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.’      

Time to face your fears

For those of you who know me . . . and more importantly those of you who knew me during residency . . . you are aware of one of a big fear I have.  I’ll admit, this fear might be a bit on the extreme side of things, but I feel that given my circumstances, it is more than warranted.  I am terrified of bats.  They are like little rats with vampire teeth and wings . . . and they seem to follow me wherever I go.  Attacking me in my bedroom while I sleep, stalking me in my place of work, taunting me when I run at dusk . . . and now they have found me in Haiti.  That’s right, folks . . . the bats follow me wherever I go.

So . . . I might be exaggerating just a little.  I have yet to see a bat here.  However, it has been confirmed by multiple employees here that bats fly through the house on a nightly basis.  Given that the ceiling is completely open (and the fact that the little buggers can sneak through holes up to ¼ inch), they very well could have been in my bedroom. 

You might ask how this conversation came about . . . I really did not flat out ask if there were bats here (I’m not THAT paranoid).  I was asked why I lived alone in Columbia, and I explained what happened . . . I was attacked by the bats that were living in the house, resulting in a rabies scare, and much anxiety resulting in the inability to sleep in the house.  The response I received wasn’t ‘what’s a bat,’ or ‘how strange,’ . . . It was . . . ‘oh, those things fly through here all the time.  There were just two here last Thursday.’

I could not believe what I was hearing.  Thank goodness I have had my full rabies vaccination (although . . . by CDC recommendations, I maybe need to have a booster).  As difficult as this whole concept has been for me to grasp, I feel I have dealt with it in a very mature manner.  [Although, I do appreciate the comical irony of the situation . . . the first email I got from my friend Kate inquired as to whether or not a Haitian bat had flown into my hair.  Kate, you jinxed me!]  I’m not walking around with a hoodie completely covering my head and neck . . . No anxiety attacks when I wake up in the middle of the night, or if I hear squeeking noises.  I’m still here (and not moving out) . . . and I have been able to sleep.  There are much bigger things to worry about here . . .

As I mentioned earlier, we have no anesthesiologist here (and the one that usually comes the one day a week or if there is an emergency is out of the country until this weekend).  I know I’ve already had some stressful situations (granted, I know I’ve been lucky over all . . . it could be a LOT worse), and I feel like they keep building up.  Today . . . it was a ruptured ectopic.

A lady came in with severe abdominal pain, BP 90/50, and a hgb of 8 (was 13 just a week ago).  I don’t know who admitted her, but she had been there for a couple hours before I was even notified and asked to perform an ultrasound, as they thought she was miscarrying.  Uterus was completely empty, with a large gestational sac with a fetal pole (with a heart beat) and a posterior cul de sac full of blood.  This is the first time that I said the F word (Fudge) out loud while working here. 

Arranging to get her taken care of went much more smoothly than this past Saturday.  Carine was here, and she more than understood the urgency of the situation.  I said we either need the ambulance to take her to San Marc now, or we need to get an anesthesiologist here . . . whichever will be the quickest.  There were people calling everyone they could to track down the ‘ambulance’ which had just left maybe 15 minutes earlier . . . people calling areas close by that might have an anesthesiologist that could help us.  They got to the driver first, and she was on her way to San Marc (she was walking, which I was hoping was a good enough sign that she would make it to San Marc prior to going into hypovolemic shock). 

It is very frustrating to know that I have the skills to help someone, but because of where I am, I can’t do anything.  The thought of someone dying here, even though I have the knowledge and ability to save them, but just don’t have the resources is terrifying.  More terrifying than bats (not more terrifying that getting rabies though . . . very serious disease that does kill people).  I knew this would be the case when I came down here, but I said knowledge and experience are two very different things.  So . . . I guess it’s time to face my fears, and just do the best I possibly can.

[I want to also make everyone aware that September 28 is world rabies awareness day . . . visit http://rabiesalliance.org/world-rabies-day/ for more information.]