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.