Haiti Reflections: Day 5 - March 19 Addendum

You know, originally I wasn't going to post this part of the story. But after I published the story of our last clinic day, I thought that this really needed to be told. I'm not one for covering up.

After dinner and debriefing, most of us wanted to go out into Chantal and see the village. At least, see as much of the village as we could see in the dark. So we grabbed some beers, cracked them open and headed out on the town.

This is where things got a little messy.

The Chantal police station

It turns out there was another bit of something being lost in translation, namely, an accurate translation of Haitian laws and attitudes towards open containers. As a result, a few of us wound up in the slammer (whatever the Creole word for that is)...

In the clink because of a drink

Bill, pictured in the center bottom, is already retired so this won't hurt him as much, but Greg and Juliet are going to have a hard time explaining this away to their respective professional licensing boards.

OK, so I'm kidding. We went to the police station and the officer on duty was kind enough to show us around. Because it's the Chantal police station, it was not a lengthy tour. But it did include a look at the holding cell.

I'm not sure what these folks were thinking but I'm not ever going voluntarily into a third-world jail cell. I'm even more perplexed by Juliet doing this, what with two of her peers there and all. Both with cameras.

So, Juliet, I can't speak for what Sarah Mattocks is going to do with her pictures of you doing hard time, but the rights to mine can be negotiated. You've got my number...give me a call.

Haiti Reflections: Day 5 - March 19

So, where was I when I so rudely interrupted myself with that outburst of photography?

Wait, it's coming back to me...

Roosters.

Church bells.

Daybreak.

That's it. It's Saturday and the last clinic day.

One thing to mention about Friday night that I left out of the last post was that as Greg and I arrived back at the Barracks we found a local amphibian hanging out - quite literally - outside the front door. It was kind of big, perhaps 4 inches long. Not sure if it's a frog or a toad, but I'm leaning towards toad because its skin isn't slimy and its not near water, two froggish traits. Either way, it's an amphibian that ribbits in Creole. It posed patiently for us before we headed in for the evening.

Kermit the Toad

It's the last clinic day and the rush is on. There are a host of people outside waiting to be seen and they are less patient today than previous days. This is because they know it's our last day and they are desperate to get the basic medical care we are providing.

We spent less time on triage today and more time on crowd control. It seemed that about every 45 minutes or so there would be a spontaneous rush for the waiting room. If it weren't for Diana's choke point, the waiting room would have been flooded with people.

There were more kids today. Many, many more kids, because it's Saturday and they are out of school. This added significantly to the overall ruckus. Rebecca, Diana and Liz worked wonders keeping them occupied with games.

The kids also loved having their pictures taken and then seeing them immediately on the camera's preview screen. They would laugh and squeal with delight at the sight of themselves and their friends. As Greg noted, for many of them the digital camera is their only mirror.

Say "Fromage!"

Rebecca's valiant - but futile - attempt to quiet the squeals

Some of my new friends

Derek and Diana chatting with some Scouts

Over the past three days, the locals Father Yves hired as translators were doing a good job for us. Today, they really brought their A game. They had learned our system and worked it without needing instructions or prompting. There were also more of them than before and we were initially at a loss with what to do with them, but again they stepped up and sorted themselves out, distributing themselves effectively within the established system. One guy, whose name I never did learn, did traffic control in the waiting room. He did a magnificent job running the room like a well-oiled machine. The extra help in triage moved things smoothly there, as well, and was especially helpful in quelling the spontaneous rushes. They really earned their pay. God bless 'em.

One lady came in on a canvas stretcher, they type you see being used on the battlefield. She went straight back to the ICU and was placed on a bed. She wasn't at all well. Her blood pressure was 60 with a pulse of 120. She was so dehydrated that she wasn't sweating. We started two IVs and buffed her up with 1.5 liters of Ringer's. She wound up being able to walk home at the end of the day, with her family carrying the now-empty stretcher behind her.

By the time we were done we had moved twice as many people through as any day before. It was an incredible amount of work and is now mostly a blur. I'm really not certain how the physicians did it.

Once we packed up we grabbed dinner (with the now-uniform Prestige beer). Afterwards, we had our final debrief. We all had a lot to process emotionally. Rebecca spoke first and really summed it up for all of us. She was moved to tears by the exceptional need we saw, the aid we provided being accepted with such deep and genuine gratitude, and by the happiness of the kids. I added that I was impressed with the quiet dignity of the older people - as Sarah pointed out, it's all they have - and the respect they showed for us by coming in their best clothes (go back to the picture from the first day inside the church and look at the number of hats being worn). We all agreed that it was an amazing experience and we have a lot to sort through in our heads and in our hearts.

Tomorrow is Sunday. Father Yves will be the guest celebrant for Mass at Ste. Jeanne. He invited us all to be guests of the congregation and said that the service would be bilingual. Of course, he said those languages would be Spanish and Latin.

Tomorrow is also national election day in Haiti. They are electing a new President. This radically changes the plans we had for traveling back to PAP in time for the Monday morning flights back to the US that many of the team have. I'll get into that in my next post.

Shoot The Hills 2011 Results

So the 10th Shoot The Hills competition is now in the books.

As predicted, the weather was pretty bad. It started out OK, with relatively warm temperatures and a high overcast that still allowed reasonably good photography. But as the afternoon progressed, the overcast thickened (making it tough to get good landscapes) and the wind started to blow (making the flowers dance too much to be pictured well).

By early evening it began to sprinkle. At this point the light was so dull and gray it was sucking the color out of everything. So I headed to my motel to retire for the evening much earlier than I have done in previous years.

But it wasn’t a lost day because of the weather. I managed to find some very pretty flowers that were in bloom...and this was not a good week for flowers or tree blooms - they are still a week to ten days away from their best showing. 

Big Four Violet

Yellow Pollen - White Petals

I also found a beaver pond. It was an active pond with a lodge that appeared to have new wood on it. I got out of the car to look at it closer and realized that there was a beaver swimming right towards me! But the beaver also saw the human walking right towards him/her and he/she immediately turned tail, dove under and swam away. I wasn’t even close to getting my camera to my eye. Not that it mattered, the light wasn’t going to let me get a shot that proved I saw a beaver, let alone a shot worthy of this contest. Undeterred by this reality, I got my tripod and set up in an area where I had a good field of view of the pond, just in case it came back out. After wasting about a half hour of my time, I realized that I knew nothing of the ecology of beavers and should really learn more for a return visit.

Beaver Pond in Bolster Hollow
The dam is visible in the bottom of the picture.
The lodge is the pile of wood at the upper left corner of the pond.

I woke the next morning at 0500 so that I could be in place for sunrise. I had looked up beavers in Wikipedia and learned that they are nocturnal (and really tremendous engineers), so the pond was where I wanted to be for first light. But it was now raining hard and light was going to be a serious problem. I broke out the rain gear and ventured forth.

When I got to the pond I saw two beavers and did manage to get what I call “proof of encounter” photos. These demonstrate that I did see what I claim to have seen, but aren’t anything that I would want to show to anybody except to prove the encounter.

Proof of encounter - Beaver swimming towards the lodge.
Or maybe it's the Loch Ness monster.

The 24-hour contest started at noon on Friday, meaning that our photographs had to be shot (as evidenced by the photograph’s EXIF information) by noon on Saturday. The rain stopped at 10:30 Saturday morning, so I was scrambling to get some of the pictures I had imagined would be good if it weren’t raining. Then, just to taunt us, God made the sun come out at 11:00. I FLEW back to the beaver pond. Of course, beavers are nocturnal (I’m now an expert in Castor canadensis) so I wasn’t going to get a shot of them, but I wanted a good shot of the pond, dam and lodge. My last shot is time stamped 11:43 am.

Into the Distance

On my return to the ‘Digital Darkroom’ at the Hocking Hills Dining Lodge I began to process my pictures and decide which ones I wanted to submit. It wasn’t easy as my shots were nowhere near what I had hoped. It wasn’t the weather that screwed up my pictures, it was rust. I haven’t had camera in-hand for a while...for far too long, actually...and my technique had suffered. There were little things that I needed to do, either with camera positioning or camera settings that I just plain forgot. It showed in the low quality of my images.

I selected my five pictures for the contest judges to review and one for Photographer’s Choice (where the contestants vote for their favorite...I really covet this one but will never be that good). I burned them onto the official CD, turned them in and went home, at ease with the fact that I wasn’t getting any hardware this year.

Turns out I was wrong. The photo that I submitted in the Abstract category took 3^rd place! I grabbed this one at the beaver pond. I was parked near some trees that were just begging to be treated abstractly, so I did. 

Bolster Hollow Abstract Trees

This was inspired by some abstracts done by Eddie Soloway. I should note that normally when an artist says something was “inspired by” they mean “plagiarized from” but in this case Eddie encouraged the use of this technique in his Natural Eye class at the Maine Media Workshops. He said something to the effect of needing to get over the requirement to hold the camera still. As you can see, I got way over that need. Thanks Eddie!

Cold, tired, dirty and happy as a clam!

My thanks to the Friends of Hocking Hills (sponsors of the contest), Barb and Jerry Jividen (originators and organizers) and all the other volunteers that make this such an outstanding event.

Brief Interruption

I apologize for this interruption in my Haiti reflections but I'm returning to topic for a moment. Namely, I've gotta talk about nature photography. Please bear with me.

As I write this it is Thursday April 14. Tomorrow is the start of 2011's Shoot The Hills photo competition. I am registered. My memory cards are formatted, my batteries are charged. I've cleaned the schmutz off my lenses and filters. And I AM READY TO GO!

I've blogged about STH before (here in January 2011 where I used the word 'incredible' three times)) and there's a link to the contest's website on the right.  I just can't say enough about it.

To briefly recap why this photo contest gets me excited: it's not like other contests. At STH, all contestants start in the same place at the same time and have 24 hours to go out and capture an image from anywhere inside the Hocking Hills region of southern Ohio. This means it's a completely level playing field. We all have the same weather, the same lighting, the same early spring flora, fauna and terrain. As Fezzik said in The Princess Bride, "We face each other as God intended. Sportsmanlike. No tricks. No weapons. Skill against skill alone." (OK, so Fezzik was talking about a fight to the death with Westley and I'm talking about photographing birds and flowers, but it's the same idea...) (And I found the relevant clip here...)

The weather forecast for tomorrow and Saturday is less than pleasant. There's a better than even chance we will have rain for most of the 24 hours. That's OK with me. I've done rainy day photo shoots before, including last year's STH (where I took two ribbons). I have a complete set of rain gear...which includes a special poncho for my camera...so no big deal. You just have to be looking for something to shoot using a different eye, a different perspective.

I'll try to post something tomorrow night from my motel. Provided, of course, that I don't exhaust myself looking for the perfect shot or fall off a cliff (I'll be careful about that, trust me. I'm the State Trauma Coordinator and I know exactly how far I'll be from a trauma center in weather where Med Flight won't fly).

Wish me luck!

Haiti Reflections: Day 4 - March 18

The day began placidly. Dawn slowly broke and warm, tranquil sunshine began to fill the room, peacefully bringing each of us out of our slumbers.

Just kidding. Roosters and church bells.

Before we departed for the mountain village of Canon, Sarah lead us on a field trip. Today is Friday and Chantal's market day. The market is less than half a mile from the clinic and an easy walk.

Chantal's main street

We travelled down the dusty gravel road with a lot of the goods that were being taken to be sold. Some of it was carried on trucks, some on people's heads, some was still on the hoof.

The market was a typical third-world market. It's a large area with stalls that are little more than tall tree branches used as supports for corrugated metal roofs.

An assortment of goods could be purchased there. Lots of foodstuffs, including fish and shrimp, but mostly bric-a-brac. There was one stall that sold sticks. Sounds sad but these were bundled in varying lengths from a few inches to 6 or 8 feet and looked for the most part to be pretty straight and sturdy. Another stand sold nothing but rice sacks from relief agencies. No rice, just the sacks. But the relief agencies make sure those sacks are sturdy enough to have a long and useful life after the grain is gone.

Rice sacks for sale - Come to Chantal where relief efforts meet market capitalism

A lot of livestock was also being hawked. Cattle, goats and pigs were plentiful. Sadly, our roosters were nowhere to be found.

After a cursory foray through the bazaar we headed back to the clinic.

16 of us piled into the Hilux. I was one of the 7 who got to sit in the cab (the one with 5 seat belts). 9 more were in the bed with the supplies. It was a very cozy 45 minute drive to Canon.

On the way to Canon we forded two rivers, one just outside Chantal, one closer to Canon. Both had very wide beds, but the one outside Canon had a considerable amount of water flowing through it - and this is the dry season. It was readily apparent that the people who live in and around Canon (and countless other Haitian villages) have a basic healthcare logistics problem. During the rainy season the rivers will be swollen and impassable. The locals can't get to help and help can't get to them. Simple things will become lethal. If your appendix ruptures, you're dead.

Canon is a teeny tiny village. When we arrived, people were lined up waiting. The line went on for quite some distance and we had a lot of work ahead of us. Father Lawrence, the local priest and a Barrack Obama look-alike, greeted us and showed us where we would be working.

Lining up for the doctor

The pharmacy window

Clouds blanket the hills on the other side of the valley

Ginny and I were on triage. We were in a classroom that was hot, lit only by sunlight and had small windows without glass. With people lining up right outside, it was very noisy. We set our initial screening desk at the door (more crowd control tactics) and put the area for vital signs as far from the front as we could. This was only about 10 feet from the doorway so it didn't really help reduce the noise at all.

There was only one urgent situation where a lady collapsed but she was easily buffed up...Father Lawrence took her someplace nearby where her daughter could help her with a shower to cool down.

We had more problems with crowd control here than in Chantal because of the people being right outside our door. They were desperate for care and sometimes things got aggravated in line and they sort of surged. It was a hassle and a distraction but personally I couldn't be angry with them.

One observation I made (which was confirmed by Greg and Rebecca who triaged here yesterday) was that the hypertension wasn't quite as prevalent nor quite as high. Don't get me wrong, it was still really bad, but there was a marked difference between blood pressures in Chantal and Canon. This only adds to the mystery of Haitian hypertension (Haititension? Hypertaitian? Gonna have to work on that...)

Another observation I made was regarding something called "health literacy." There are many definitions but generally, health literacy is the ability to understand health information and to use that information to make good decisions about your health and medical care. There's no standardized scale for determining health literacy but if there was, Canon's would likely be close to zero.

Case in point: I was triaging when a 24 year old woman came in. Through Jean-Pierre, the translator, I learned she was having abdominal pain with her menstrual period. I asked how the pain was different from her normal period. There was a sort of puzzled, spluttering exchange between the patient and Jean-Pierre and I got a very non-specific answer. I don't recall what it was but I knew to try a different approach.  I asked: "How long has this been going on?" The answer: "12 years." 12 years of painful menses in a 24 year old means that nobody ever told her that pain will accompany her periods. She wasn't alone. I had a handful of these, as did Ginny.

Triaging in Canon is also where the full impact of the term "lost in translation" hit me. When Haitians speak of pain in a particular body area, they tend to make sweeping gestures indicating the entire area is affected, whether that be head, chest, abdomen or limbs. It takes some work to narrow it down to what specifically, if anything specific, is hurting.

One elderly lady came in and her gesture was atypical. She didn't sweep across her chest with an open hand. Instead, she used a single finger to draw a fairly tight circle in the middle of her left pectoral.

Jean-Pierre: She says she has chest pain.
Me: Pain in her chest or in her breast?
Jean-Pierre: Uh, what is the difference between them?

Lost in translation. The translators are smart people (hell, I only speak one language) but they aren't medically trained. The difference between breast and chest seems obvious in English. But when translating, your vocabulary can be limited, especially when working in a specialized area like medicine or engineering or finance. If the only word you know for anything between the shoulders and the bottom of the ribs is 'chest' that's the word you have to use. This was something I hadn't been taking into account for the past three days and it still bothers me intensely that I may have been missing things because I wasn't paying closer attention to the patient-translator interaction.

In this case, Jean-Pierre quickly picked up the difference and got clarification that it was her breast. He also added the differential question to his repertoire (he made the difference clear in all subsequent females presenting with pain below the shoulders and above the abdomen). Sadly for this lady, by the time your breast tumor begins to hurt you're probably too far along to be helped by even the most advanced medicine.

Like yesterday in Chantal, the day in Canon was long and mind-numbing. There were a few people that we weren't going to be able to see. They were given white tickets that, if they could make it there, would get them to the front of the line in Chantal tomorrow.

Once everything wound down, we piled back into the Hilux. This time I got to sit in the bed. Oh, lucky me. Father Yves did a very good job of minimizing the bumps but these were rural gravel roads so it wasn't possible to miss them all. Sitting on the edge of the bed, clinging for dear life, was quite literally a pain in the ass. My hands were aching from my death grip. And because of the equipment in the back, my feet were contorted, which wasn't too bad in itself but Sarah kept sliding off the boxes she was sort of sitting on and onto my legs. Trust me folks, you just haven't lived until you've forded a Haitian river in the bed of a pickup with a physician sitting on your ankles.

We arrived back in Chantal as they were finishing their workload for the day. We had the standard dinner, Prestige and debriefing. Then off to bed.

Haiti Reflections: Day 3 - March 17

The day dawned with roosters crowing and church bells ringing...it's the way life is in Chantal. I managed to sleep really well despite the ruckus of the indigenous fauna. I was told by the other guys in the Barracks that they were as loud and as frequent as the previous night, I just was too tired to hear.

Got up and dressed and headed to breakfast. I'd like to pause for a moment to mention a really delicious part of breakfast that I left out of my previous description: the coffee. Rebo Coffee is a Haitian coffee that is dark, flavorful and robust, but it's not acid. It's this last part that a lot of people on the team commented on the most. I enjoyed it thoroughly (enough that I brought some home). Because the beans are grown and roasted there in Haiti (formerly the leading exporter of coffee in the Caribbean) I encourage everyone to buy some from them (http://www.rebo.ht/index.shtml). The Haitian economy could really use the boost and you'll get a great cup of joe in return.

The team that was going to Canon piled into Father Yves pickup - a fairly new Toyota Hilux with a crew cab. There were 16 people and a day's clinic supplies in a mid-size pickup that has 5 seat belts. Over on Juliet's blog, there are pictures of what it looked like. I called it the Haitian Mobile ICU.

As the clinic opened we began the triage process with just three of us, Bill, Connie and myself. Because half the docs were gone, we had to slow down and even frequently stop the flow of patients into the waiting area.

The chief complaints were largely the same as before but we did note a bit of a twist. It was more difficult to get details of what can be described as "female problems" and, to a lesser extent, "male problems." This was because of the make up of the the team doing the questioning: a female nurse and a male translator. Over dinner this was discussed and many were attributing it to culture, but I think that gender-specific medcial complaints/problems are hard enough to discuss with your own gender in your own culture. This was a source of frustration for the physicians because there were a large number of women with a complaint of "vaginal infection" who also had a host of other problems that were undiscovered until they got into the examining rooms.

Around midday, Diana, Fred and I assisted Sarah with a 2 year old boy who had second degree burns to his right should, upper arm and chest. He had hot water spilled on him. Sarah was having to do a fair amount of debriding (removing the dead tissue to prevent infection and allow healing). She did a good job despite not having the tools she really wanted.

Sarah had Mom lay down (on a desk at the back of Dr. Rich Salkowe's examining room) and hold the boy to her chest. The boy was remarkably calm. He cried and fussed, but Mom didn't have the titanic struggle on her hands that one would have expected. There was no wrestling match, she simply had to hold him snugly. (One of Shelagh's co-workers, Chris, who has also been to Haiti, said that Haitian children are more tolerant of pain than American kids, probably because of expectations - Haitian kids don't expect life to be pain free, Yankee guttersnipes (and their parents) do. It's an interesting theory that seems to have applied here.)

Once Sarah was done with the debridement, she applied a layer of lidocaine cream, numbing the area. The poor kid needed it...when Sarah finished applying the dressing and the lidocaine kicked in, he conked out. The family was referred to the Medicin sans Frontier clinic in Les Cayes where he can get the definitive treatment he needs for free. This was where I had my first chance to tell a patient, "Bon chance" as they departed. Both parents smiled gratefully at my small comment. But there's no guarantee they will take the little boy to the MSF clinic...we can only hope they did.

While this was going on, Rich (aka 'Doctor Reeshard') was continuing to see patients. He maintained an admirably even keel, despite sharing his room with a crying child, a medic, a nurse and a medical student scuttling around the searching for and retrieving equipment, and his translator being forced to translate for him and Sarah at the same time. Rich was a picture of equanimity.

Returning to triage: The hypertension continued to be overwhelmingly prevalent and catastrophically high.

I learned that having a good quality stethoscope has a drawback in this setting. Good stethoscopes will press gently into your ears so that they seal out external noise. It's part of what makes them good. But after taking about eleventy-thousand blood pressures, my ears HURT. When the ache started I glanced at my watch. It was only 11a.m. I was pretty sore by the end of the day (with a rare case of otitis externia).

The day was long and mind-numbing. When the team returned from Canon we had dinner and debriefed over our Prestige beer. We also made plans for tomorrow's split team. Greg and I will swap: he will stay in Chantal and I will go up to Canon.

It was St. Patrick's Day but because of fatigue the celebrations were subdued. I could have been convinced that the Prestige was green beer as, A) it was dark on the porch while we were drinking it, and B) we were drinking it right out of the brown glass bottles.  Who would know what color the stuff was? But then I overheard an odd, trying-to-explain-my-culture conversation between a couple of nurses and a couple of translators. The nurses were wearing glowing shamrock necklaces. The translators wanted to know why (there's not much of a link between the Irish brand of Roman Catholicism and the Haitian brand so the holiday is completely unknown to them). The nurses explained that it was St. Patrick's Day, St. Patrick is the patron saint of Ireland and his day is always a big party and the Irish like to drink a lot and shamrocks are a symbol of Ireland. It was simply not being grasped, probably because the Haitians weren't going to understand why Americans were celebrating an Irish holiday in the first place. It was kind of like listening to somebody trying to explain baseball to a Martian.

At that point, I knew my beer wasn't green and I went to bed.

Haiti Reflections: Day 2 - March 16 (part 2)

The number of people we saw with hypertension was staggering. It was in excess of 90% of the adults. And we're not talking about anything even close to normal B/P. In nearly 30 years of EMS, I've seen fewer people with pressures over 200 than I saw in those four days. Most of those EMS patients with B/Ps over 200 were suffering a traumatic brain injury or a stroke (hypertension is a common response to brain swelling); the Haitians were just walking around with it. The highest I measured was 264/130. We talked about it but we're at a loss for why this might be so prevalent and so severe.

Dental patients were in abundance and this was expected. Dental hygiene is non-existent and tooth decay is rampant. Our dentist, Dr. Joy Jordan, was one very busy lady.

Just before noon, two people - one male, one female, both elderly - were dragged (literally) into triage within minutes of each other. Both went down while waiting and were victims of heat, dehydration and probably low blood sugar. The guy had a seriously decreased level of consciousness and was cyanotic around his lips. He gave the distinct impression of a man actively trying to die on us. Both were taken to an area in the middle of the clinic that had a couple of beds, which became known as "The ICU" because that's where we took and treated all the seriously ill people. We started IVs on them to buff them up and worked with Dr. Vania Francois to get them back to their baseline. (Vania is Father Yves' sister.) (His sister as in biological sibling, not his sister as in a nun.)

There was a steady stream of kids headed to see our two pediatricians, Drs. Sarah John and Beau Laguerre. We didn't do triage on them as all aspects of kiddie care was being done by the pedi people.

In all, we saw over 600 people and told 500 to come back tomorrow. This was actually a low number as we got off to a late start due to having to set up.

After triage was finished processing the last patients of the day but they were still waiting to be seen by the physicians, Father Yves took me next door to show me the house his mother is building (his mother as in Mom and maternal progenitor, not mother as in a nun). It's a nice place and Mrs. Francois seems like a very nice lady. To turn out kids like Yves, Vania and Sondi (who was translating and helping out in general), she must be. It's also evident where they get their brilliant, ever-present smiles.

Sondi and Mrs. Francois

Father Yves and I then went back to the school and I got another look around without kids this time. He told me that the school is going to have to be demolished and rebuilt, not because it was damaged or decaying but because it doesn't meet the new Haitian government earthquake codes.

Father Yves also told me about the deal that the government has made for the clinic. If a complete clinic is built (a new, purpose-designed building that is medically equipped), the government will provide two physicians to staff it full time. (Each person whose medical training is paid for by the Haitian government owes two years of service, so that's how it would be staffed.) The cost: $300,000.

When the last of the patients left the clinic, we headed to dinner. The food was, as described in an earlier post, tasty and satisfying. Father Yves also provided us with cold beer (!!!). Prestige beer is Haitian and a very nice beer. We didn't expect it, so it was that much more delightful. It also brought to mind Benjamin Franklin's saying: Beer is proof that God loves us and wants us to be happy.

After dinner, we debriefed, going over what went right and what could be done better. We also learned that the team would be split for the next two days with half going into the mountains to a village called Canon.

Greg and I talked it over and he would be the medic going up on the first day and I would go up on the second.

After the debriefing, I went to the Barracks, wrote my journal entry for the day and fell into a deep and easy sleep.

Haiti Reflections: Day 2 - March 16 (part 1)

Our first clinic day dawned and we grabbed our breakfast then started setting up.

Dawn over the clinic.

We grabbed our baggage and began unloading it all, distributing the supplies we brought to the appropriate areas. These areas were triage, general medical, gynecology, dentistry, pediatrics, lab and pharmacy. There was also a storage area for overflow.

The section with the most setting up was the pharmacy.  Everybody dedicated a sizable portion of their 100 pound luggage allowance to medications.  Alex and Sharon, our pharmacists, had to sort out and organize the meds. They also set up a counting and dispensing system that seemed to work very well.  The amount of work they and their assistants had to do to set up was enormous, and their level of work continued to be prodigious until the last patient left on Saturday.

Alex and Sarah at the pharmacy's counting table.

Before the clinic gates were opened, we went next door to the church, Ste. Jeanne de Chantal. The church was opened up so that the people coming to the clinic would have a place to sit that was out of the sun and off the street. This was a to avoid a huge problem during the last mission - people were crowding the streets and then dropping like flies in the midday sun.

We entered to find the pews packed:

The picture above shows most, but not nearly all, the people waiting in the church. I'd guess that about 30% of the church's capacity is in additional pews on either side of the altar. There were also people waiting outside and more coming into town. As Father Yves introduced us as a group to those who were waiting patiently, I said a quick and quiet prayer for strength at the realization that this was just the tip of the iceberg.

After that, we went to the other side of the clinic to the school. The kids there were like kids the world over: happy, friendly and adorable. We were there as they assembled for their daily prayers.

The school rooms are spare but functional with desks and chalkboards. Annual tuition is $50. A pittance for us, a king's ransom for many of them. Each day they get a good education and lunch...for a lot of them it is the only meal they will eat.

We went back to the clinic to finalize our set up. I was in triage where we would determine the reason each person came to the clinic (their chief complaint) and take their vital signs. We also placed ourselves in the role of traffic cops. Diana, one of the nurses, placed a desk at a strategic point at the entrance to the building. This allowed us to control the flow into the waiting area, keeping it from getting out of hand (this was another problem encountered on the last mission: a waiting area so crowded nobody could move and so loud the physicians had difficulty hearing their patients).

We were also introduced to our translators. These were locals, mostly men but a couple of women, who had varying degrees of fluency but all were eventually situated where their abilities were matched to their task.

It was during these introductions that I saw it. I couldn't believe it. I stopped and looked a second time. I blinked. I checked my glasses. I wasn't seeing things. It was real.

Here I am in Haiti, some 1,500 miles from home physically. Culturally, I am on another planet. And yet there he was, a Buckeye fan:

Only hydrogen is more universal than the Buckeye Nation.

Adzi (no idea how it's spelled but that's how his name is pronounced) has actually been to Columbus and has been on campus. He aspires to attend OSU. Having worked with him directly over the course of several days I can say he's probably bright enough, and certainly has enough fluency.

The walls of the compound were important to maintaining order. People were desperate for medical attention. The gate between the clinic and the church was another important "choke point" where the flow of people could be controlled. The local guys who manned the gates did a pretty good job of keeping things regulated and not allowing us to get overwhelmed. Here's a picture I took over the wall of what they were dealing with on the outside of the wall:

All of those people are crowded against the gate. Unfortunately, these are the ones who are younger, stronger and healthier than many of those waiting patiently in the church. If you've ever read Dale Carnegie, you'll recognize the idea that each person thinks of their own problem as being more important than yours. For these folks, their need for medical attention drove them straight to the gates, bypassing those who had been waiting. They were also driven by sense of urgency created by the brevity of our visit. They walked for hours in the heat to get there and knew that if they didn't get seen while we were there, it would be months before anyone would be back, if there's a return visit.

Then the gates opened.

Each person entering was sent to the initial triage area where they were given their "medical record." This was half a sheet of paper with spaces for their name, age, chief complaint, vital signs, physical exam, physician notes and treatment record. These records were collected from each patient before they left the clinic so that the nuns would have the ability to follow-up with those who might need it and so that there was some basic record of what we were seeing.

The initial triage area was outside the clinic, with benches set in the shade. The patients then went to the next "choke point" (Diana's strategically placed table) to get their name entered into a log. Bill was instrumental in crowd control at this point and wrote a LOT of names into the book. While some vital signs were being taken in the initial triage area, most were being taken in the area just behind the registration table. This was my main task (along with assisting Bill and Connie in controlling the occasional crowd surge).

After triage, patients were sent to the waiting area where they were then sent to the appropriate physician.

Looking from triage into the waiting area

Looking from the waiting area out to triage

To be continued...

Haiti Reflections: Environs and Accomodations

Before I continue the story I want to give a little bit of a description of where we were.

As previously described, Chantal is a small village with a population of about 1,500 people (in pre-earthquake times). But even in the far southwestern reaches of Haiti, there is nothing The Google doesn't know or cannot see. It can see Chantal:

You can see that Chantal is indeed a small place, and like many small villages all over the globe, the church is one of the largest structures. It doesn't dominate like European cathedrals, but its presence is unmistakable.

The main road is paved, smooth and nice to travel on but the rest are gravel. The market place is crammed full of stalls that are just corrugated sheet metal roofs held up by tree branch poles. It's really pretty large. More on it in a later post.

Within this little village, we worked in an enclosed area that contained the clinic and the nuns' residence (please forgive me if there's a proper name for this, a la 'parsonage', but convent doesn't sound right to my simple Protestant ear). While we did venture forth from this area on a couple of occasions, it was our universe for the bulk of our time in-country. Here's a detailed picture of that universe:

The Barracks is the name I used for the men's dorm. I used the term enough that I did hear one other team member using it in conversation and whoever he was talking to knew what he meant. It was a smallish building (wild-assed guess here is that it's 20'x30' but I wasn't really paying attention) that was mostly open inside. There was a T-shaped divider that made three "rooms" but the wall didn't go all the way to the ceiling so we could all talk to each other (and hear each other snore, roll over, etc.). The rear few feet were also walled off to create a restroom area. These walls didn't go all the way up either so your daily ablutions were also audible throughout. The restroom had a sink with a mirror, a flush toilet and a "shower." It was a cold-water shower - a mixed blessing in the tropics - and didn't have a shower head. It was just an overhead 3/4" pipe. It was funny listening to others showering because you could tell when most of them stopped splashing water on themselves and actually immersed in the stream. It was an act announced with a tell-tale, "Ungh!" as cold water hit an overly warm body.

Our beds were simply a mattress on the floor. We took our own sheets (mine were treated with permethrin so that I would sleep unaccompanied by creepy crawlies). After a long day of hard work, I had no problems with the level of comfort being provided. But then again, it got to pleasant temperatures at night so the lack of A/C and fans wasn't a problem. Just open, screened-in windows for climate control, and for allowing us to clearly hear the dogs and roosters.

The roosters were really something else. They stopped crowing around dinner time. This break lasted long enough for them to catch their breath and then announce with a hearty "Cock-a-doodle DOOOO!!" that it was now 10 p.m. and time to go to bed. Sporadic crowing would go on throughout the night until about 3 a.m., at which time it would begin in earnest. All-out, full-throated rambunctiousness would erupt at 4 a.m. When the church bells tolled at 5 a.m. and again at 5:30, it was time for us to surrender, get up and start the day.

For those who were on the team, this picture (honestly unretouched) will explain something about the roosters, perhaps confirming a few suspicions:

Father Yves and the nuns made sure we were well cared for. We had a near-limitless supply of bottled water, which was very comforting. But we were also well-fed. Breakfast had scrambled eggs (which everyone seems to have loved), real oatmeal, bread, peanut butter, honey, bananas and mangoes. Dinners were equally generous with a different meat each night (fried), fried plantains or bananas, fried potatoes and rice and beans. It was all good food, if a little bit of a challenge for ones statins. The only problem noted by many was that when we had chicken, it wasn't one of the roosters.

Lunch was "on our own." We were told ahead of time to bring protein bars and that we would have to sneak in a bite when we could. It wasn't an easy thing for any of us to do when we were surrounded by people who were underfed, malnourished or starving. More than one person said they found it hard even to drink water in front of the locals.

So that's about it for our basic room and board. Next, set up and clinic day number 1.

Haiti Reflections: Day 1 - March 15

Shelagh dropped me off at Port Columbus and I left cold and rainy Ohio early in the morning, headed for Miami where I would meet up with a large part of the team.

Juliet Geiger, my professional counterpart from Pennsylvania and the one who suckered me into this trip*, did two things very important to this phase of the mission.  First, she kept everybody up-to-date with her blog (http://chantalhaitimission.wordpress.com/).  Second, she created a document with everybody's picture, flight number/time and contact information so that we would know each other when we got together.  It worked well and about ten or eleven of us met and started to get acquainted prior to boarding.  We would all become very familiar with each other in the next 24-36 hours.  Dr. Sarah John gave us a short briefing on what to expect when we got there.  *OK, so she didn't sucker me.  She's not that type.  She said she was going and asked if any other state trauma coordinators wanted to go, to which I said yes.  I'm very, very glad she asked.

I was a little nervous before leaving home because I was going on this trip without really knowing anybody.  Juliet and I had some professional interactions but we had no previous social contact.  I'm an experienced international traveller but I was going into this one on more faith than I normally put into my planning.  (But now that I type that, I realize that 'faith' and 'planning' are pretty much mutually exclusive concepts.  Deities, karma, kismet, luck and other similar constructs are all notably absent from the Emergency Management Agency's disaster plans.)

The flight was on a Boeing 767 that was filled to capacity but had very few Haitians.  I sat next to and had a pleasant conversation with a man named Bob Cox from Minneapolis who was going down to build a church and a school with his church group.

When we arrived in PAP (that's Port-au-Prince, but I'm too lazy to keep typing it out.  Get used to it.) and it was exactly what Sarah had told us in our briefing: a third-world airport.  There is one runway, no taxi strip (see picture).  That, for the uninitiated, means that when you land, you stop, turn around and then taxi on the runway to get to the terminal.  This also means that no other planes can land until you are out of the way.  (It works the same ponderous way on take off, too.)  It must have been a logistics headache of the first magnitude during early phases of the earthquake disaster relief.

The terminal was of reasonable construction with rather dull painting and non-existent decor, air conditioned and surprisingly orderly...up to the immigration desk.  But once we had our passports checked and stepped past the desk, it was a baggage claim free-for-all.  Baggage claim wasn't dangerous or scary...there was just no order and no sense of direction.  Nobody was even certain that the baggage coming out was from our flight or another.  It may well have been from multiple flights as there was only one conveyor.  It probably took us 45 minutes to an hour just to get everything gathered up and get the group reassembled.

Then it got worse.

When we stepped outside the building, there were many, many people there to help us with our bags.  They were the equivalent of Skycaps and all were uniformed but apparently earn their living through tips.  They all spoke English and they were extremely persistent in letting us know that we needed help, specifically their help, with our bags.  It was an unfortunately long distance from the terminal exit to the parking area.  Father Yves Francois, who met us at the terminal, managed to hustle us to the waiting buses with what was, in retrospect, a minimum of hassle with the Skycaps.  It was stressful for most of us at the time because we had no idea of how long the badgering was going to last.

Our bags were loaded on one bus, we were put on another and we departed for Chantal.  Through PAP. During rush hour.  It took us two hours just to get outside the PAP metro area.

It has been 15 months since the earthquake - one of the worst ever in terms of lives lost.  The devastation is still evident in the rubble of the collapsed buildings.  The National Palace is in the same condition and posture now as it was immediately after the quake (I saw it but wasn't able to get a picture so here's one I found on Flickr).  Tent cities are everywhere and are enormous rabbit warrens of disaster relief shelter tents and makeshift tarp tents.  But remarkably, PAP is recovering.  Despite having crap for infrastructure before the earthquake and losing a significant chunk of that in the earthquake, progress is being made.  Buildings are being torn down (there were some big buildings that still looked perilous, but not as many as I expected) and the main roads and sidewalks are passable.  The trade off for this progress was putting all available garbage removal resources into rubble removal.  It was apparently a conscious decision of the Haitian government to do it this way.  As a result, the garbage accumulates in the gutter or in a few Dumpsters and is occasionally burned (more on that particular fragrance in a later post).  Having been in those streets and seeing the state of the buildings over a year later, I can't say I blame them, my inner public health wonk notwithstanding.

According to Google Maps, the trip from PAP to Chantal is 216 kilometers, about 134 miles:


View Larger Map

Google Maps also says it takes a hair over 3 hours to get there.  But Google Maps doesn't take unpaved roads into consideration.  Or three rivers with no bridges that need to be forded.  Or carnivals taking place during Lent in villages on the main road.  Our trip was closer to eight hours.

When we arrived in Chantal, we stowed our gear, got shown to our quarters and hit the sheets at 0130 on March 16.

Haiti reflections, intro

I've now been back from Haiti for five days.  I was back to work for two of those.  But my head and my heart are still in Chantal.

It was an incredible experience.  We saw an extraordinary number of people - over 8,000 - who had no other access to basic medical care.  The people, both the Haitians and the rest of the team, were amazing.

I kept a diary on my trip but I can't really do justice to the trip by simply transcribing it here.  I was so tired at the end of each day that I only recorded events, not what I thought and felt.  I'll try to get those down here on the site.

Going to Haiti

Dear family, friends and colleagues,

On March 15, I will be departing for a one week medical mission to Haiti. This mission is through the Care to Share program sponsored by the Catholic Diocese of Palm Beach, Florida. Juliet Geiger, my professional counterpart in Pennsylvania, has created a blog to get the word out in hopes that it will inspire others to join us or to donate. It can be found at http://chantalhaitimission.wordpress.com/.

The town we are going to is called Chantal. It is 250 miles southwest of Port Au Prince. It is a very rural community with subsistence farming and some rice agriculture. It is normally a village of about 1,500 people but that has doubled with refugees from last year’s earthquake.

Why Chantal? The big NGOs are set up pretty well in Port Au Prince and the Haitian government asked that other groups travel to the hinterlands to care for the displaced. There are over 2 million internally displaced people in Haiti right now. With the surrounding mountain villages and seaside villages many hundreds more folks come to clinic there, often walking 4-5 hours to be seen.  There is no doctor or dentist or pharmacy within hours of Chantal by vehicle.  Two nursing sisters at the local Church run a small dispensary and are providing us with a site. One of the team members who is returning said they (7 doctors, 7 nurses, a dentist, a pharmacist and 20 non-medical helpers) saw 4,000 people in four days last August.

At this time, the team is all but complete but we are still in need of physicians and in special need of a dentist. Juliet’s blog has contact information if you (or a physician, or a dentist you know) are interested in joining us.

So what do we need? Money works really well (Juliet’s blog has the information on where to send your generous donations). It will be used to build a permanent clinic in Chantal, buying water purification systems (www.edgeoutreach.com), and stocking the Chantal clinic with medications and medical supplies. Through special relief programs like Crosslink and MAP International (www.map.org), $1,500 dollars will purchase $13,000 retail value of medications to treat diarrhea, malaria, anthrax, hypertension, parasites and cholera.

We can also use medicine and vitamins that we can take with us. Once again, Juliet’s blog has some good details.

In terms of durable medical equipment, if you happen to have otoscopes or ophthalmoscopes sitting around, Chantal’s clinic is in serious need.

Finally, we can always use prayers and good wishes.

Please let me know if you have any questions (and to get two out of the way: 1) I still have all my marbles, and 2) yes, Shelagh knows that I’m going).

Thanks and God bless!

Tim

Suffering for Your Art

Below is the text of an expository essay I wrote.  It's less expansive than what I want but the essay's word limit forced brevity on me.  It also limited my ability to explain why the suffering part of nature photography is the fun part of it (mainly because that's an entire Master's thesis in psychology).  I may expound on this later as it's a great topic.

“If you’re a nature photographer and you’re not suffering for your art, you’re doing it wrong.”  This is a saying among nature photographers and summarizes the deficit of comfort and surfeit of failure which one usually needs to endure in order to capture a good image from the wild.  Whether shooting pictures of landscapes, flora or fauna, the nature photographer needs to be prepared to work in conditions that are beyond their control and not of their own choosing.  They also need to be willing to accept serial disappointment and failure. 

When one mentions the word “photographer” many people think first of wedding and portrait photographers.  These photographers have almost complete control of their environment.  They control the lighting, the setting and the subject.  They can pose their subjects and anticipate many of their needs, such as what additional lighting will be needed for the church where the wedding is held or which flattering backdrop to use for a portrait. 

For the nature photographer, however, control of lighting, setting and subject is beyond a luxury; it’s largely impossible.  You, as the nature photographer, can do things to enhance the chances of favorable conditions, but in the end you are at the mercy of the elements and the subject.

Lighting can’t be controlled by the nature photographer, but it can be understood and steps taken to account for it.  The best natural light comes in the hour after sunrise and the one before sunset.  This means early to rise and late to bed, guaranteeing little sleep, especially during the long days of summer.  But if the light is bad because it’s overcast, you have to try again tomorrow or the next day.

The nature photographer’s working conditions are, like the lighting, whatever God gives you that day.  It can be freezing cold, blistering hot, or stormy.  The terrain can be dangerous cliffs, leech and mosquito infested swamps, burning sands or snowdrifts.  These conditions are dictated by the setting in which the subject can be found.  This means that if you want polar bears as your subject, you will be headed to the frigid climes of the Arctic Circle, and if you want pictures of toucans, you’re off to the jungle.

For the nature photographer, patience is a not a virtue, it’s a necessity.  You must be able wait for hours on end for your subject to appear, or you can spend hours or days trying to hunt it down.  Even if you are lucky enough that your paths do cross, your subject is not going to pose and your encounter may be so fleeting that you are left with an image in your mind’s eye but not in your camera.

It is rare for a nature photographer to get a good photograph without having endured some discomfort or inconvenience.  Travel to remote places; bad weather and lousy lighting; uncooperative or absent subjects; harsh, hostile or dangerous environs; these are all some of the miseries nature photographers must suffer to do it right and create their art.  It is fortunate that nature photographers take sort of an ironic pleasure in these sufferings so that nature can be brought to everyone else.

My favorite photo contest - Shoot The Hills

In the typical photo contest, you enter a picture that you've already made on a given subject, i.e., nature, human interest, man's inhumanity to wildebeest, etc.  But Shoot The Hills, held annually in the Hocking Hills region of southeastern Ohio, is unlike those.

I like to refer to STH as a "photographic rally."  All contestants meet in one place at the beginning of the competition.  In front of a judge, you set your camera's clock to match the official time clock, format your memory card, then take a picture of an official reference object (usually a judge holding up a card that says "official start photo").  Then you wait, sequestered with the other photo bugs, until the word is given.

When they say "Go!" you have 24 hours to capture your images.  You are limited to a geographic region but it's several counties, so it's not the area that's limiting, it's the clock.

The challenge is incredible but the results of the winners are incredible, as well.  One of the other regular contestants (I'm sorry I can't recall his name) described it as, "the most frustrating 24 hours you'll ever love."  He's spot on with that.  I love this contest.

It's held early enough each year that the full spectrum of Hocking Hills' incredible flora isn't available for pictures yet. The only flowers reliably in bloom at the time are trillium.  There are invariably a lot of trillium pictures.  Dogwoods and red buds are also usually in bloom and ferns are just starting to unfurl.  But that's about it.  It really adds to the challenge.

Last year (2010) I managed to get two ribbons, one in Landscapes, titled "Lake Hope Sunrise," and one in Flora, titled "Big Four Mayflowers."  Both were Honorable Mentions, so I guess that makes me almost good as a nature photographer.

A lot of nature photography that produces great images involves location scouting, advance planning, return trips to the same location under different lighting/weather, and most importantly, significant amounts of patience (with a supply of auxiliary patience in your camera bag).  If you're up for a challenge as a nature photographer, this is a good one as most of these things are out of your control.  I highly recommend it.

First post

As if I don't have enough hobbies to keep me occupied, I've decided to take my photography to a new level. Only slightly elevated, but a new level nonetheless.

I'm starting this blog and have "established a presence" for my works on ImageKind. The link to my ImageKind site should be stupefyingly obvious. But just in case my marketing savvy isn't working, it's on the right side of the page. I only have one of my galleries linked here but click on it to discover more.

I haven't a clue as to how often I will post here, and even less of an idea if anyone will bother reading this or subsequent posts. But it keeps me off the streets.