cold shower does not keep you from sweating?  Where you feel dizzy every time you stand up?  Where you constantly feel like your heart is feeling way too fast?  Where there is no end of a cold pool or air conditioning in sight? 

This week has been that way.  [Either that or I’m going through menopause.]  I feel as if my brain is being fried; like it takes up so much energy just to think.  Yet with this heat exhaustion, it is too hot to really get a good nights sleep.  Everything feels as if it were at a standstill.  Yes, I still see patients every day, and yes, we are still screening every woman we can for cervical cancer and LEEPing them when we have the chance.  Equipment is starting to slowly dwindle (luckily Sandra has done more than her fair share of the work in the states and has shipped some necessary equipment that should be here tomorrow). 

There is a part of me that is worried that this whole project wont be successful.  What if, after I leave, everything I’ve done and taught is forgotten?  And, if it is forgotten, does that make me a failure?  Did I really do my best in ensuring success of this program?  Did I do my best in educating the staff here of necessary components of women’s health care?  Honestly, right now I feel like the heat is hindering my ability to really perform and teach up to par.

On the other hand, glass half full, even if this is not the victorious program that I intended, at least it will have made a difference to the people I have treated in my time here (just like the star fish story).  This whole situation has been one gigantic leap of faith.  Although implementing a screening structure with training highly relies on me, the final outcome is kind of out of my hands.  And I still don’t know what it will be, which is almost as exhausting to fathom as the heat.

Many of my previous teachers have told me how much respect they have for what I am doing here.  I really don’t think that I deserve any more attention than any other person.  Things like this don’t happen with just one person.  We all take chances, entrusting our livelihood in others on a daily basis . . . whether it’s a parent entrusting their child to drive their car for the first time, an attending allowing a resident to perform a surgery under minimal supervision, or making the decision to finally let them graduate into the real world of medicine [or donating an expensive LEEP machine to a hopeful cause]. 

To all the teachers and healers of the world, I commend you for continuously fighting the good fight.  I would not be where I am today without your guidance and faith in my capabilities.  Although I truly hope that it cools off just a little bit here . . .  to my metaphorical heat, I say ‘bring it on.’