Just your typical saturday

To start off . . . I can now empathize with the small town obstetricians who used to dump the ‘pre-term labor’ patients on us during residency.  Yes, I can admit that some patients who were sent to us for evaluation were complete bogus . . . I truly hope that their reasons for transport had to do with patient (specifically infant) concern as opposed laziness.

It was my typical Saturday here . . . sitting at the kitchen table, catching up on some paperwork . . . sweating profusely . . . when one of the physicians tells me he has a pregnant patient downstairs . . .

           

‘okay . . . can you tell me about her,’

‘She doesn’t know her due date.  She said she felt some water from her vagina, and bad epigastric pain.’

‘Did her water break?  Does she have any idea as to how many months she is?  (NO ONE uses weeks here . . . I’ve leaned to stop asking)

‘She has maybe six months.  No . . . her water is not broken . . . I checked.’

‘Did you perform a speculum exam?’

‘No.  I check her cervix.  There is no dilation.’

‘So . . . that is not how you check to see if some ones water has broken.  You need to do a speculum exam . . . I’m just going to go see her.’

I head downstairs to find a woman who is very obviously laboring . . . [she had been told to go home, and even had her prescription filled for pain medicine].  Speculum exam reveals black hair.  She was 5/100/0, and this was her second baby.  A quick BPD showed 31 2/7 weeks.  The closest hospital with a neonatal resuscitation, and the ability to intubate is at least an hour from here. 

In the back of my head . . . I’m thinking . . . I long for the days when this situation was stressful in Columbia.  The days where the intern on night float sent home a laboring 24 weeker while you were in a cesarean section, but the patient still managed to make it pack in time to deliver the baby breech just off the stretcher.  Or the PPROMers who have been getting narcotics for their pain all night, and a you see hair when you perform an exam.  The ending with those cases would always be a neonatal resuscitation team, with all of the equipment necessary to take care of the baby.  [And there is a team of people that follows orders and knows what needs to be done].

I started thinking . . . maybe we can stabilize her and get her to San Marc . . . we can give her some magnesium, give her some antibiotics, betamethosone  and use the ‘ambulance’ to get her there.  [I know that was VERY wishful thinking].  I told the nurse she needed to start an IV right away and get antibiotics in her while I looked for the other medications. 

Apparently right away means after the patient has eaten something, as when I came back in the room after looking through the pharmacy, the patient was sitting on the exam table with a bowl full of meet and rice from our kitchen (some sort of cultural thing . . . it is dangerous to give any type of antibiotics without having food in your stomach).

Next thing I know, the nurse is moving the patient to the delivery room . . . still without an IV in her arm, saying (in creol) the patient needs to push.  Nothing I had said, requested, etc, was listened to . . . it was as if no one cared.  As soon as the patient got on the delivery table, finally with an IV in, she was crowning.  I gowned up, delivered what appeared to be a 32 week infant. 

I carried him to the resuscitation table, stimulated the hell out of him, dried him, asked about five different times for more warm dry blankets . . . and was denied the opportunity to give the baby to the mother.  At least when the nurse returned, she had a heating blanket on him.

I say that we need to get the baby to San Marc where there is the closest thing to an NICU.  The physician tells me that he would need to call the driver, who might be in port au prince.  Finally, after a conversation that should have taken 2 seconds, I convince the other doctor to actually call the driver and have him come to take the baby in the hopes of preventing him from dying.  [The baby is now finally on his way to San Marc.]

For all of this stress, I feel as if I did nothing to help, and even if I did, there is still a good chance the baby will end up dying.  As a physician, healer, good Samaritan, whatever you want to call me . . . I feel like I have failed. A 32 week infant would live in the states . . . and you would have everyone surrounding you working at optimal levels to ensure that baby had every possible chance they could.  It is so frustrating!

Good things come to those who wait

I wrote this last night (due to yet another big storm, unable to post it until this morning)

Patience is a virtue . . . one which I admittedly have not always maintained to its full capacity.  You learn quickly working in a place like Haiti, that this is an essential asset in keeping your sanity.  The three weeks I’ve been here has been more than a test of my endurance (which I have always considered one of my better features . . . at least when it comes to running . . . I may be slow but I can go the distance!), but a test of my ability to adapt to situations I literally have no control over.

I have always joked about my life being an example of the serenity prayer . . . ‘please allow me to accept the things I can not change, change the things I can, and always be able to tell the difference between the two.’  My issue was always telling the difference between the two (I know . . . very odd . . . a doctor wanting to control everything). 

I recognize that up to this point, I have been pretty redundant . . . just my silly attempts to sound philosophical or something.  Also, without living here, it is really difficult to given clear cut examples of what I am talking about.  I’m in a country where the lifestyle is very different from what I’m used to (everything runs on island time, which means I am actually early for everything)  . . . working in a place that is not used to having a gynecologist (ie it has taken a while to enforce the concept that I can not do my job without speculums . . . they need to be sterilized every night or I can’t do what I came here to do).  Everything with patient care takes so much longer, because I am the one putting all the equipment together (although I must say now that the storage room is somewhat organized it takes a bit less time).

So my great examples as to how patience has paid off this week . . . let’s start with Carine.  After a week of not knowing when she would be here . . . having not worked with her since my first week . . . she was finally here on Monday!  Most importantly, she was doing speculum exams by Tuesday, and on Wednesday she was accurately performing VIA (now we just need to get the LEEP thing down, and maybe a few more screening exams).

Now for the finale, if you will.  Either absent or very limited internet for a week and a half . . . had no control over it, and after the first few days I was in acceptance mode.  I have been reluctant to make any statement regarding some false publications made by ABOG, as not to jinx myself in respect to my boards.  But, now I can.  Last year, the ABOG written boards publication stated that everyone taking their written boards on June 24, 2013 would receive their score no later than August 15 . . . this was a dirty lie (I found that they had changed the date to no later than September 1).  I waited patiently, and not having the internet last week actually helped prevent me from thinking about it.  It was the first thing I checked once I logged on to the inter web . . . and I passed.  Nine LONG weeks of waiting . . . the final result well worth the wait.

Count Your Blessings

When I think about it . . . there are so many things I have in my life to be thankful for.  I have very supportive parents who have always emphasized the importance of care and compassion for others (I guess you may have taught me something).  I have two wonderful sisters, a soon to be brother in law, two fabulous dog nieces.  I have friends who have proven that long distance will . . . if anything make our relationships stronger.  I've got a great job I'll be starting once I fully return from Haiti.  [I not only get to move to Alaska . . . I get to have one of my best friends come with me!]

Today, I was listening to this song by a small band from Colorado (Paper Bird) . . . it's called Blood and Bones . . . there is a part that says 'how sweet this life can be, when your home sweet home is everywhere you go,' and I realized how true that is.  Even though I'm so far away, I know my foundation (which includes many of you who are reading this) are still with me.  [Jen, assuming you remember our conversation a few months ago, good theme song :)]   

Being here makes me realize how many things we are blessed to have . . . specifically our health care system.  How awesome is it that the things we bitch about are prescription coverage plans, or when people are taking advantage of the system.  For those who know me, and my tendency to be dry and sarcastic, the previous statement was not meant to be taken that way.  I'm serious . . . if these are the things that we have to complain about, then we are pretty damn lucky.

I knew that there would be people here I would be unable to help.  I knew that there would be people coming with advanced cancer.  [I was honestly expecting that it would happen sooner than it did].  Knowing these things does not make it any easier when it happens.  That first patient came today.  56 years old . . . went through menopause 10 years ago . . . bleeding for the past year.  They live in San Marc, but they came to OSAPO to see the 'white' gynecologist to make her better.  First time she went to see a doctor to evaluate it.  Advanced stage (at least IIIB) cervical cancer.  I sent her back to the hospital in San Marc in hopes that they might be able to offer some kind of palliation (we don't even have po narcotics here . . . she was stable and dying . . . nothing I could do).

So . . . with this humbling moment in time . . . I will say we are all very lucky to have the access that we do to health care.  It isn't perfect, but it is so much better than it could be.  Today was more of a reminder than I wanted as to why I am here.  There is nothing I can do for advanced staged cancers . . . but maybe some of the work I'm doing will prevent this from happening to someone else.

And the consults continue

8/24/13

As I am sitting here, waiting for what will be both my first vaginal delivery both as an attending and in Haiti, I thought I might share with you some important things I’ve just learned about working at this little clinic.  [Specifically, these are things regarding agreeing to perform a delivery or any important job in an area where you don’t speak the language].  First and foremost, never agree to anything when your nurse isn’t at least partially fluent in english.  Now, I never really agreed to do anything . . . the physician here on call decided that she did not want to take care of the patient, so she told the nurse to come to me.  I really don’t mind the work . . . I was just studying prior to the consult (still no internet . . . not until Monday I’ve been told, won’t hold my breath).  Being told first that she is a multip (I didn’t ask that specifically . . . I asked, has she had babies before), then fifteen minutes later that she has never given birth before; Being told that the fetal heart rate is 16 (that’s right, sixteen) . . . freaking out trying to get a Doppler to confirm to find that the heart rate is in the 150s; Asking if the patient feels like she needs to push, and the response you get is okay; Waiting forever to just get shoe covers; unable to obtain any kind of history from the patient . . . and then being asked to write her orders, when you know they will not be understood or truly followed . . . all reasons why this whole thing was definitely not my ideal set up for a delivery.  I’ll let you know how it goes.

 . . . . it turns out that performing a delivery is much more fun than repairing a third degree [on a patient you did not deliver].  I must say, I was probably more entertaining here than I am with our folks in the states.  For those of you who have not worked with me on L&D, I have a tendency of being somewhat of a cheerleader.  Turns out,  I have not changed since residency, and have no problem coaching in english to a patient who has no clue what I am saying.  Eventually, we got things to work . . . a primip with no epidural (and no lacerations . . . I might add), and a beautiful 6 lb baby girl. 

I get the feeling that people are in more of a hurry to get people delivered here than in the states.  The nurses looked at me like I was crazy for not wanting to cut an episiotomy . . . and also acted like I was nuts for not wanting them to stretch out the perineum while she was pushing (yes . . . I did learn something about delivering women without epidurals in residency . . . and I apologize to all of the non-gynos reading this as this may have been a bit graphic, but it is part of what I’m doing here . . . what did you expect?).  

In the end, I really am here to help out and provide what little knowledge I have in attempts to maybe make the world a slightly better place.   I realized (especially today), that for most deliveries, we really don’t do all that much (especially here . . . where we really don’t’ have the means to make any type of intervention if needed).  That being said, they are still a very fun and fulfilling part of the job!

These pretzels are making me thirsty

8/23/13

Yesterday, as I was working on my computer, sitting in the sweltering August Haiti heat, thinking of all the abnormally entertaining aspects of my life here, I decided I needed a catch phrase to sum up my state of mind.  For some reason, the phrase that kept on coming to mind was ‘These pretzels are making me thirsty.’  I have no clue why, but it just seemed to fit.  

Now, I recognize that in my last post, I may have seemed a little bit mellow dramatic about the internet situation.  As I am writing this, I have yet to post anything, as we still do not have internet (I’ve been assured since Wednesday that it will be available the next day . . . I’m not holding my breath), so it will most likely appear that my feelings on the subject are somewhat unstable.  The truth is, as I’ve gone several days without it, it becomes less and less difficult to deal with. 

I thought I’d take a moment to tell you all a little bit about my daily life here.  The day starts off with random, inconsistent crowing of the various jungle roosters.  Once I’ve made the decision that it is a reasonable hour to get up, I grab my pocket mirror and other essentials for the bathroom, with the hopes that it will not be occupied (there are no mirrors in the bathrooms, and there are only two bathrooms for approximately ten people).  We have a nice communal breakfast in the kitchen, and then off to clinic.

Now . . . clinic has it’s ups and downs.  I’ll admit there have been some sad and frustrating situations.  There was the PPROMer; . . . the lady who I attempted to do a LEEP on earlier this week (when we could not get the bovie pad to work, she took it as a sign that she should not have her lesion taken care of . . . I must have spent twenty minutes trying to convince her otherwise, but she declined . . . .something to do with voodoo or what not); and the 22 year old who was just diagnosed with HIV and also had zoster (I was the first physician she saw after her lab results came back). 

Enough with the Debbie Downer . . . as there are also some very amusing things that occur on a regular basis. First of all . . . chickens frequent the clinic.  I don’t think a single day has gone by where I have not seen a chicken running through the waiting room.  The patients are also very pushy . . . sometimes I feel like I’m surrounded by a bunch of New Yorkers on the subway during rush hour.  When I was evaluating a bartholin’s cyst the other day, the patient kept on trying to show it to me while I was performing her exam (very annoying, but I could not help but laugh to myself as it was happening). 

My interpreter has no clue how to pronounce my name, so she often introduces me as what sounds like Dokte Vroom de Vroom (not as good as the Dr. Dander Her that a patient wrote on her records during my days as a resident, but still, amusing).  If only that was the only problem . . . as she does not understand the concept of a hysterectomy, or a cyst, or really understand any medical phrases, as when people are not actively menstruating, she tells me they are in menopause.  These pretzels are making me thirsty.

For those of you who worked with me in residency . . . working her has allowed me to be more unlike an Oklahoma girl than I was in residency (Kayla, I’m sure you don’t’ think that’s possible . . . I assure you it is).  I only wear comfy sweat proof clothes during the day . . . I only wash my hair once or twice a week . . . I didn’t bring a stitch of makeup with me . . . no plucking of the eyebrows.  I assure you I continue to be hygienic, but the only time I look in the mirror is to put my contacts in.  It’s nice not worrying about those things!

So . . . end of week two of my screening experiment.  Sixty-one patients have been screened.  Five LEEPs have been performed.  Carinne has yet to have any training.  Granted she comes on Monday, I only have five full weeks to ensure that she is competent to continue the screening and perform a LEEP.  [Given my inability to stay in the country for more than three months at a time, I will be going back to St. Louis for a couple weeks in October, and then return to help with the multiple medical teams coming to the area in October and November.  It is my hope that upon my return, the screening will be continued while I am gone in October].  These pretzels are making me thirsty indeed!!

A Hard Rain’s A Gonna Fall

8/21/13

A statement that seems so appropriate metaphorically and literally.   It’s been frustrating week . . . and it’s only hump day!  For those of you who have not worked/volunteered/whatever in a third world country, it is important to go in knowing that unless you are personally taking care of everything (and I mean everything) . . . NOTHING will ever go according as planned.  Also, NEVER underestimate the healing power of music.

I really have no complaints of any of the people who have so graciously invited me to their home atop the clinic.  Everyone here has been so nice and accommodating.  They have even given me my own room (something that I insisted was not necessary . . . but it’s nice to have privacy).  Now that Sandra is gone (and my soon to be second in command in kicking cervical cancer on it’s ass is no where to be found), everyone has been practicing their english with me.  I have felt very welcomed here.

In really reflecting as to where all my frustrations stem from . . . it is probably just cultural differences and the language barrier.   In clinic, the staff has a tendency of walking into the exam room as they please to give you more patient charts.  Today, while I was in the middle of getting a patient history, I was interrupted five times!  I also realized today (as I’m familiar with some of the French/creole terms) that my interpreter interchanges the terms ovary and uterus . . . something that I find more comical than upsetting.  She’s just not someone I’d want interpreting during an emergency.

With the lack of communication between people here, I am honestly surprised how anything gets done.  I was told yesterday that there will not be an anesthesiologist here until September 7, something that many of the other staff were not aware of seeing as earlier that same day one of the nurses was telling me I should schedule a hysterectomy this week (reasoning why is a long story . . . but I get the feeling that there are a lot of non-indicated surgeries that are performed here, hence the reason I have not needed to schedule a hysterectomy after being here for two weeks). 

No one knows when Carinne (the nurse I will train in cancer screening) is coming back . . . no one can tell me if I’ll need an interpreter next week . . . and no one knows when the internet will be back for good.  For the past several days . . . I’ll maybe get ten minutes of internet time a day (with my priorities of [first] attempting to complete an online application for hospital privileges in Alaska, and secondly updating my blog so that people like Dan Jackson can be entertained (I’ve thoroughly enjoyed all of the encouraging posts from everyone!)). 

I’ve said this before . . . I know that not having the interweb is not the end of the world.  I challenge you to abstain from using a phone or internet for an entire work day . . . then tell me how easy it is.  I’ll admit, I have become quite accustomed to using this amazing thing . . . for work, entertainment, communication . . . I have no clue how people functioned without it years before.

As I’m sitting here typing listening to a genius playlist of ‘I’ve seen all good people:  your move,’ I don’t feel so disconnected from my family and friends.  The song came on last night while I was working out . . . just hearing the start of the song, I was back in St. Louis running with my dad (he’s telling me how this was one of the best songs by Yes because it was all acoustic . . . so out of character) . . . I was going to see Almost Famous at the Chase with Joe V and Melissa . . . I was finishing hospital hill for the fourth time.  Have you ever noticed how a certain song can take remind you of a happy time in your life . . . or if you’ve had a bad day for one reason or another, you can here a song for the first time, and it suddenly makes everything better? . . .

In medical school, it was the songs of Bob Dylan and The Allman Brothers and Joni Mitchell (to name a few) that reminded me of a simpler time . . . hot summer days at the pool . . . long car rides with my dad, where he would tell me in detail what every song was about (and as I got older, he would tell me stories of what he was doing when the album came out . . . which significantly contributed to my love of the Grateful Dead and ‘Friend of The Devil.’).  During residency . . . it was the music of Florence and the Machine and Michael Franti (despite Dan Robertson’s feelings . . . I like his positive point of view!) and Mumford and Sons would turn my frowns upside down after a bad day. 

Now . . . I can’t emphasize this enough . . . the named artists are just a small representation of my extensive musical collection.  There is just so much artistic talent that has the capacity to promote positive energy, if you let it.

I just wanna dance

(this was written on August 19, 2013 . . . due to internet failures I was unable to post it until today . . . enjoy!)

In my last year of medical school, I attended a nutrition conference with a few of my friends.  This conference was put on by CMBM (community of mind, body and medicine) . . . in case if you can’t tell by that short description, it was very vonde friendly.  On one of the mornings, one of the lecturers had us all stand up, close our eyes, and dance . . . making the point that dancing can always put you in a good mood . . . a very true statement . . .

Last night was my first night consult.  In order to better understand, I’ll start with explaining the way the delivery process works here.  The physicians delivery the baby, and apparently will routinely cut episiotomies, and then leave the nurse to do the repair.  I had heard the lady laboring downstairs . . . so when nurse Bernadine came knocking on my door saying ‘dokte vonde, I need your help . . . come quick,’ I had an idea of what she needed (luckily wasn’t a massive post partum hemorrhage . . . just the laceration repair).  A complete evaluation of the patient revealed a partial third degree laceration.  Finding the appropriate suture was difficult enough . . . but then imagine sitting in a poorly ventilated room in the head of Haiti, attempting to repair a laceration with a camping headlamp, using only local anesthesia, with a patient who understands nothing you say, and a nurse who maybe understands a third of what you are saying.  A set up that would make Courtney Barnes cringe. 

By the time I was finished, I was dripping with sweat  . . . and all I wanted to do was clean up, send out a few emails, and go to bed.  Once I got upstairs, I came to find that the internet was once again not functioning.  The internet we have here kind of functions like a cellular data plan.  There is the option of having unlimited, or you pay ‘before’ you go.  Everyone had been under the impression that there was unlimited data, but for the past two evenings, a message keeps on coming up on my computer stating (in Creole . . . so I don’t know the exact words) that we need to buy more data.  VERY VERY frustrating!  I know . . . I’m acting like a princess.  If not having the internet is the only thing bad going on, then things really aren’t that bad, but it is very nice to feel somewhat connected to family and friends when you are so far away.

Then comes the morning . . . another busy day at the office.  One of my screening positive patients came back for her LEEP . . . and I don’t’ think I could have asked for things to go more smoothly.   I saw seventeen patients from the morning through the afternoon . . . thirteen of which had vague complaints of belly pain (if she has a vagina, then it must be GYN in origin . . . right!).  On the plus side, I have gotten really good at evaluating abdominal pain . . . I diagnosed a case of H. Pylori today! [the other theme seemed to be PID/cervicitis, which I’m fairly certain I diagnosed and treated at least five or six cases. 

By the end of clinic, I was famished . . . I didn’t break for lunch as I have a problem leaving five or six patients waiting just because I want to go eat.  First thing I find out when I go to my computer . . . the internet is not working again!!

So now . . . to the theme of the day.  I’m going to admit something that could bring forth some mocking or scrutiny, but what the hell.  In my attempts to somewhat stay in shape during my time here (it is my goal to run a 15 k with my dad in December . . . and probably not the safest or smartest to run on the one road that is covered with livestock and motor bikes, and the occasional truck), I brought Zumba videos to work out to.  For those of you who don’t know, Zumba is the newish latin dance workout craze . . . everyone is doing it.  Most days, I’m forced to be somewhat silent in my workouts as there are open ceilings, but today, there was a big storm, which meant I could be as loud as I wanted.  I zumba’d like no other, listening to the sounds of Laura Marling, Mumford and Sons, Vanilla ice, The Allman Brothers, etc . . . dancing truly does put you in a good mood.  I highly recommend it as a therapeutic remedy for all!  

Memorable Moments

With the quietness of the weekend, I’ve had the chance to reminisce over the experiences in my life that have lead up to this . . . and I can’t help but think of Dr. Griffin.  [Although I’m certain that many of you reading this are aware of the phenomenal person he was . . . for those of you who do not, he was an amazing teacher and mentor, who brought the concept of care and compassion for your patients to a whole new level.  I was trying to think of an adjective to describe him in my introductory sentence, but then realized that I could not think of anything that would truly do him justice.  Plus, his name stands just fine on its own.]  He was the first attending I ever did a colposcopy [and cervical biopsy] with.  I can still hear him telling me not to be a pansy when taking the biopsy.  He was the first person I ever did a LEEP with . . . when I did not have everything set up and ready to go he got a little irritated with me, but then apologized as he said he did not realize it was my first time.  He listened to everything you had to say . . . I remember times going to visit him and he would ask me how my dad was enjoying retirement from AB, or about my cousin on Broadway . . . these were things that I had maybe told him in passing several months before, but he had listened. 

Dr. Griffin died almost exactly a year ago, but the moments that I have had the opportunity to experience with him are still very much alive in my heart.  Our lives are made up of special moments . . . whether it’s a special weekend you spend going on runs and to baseball games with your dad . . . a surprise random phone call from your little sister, which turns into a lengthy conversation about careers and future goals . . . an evening with your mom and old family friend that gives you the courage to take a job very far away from home.  I have many others to include, but that would take all night to write!  Part of what makes these moments so special is the people who are a part of them.  I am so blessed to have so many amazing people in my life . . . the mentors I have acquired along the road . . . my friends (a very broad term, as some of you are more like family . . . you know who you are) . . . and my family (especially my amazing parents and sisters . . . I feel so lucky to be a part of your lives).   

In the short time I’ve been here . . . there are some experiences that will not be forgotten . . . The live chicken in the car trunk (Yes Wesley, I’m convinced it was going to a petting zoo).  The first LEEP I performed was somewhat of a mess, and I couldn’t help but chuckle in my head, knowing that it could only get better (trying to do a procedure with a Haitian nurse who doesn’t speak english and an interpreter who does not fully understand gynecology and procedures, plus the first time I’m using the machine, does not make for a smooth ride!!). 

On Friday afternoon . . . when I thought I was finished seeing patients, I was told there was one more.  She had been seen by another physician, and he wanted me to see her as well.  As I was wearing my negative nancy pants, I assumed that it was because she needed a pelvic exam (something that occurs quite frequently here . . . they are doing a great job of making me feel like I’m working at WCH again).  It turns out, it was for infertility, in a 17 year old (not quite to the point yet . . . almost there).  The doctor really just wanted my opinion on what could be done for her, which turned into a teaching lesson on the basics of infertility.  I was reminded how nice it is to teach to someone who is really interested in learning. 

I’ve spent the last two nights with some of the staff doing English to Creole translation . . . I’ll help them with their english pronunciation, they help me with my creole (which is still REALLY bad).  I think that my lack of ability to make certain sounds with my mouth has been quite entertaining.

Now, for my most memorable moment of the week . . . trying to get in touch with my sister.  On Wednesday night, I got a facebook message from her stating that she needed to talk to me right away . . . she had some big news for me.  Right away ended up being two days, and despite my parents attempts to keep the surprise, I knew what the news was.  After several minutes of trying to get the sound on skype to work, we could finally see and hear each other.  I believe her exact words were “how would you feel about officially making Jesse part of the family.”  My older sister is engaged!  (Jesse . . .if you are reading this, I’ve known you would make a great brother in law since a conversation we had on Christmas eve . . . for political reasons I’m not going to post the specifics).  I am so happy for them . . . and greatly appreciate the fact that their public announcement was delayed until I was given the news. 

I am sure that the remainder of my time here will consist of several special memories . . . but, from a personal standpoint, I don’t think anything will replace the experience of receiving such a special announcement from two people who hold such a special place in my heart.

Another Day . . .

Yesterday, I spent the entire day traveling.  I had found out the day before that the 15^th was a holiday, meaning the clinic was only open for emergencies.  As I had nothing better to do, I was invited to go on what felt like the Paul Farmer’s Haiti tour.  We started at the new hospital in Mirebalais, which was quite impressive.  As I was on my tour of the OR suites, I was partly expecting to find a Da Vinci.  All the rooms had head lights with cameras connected to them, I’m fairly certain most rooms had two computers, white and bright and completely sterile, and actually cold!  Equivalent and even better than some of the hospitals in the states, and very beautiful landscaping. 

From there, we drove by the very first PIH hospital in Cange; then our final destination in Henge before turning around and heading right back.  We spent much more time in the car than we did any of the places we stopped, which meant I had a lot of time to meditate, contemplate, etc.  I was able to appreciate the scenery, and truly understand the title ‘Mountains Beyond Mountains.’  I thought of how in just under five months, I’ll trade this sauna of mountains for snow-capped mountains in the great white north . . . something I am very excited about. 

I hate to admit this, but there is a part of me that wishes I were in Alaska now . . . that would have been much easier.  But, anyone who knows me knows that I always like to make things more difficult for myself.  I’m not sure if it’s catholic guilt, or penance for anything bad I’ve done in my life, but I do feel that this is a task meant for me to bear . . . this is very different from the past mission trips I’ve done where there are other people you can easily communicate with, and understand where you come from surrounding you, I’m alone for the time being, and it would be a lie if I said that I wasn’t lonely . . . but to quote a very smart fish . . . I need to ‘just keep swimming.’ . . .

So, today . . . another day in clinic.  Another day where every patient with belly pain is sent to see me.  Another day of struggles with my interpreter . . . needing to make things as basic as possible, and explain things multiple times, I thought I was going to loose it.  Even something as simple as getting a patient’s pregnancy history seemed to take forever.  The day actually started out somewhat successful.  First patient . . . only came for screening . . . 31, VIA positive, performed a LEEP . . . still had some glitches, but it went more smoothly than the first, things were going well.  By the time I got to the patient who told me that she was having increasing pain in her ovary every time she washed her vagina with Clorox, I thought I was going to lose it.  I’m not sure if I can keep this up for the next seven weeks. 

So . . . now the end of week one of the VIA see and treat protocol at OSAPO.  18 women have been screened, two positive and treated the same day, 3 more positive and hopefully not lost to follow up.   

Decisions Decisions

I feel like I’ve spent my entire life second guessing myself . . . should I have bought this or that . . . was that trip really worth the money . . . did I make the right choice in regards to this, that or the other.  The problem is, the decisions we make can have ulterior motives, and sometimes they aren’t even that obvious.  My entire chief year . . . every case that I gave to a lower level, I would always wonder if I was doing it completely out of the kindness of my heart or because I was being lazy.  Then there is also that fear of . . . If I spend enough time not doing something, am I going to forget how?  Will I lose my skill set?  Did I ever really have one to begin with?

As I had mentioned earlier, the nurse who was supposed to be helping me for the second half of the week had to leave the country emergently for a sick child.  She will be back on Monday (hopefully), so I’ve got several days here without an interpreter.  Yesterday, arrangements were made for a medical interpreter to come by this morning.  Shortly after I was notified of this, our surgeon notified me that he had two hysterectomies scheduled at another hospital, which he wanted me to help him with.  What gynecologist wouldn’t want the chance to perform two abdominal hysts in a day.  If you add a vaginal hyst in there, it would be like Christmas.

So . . . the decision . . . do I arrange to have the interpreter canceled for today so that I can go to the OR and remind myself that I am still capable of operating (a fear that I admittedly have); or . . . do I stay, and continue my screening efforts (with the knowledge that there will hopefully be many surgeries to come).  I think that the right choice was obvious from the get go . . . I stayed.  I did not come here to become a better surgeon, and increase my exposure to open cases . . . I came to teach a very simplified skill set that will hopefully save lives.  I screened three people today, two were VIA positive, and we did our first LEEP.  The second gal lives close by and will come back on Monday for her treatment (I know . . . goes against the concept of see and treat, but at the moment we only have one coated speculum . . . something that will be changing in the future).

All in a day's work

So . . . upon arrival I was reminded of the challenges I’ll be facing during my time here.  Something I was ‘aware’ of prior to coming, but something you can’t prepare for.  It’s funny, as it really doesn’t matter how much you know your getting into . . . you really don’t realize it until you are living it.  The simple things . . . like internet, cell service, srub techs, patient transport, communication with people who speak your own language fluently . . . are really the things that get you.

I performed my first cesarean section as an attending this past Saturday . . . I had a non-surgeon Haitian physician assisting me (one who at least spoke a little English), and I was my own scrub tech.  It’s amazing how such a simple procedure can feel so exhausting.  As if that weren’t enough, I spent the entire day worrying . . . what if I got into the uterine arteries and didn’t know it . . . what if she ends up having a post partum hemorrhage . . . what if I need to take her back to the OR . .  . what if I’m causing more harm than good??  . . .

Besides the cesarean section, I had other tasks that kept me busy over the weekend . . . helping Sandra clean out the storage room (which . . . nick if you are reading this, made your place seem clean and organized) . .  . and most importantly putting together my introductory presentation for the cervical cancer screening project. 

Come Monday . . . I was ready to get started.  We didn’t have everything we needed yet, but I at least wanted to start thoroughly getting the staff educated as to my plans, as nothing I do will really make a difference unless they continue doing what I teach them.  Sandra interpreted as I discussed the very basics of my intentions to some of the female staff . . . all four were on board. 

I had also found out that morning that the nurse who was to be my interpreter and the first to learn how to perform VIA had to go to the states emergently as her daughter had appendicitis.  She’d be gone for the week.  With Sandra leaving on Wednesday, I would have no one here to assist me . . . something that could possibly push things back a week.  But, Sandra said she would make sure things were taken care of.  I will say right now, even though she wont be here with me the entire time . . . this project would not be successful without her.

 Then . . . to clinic I went.  Just as I had the two previous days, I was deemed responsible for seeing every GYN patient and every pregnant patient.  With the charts stacking up prior to be even getting there . . . I made the decision to go ahead and start screening people.  We may not have had everything ready . . . but so what?  I came here with the sole intention of ridding the Haitians of cervical cancer, and I’d be damned if I ended up spending the whole time feeling like an intern in triage for the next several months.  The first patient happened to be the cousin of the lady I had sectioned on Saturday.  We offered her the screening, and she accepted.  Finally . . . we were getting things started.   Five people screened in the first day . . . one positive who wants to have a hysterectomy for Fibroids . . . success.  I found that the post op hgb for my cesarean was 10.3 (from 11), and she was good to go home. 

Then, my last patient of the day . . . a very simple pregnant woman who said her last period was sometime in December . . . also said she had been leaking urine since she was pregnant.  Unfortunately, it was not her urine she was leaking.  She was ruptured at most likely 27 weeks (by a growth scan by an OB physician who comes to OSAPO once a week . . . [someone who spent some time working with my second year Docent, Dr. Wickstrom in Kansas City . . . Dr. Wickstrom also worked with one of the partners at my new practice in Alaska . . . very small world]).  No NICU here or anywhere close by.  We discussed that she needed to be transported to another hospital better equipped for a 27 weeker.  And transport means we write the orders and the patient needs to find her own way to get there.  As I said before . . . the patient was very simple minded, and could not repeat our orders.  She had come alone.  Luckily another woman at the clinic knew her mother and said that she could help make sure the message was relayed and she got the proper care.  We gave her the day one antibiotics, a first dose of BMZ.  She then left.  I would have kept her until we could provide transport for her, but no one seemed to want to help.

 At this point . . . I was so frustrated with the system . . . what I really wanted to do was go on a nice long run with my dad to talk it out.  Unfortunately, not possible.  It’s amazing how one simple day can contain such a mix of emotions.  A very eventful day, I must say.

Arrival

I would hope that anyone reading this has some idea as to my plans and goals in the short time I'll be just south of Miami . . . I'll do my best to keep my writing somewhat organized, but for anyone who has had a long conversation with me should know that's hoping for a lot.

It was about a year and a half ago that I made the decision to come back to Haiti to help maybe make some difference in the OSAPO Roussou clinic.  I discussed it with my family, close friends and colleagues, and of course had almost nothing but support.  After having a long discussion with my friend Sapna on one of my many trips to Seattle, she inquired as to whether or not I had read the book 'Mountains beyond Mountains,' a biography about the founder of Partner's In Health, Mr. Paul Farmer. This was one of the very few books that I actually read from cover to cover during residency.  I'm sure that some of you are familiar with it.  Now, there is a stronger connection to my trip coming up . . . I promise.

August 7, 2013 . . . I had just gotten on the plane headed for Haiti.  I was a ball full of emotions (fear, excitement, exhaustion, among many others).  I checked my phone one last time for any messages as I knew we would be taking off soon, and I had received a text from Sandra notifying me that Mr. Paul Farmer himself was on the same flight as me.  I almost cried . . . just from the shear explosion of too many emotions at once.  It somehow made some of my fear disappear in a way that is difficult to explain.  I was on the same plane as a legend . . . a medical missionary celebrity.  I didn't even see him until we were off the plane.  He and his two colleagues were sitting right across from me as we were waiting in the back room, where missionaries and other 'special' people now get to go upon arriving to Haiti.  Sandra tried to encourage me to introduce myself to him, but I did not want to disturb him.  I did eavesdrop on their conversation . . . I felt like I had somehow found myself in the novel of Dr. Paul that  had so greatly illustrated his life's work.

I had texted Sapna prior to leaving the states, telling her that Paul Farmer was on my flight to Haiti, asking if she thought that was a good omen for my trip . . . indeed I can only hope that is the case.