L’hôpital de Passe Catabois en Haïti

(a photo-blog proceeds text)

Around this time last year I found myself working a white-collar job in Manhattan. I was expected to maintain a clean and well-suited appearance, as is the custom among affluent crowds of businessmen. My life consisted of a number of age-old customs made all the more pleasant by the friends and coworkers that surrounded me. I appreciated the implicit dress-code and the clean and neat lifestyle, as well as the pay. The pace of life was fast and busy. I seldom had time for lunch, and when I did, I ate some of the best sandwiches, pizzas and sushi that you could find. Manhattan thrilled me, it always has, and it made me excited and glad to be alive. My life was good. I was content, but not happy.

Fast forward approximately a year. I find myself on a 20-passenger plane with two friends that I had made in medical school. We had just come off of a 15-hour flight from Guadalajara, Mexico and now find ourselves amidst the sweltering heat of a Haitian summer. Trapped in the claustrophobia-inducing airplane, I began to doubt its sturdiness. Just going by the dated and worn upholstery on the seats, the orange and blue veneer on the inside walls, and the Portuguese “No Smoking” sign, I surmised that the plane had been constructed in Brazil in the 1960′s. The machine trembles like an earthquake as it struggles to lift off of the unpaved, uneven and unsafe dirt runway. Being agnostic, naturally it had been a while since I last uttered a prayer. But this seemed like an appropriate time to bust out an Our Father. I reminded myself that Daniel, another friend who had advanced a day earlier, had already reached our common destination. This fact consoled me, but only slightly.

I look out the window, barely able to enjoy the view as we flew for an hour from Port au Prince to Port de Paix in an airplane that dares to defy logic by rotating across its horizontal axis as if it were a helicopter. Had I really come 1600 miles from the comfort of my beautiful city just to die on a windy airplane flight in Haiti? Where were the gorgeous skyscrapers, the vibrant sidewalks, and the smell of garbage, pizza and women’s perfume? In the 4 months that I had been away from NY and in Mexico beginning my first semester of medical school, I had never gotten homesick. But at that very moment as my life hung on by a thread, I missed Manhattan, and most of all I missed my parent’s backyard in the suburban setting of Long Island, where I had learned to shoot a bee-bee gun, cook a perfect steak and pull off a rainbow with a soccer ball.

When I opened my eyes, I realized that my prayers of landing safely had been answered, but without the company of our luggage. The airline only needed to account for 20 bags. Apparently this was too much to ask.

Four hours later, with our luggage in hand, we were leaving the busy town of Port de Paix and on our way to the rural countryside of Passe Catabois. Anything seemed possible at this point because it appeared that the worst was behind us.  Even the deep river that stood in our way was no obstacle for our tough and ruthless driver, Dr. Anne-Marie, and her navigator, our resident nurse, Jacqueline . We were well on our way to the Hospital of Passe Catabois.  We would soon realize that very little could have prepared us for what we were about to see and experience.

Jessica, Akosua and I were reunited with Daniel on the hospital grounds. We were in the midst of an ongoing project that had been started by the Dutch Doctor, Anne-Marie nearly ten years prior to our arrival. There was a history and a great level of respect between her and the inhabitants. Everyone from the residents to the donkeys under them acknowledged the doctor as she passed in her unique white Toyota truck, recognizing the impact that she has had on the quality of life in Passe Catabois.

For Dr. Anne-Marie, or simply “doctora,” as Daniel had instinctively dubbed her, life as a tropical physician in Passe Catabois had started at the foot of her bed where she saw patients and performed surgery. The grounds on which she built her first hospital were then expanded to meet the requirements for a larger and more capable hospital that now houses over 30 patients, a proper operating room, and various containers of supplies. Adjacent to the hospital stands a Baptist church, and a well-sized school equipped with a playground and half a basketball court that is used to play soccer. Additionally, at the apex of the territory sits a guest house for Baptist missionaries and hospital volunteers. I was more than impressed by the amount of work that had been done in only ten years, and with very limited funds. What struck me as a bigger feat was the fact that the whole operation had run without electricity until a few missionaries installed solar panels about a month prior to our, albeit improbable, arrival.

Being only first-semester students, Daniel and I had not been required to take any kind of specialized clinical courses. All of our knowledge came from our volunteer experience in emergency rooms, from the small amount of experience acquired during PMC, and from the theoretical aspects of clinical practices as described by our text books. The latter would seem to be the most applicable in this sort of scenario where we had to be prepared to treat anything and everything that would walk through the door, and often times with limited guidance. Jessica and Akosua, second-semester students, felt just as unsure as us. Even the two nurses that assisted Dr. Anne-Marie, agreed that very little could prepare us for what we were going to see, and they advised us to try to be as self-sufficient as possible while keeping a flexible and creative mind. Their backgrounds had allowed them to specialize in but a few aspects of medicine, so we certainly had to hone in on our courageous sides in order to face the various difficult cases that were present at Hopital Passe Catabois

The most prevalent illnesses in Haiti are Tuberculosis, HIV, Cholera and malnutrition. Patients were placed in rooms according to their diagnosis; so the cholera patients had their own room in order to minimize the chance of contaminating other patients, especially the ones with compromised immune systems. It seemed to be the case that almost all of the locals had compromised immune systems due to malnutrition or some other cause. I can conclude this based on the fact that none of the members of the well-nourished staff have ever contracted tuberculosis in this setting where face-masks are only used in the operating room (OR), and where gloves are seldom used unless you’re performing an HIV test or handling materials in the OR.

On our first day, we were assigned to different patients. Jessica had the seemingly-easy task of caring for a malnourished baby. We would soon learn that this was the toughest up-hill battle in the hospital. Daniel and Akosua were seeing various patients as well. I was given the charts of three patients that presented with tuberculosis-like symptoms. The doctor had a suspicion that something else could be affecting their systems and causing ascites and multiple tissue damage. I gathered as much literature on tuberculosis as I could find in the hospital. Three days of research would lead me back to the same questions, and little answers. Not having the modern diagnostic tools of a well-equipped hospital made diagnosis a rudimentary process where nothing short of instinct and old-school diagnostic tools would suffice. The baby that Jessica had been taking care of died the next morning; there was nothing any of us could have done to prevent this from happening. The doctor explained to us that often times babies with her condition, known as Kwashiorkor, appear to get healthier, stronger and more alert, and in an instant their condition worsens and they die. It’s the rapid recovery that alerts a physician to this eminent death, so it is more favorable for the patient if the road to recovery is a slow and gradual one. In the interim, another baby was born out of a C-section. A 10-pound baby girl emerged from the 16-year-old mother. My shocked reaction was not just due to the placentae that had been placed in my hands in lieu of a twin, but rather at how large the Haitian baby was. This one, I hoped, would not fall victim to malnutrition as well.

We learned early on, in the first day to be exact, that malnutrition and premature birth were the most dangerous factors afflicting neonatal patients. As much as we wanted to help that first infant patient, there was little we could do for her. Our attention had to be diverted immediately to the new teenage mother. There was little time to spend mourning the loss of that morning.

The following afternoon an emergency case rolled through the doors. She was a teenage girl presenting with blunt head trauma after getting into a fight with her boyfriend’s wife; a fight she obviously lost. The patient was either catatonic or unwilling to talk. We assumed the latter and pressed her and her family for some answers. One conflicting story after another came our way, and it became apparent that whatever had happened to this girl was a point of embarrassment for the family. They failed to see the importance of an accurate medical history, and neither they nor the patient trusted us enough to tell us what else had happened. So aside from the fact that she had been involved in a physical confrontation, we knew nothing about this girl.

We dressed her wounds, checked her vitals and made her comfortable. Without more information, our hands were tied. Her ability, or willingness, to speak returned later that night, as her vitals showed slight improvement. This dark episode in her life seemed to be passing, and we felt confident that she would make a full physical recovery. The following morning she began coughing up blood, again. This time, a sizable chunk of tissue accompanied her sputum. Her vital signs quickly took a steep drop, and in her final hours she began to confess to the attending doctor that she had attempted to commit suicide. Had we known the extent of the internal damage that she had suffered, maybe something could have been done. The 15-year-old girl passed before noon.

Not all of our experiences in Passe Catabois were of the depressing kind. We met extraordinary people there. Madame Odette, one of our HIV and TB patients had a real love for life. I never saw her wear anything else but clean clothes, a well-groomed head of very smooth hair, and a grin from cheek to cheek. The smoothness of her hair was a symptom of the combined effect of HIV and TB, but it was always well-kept. Her spirit and joy really gave us a lot to consider when we ever find ourselves in a bad situation, about to start complaining and bickering over the minute details of our privileged lives. Madame Odette is a true role model, and a great representation of the emotional and physical strength that exists in most Haitians.

Dieu Bon, a 14-year-old boy who had suffered from malnutrition from an early age helped me to see how well Haitians in Passe Catabois deal with the death of loved ones. Dieu Bon, which actually means “Good God,” barely survived adolescence when his parents died and left him in the incapable hands of his aunt. His malnutrition stunted his growth, and his aunt would not help things by stealing the food that the hospital provided for the boy. As a solution, he was given his meals in the hospital, and much to his chagrin Dieu Bon was able to spend time playing soccer with the patients’ younger family members: A treat, considering his aunt was not sending him to school.

Dieu Bon had a younger sister who was not as lucky as he. During our stay there, she died from malnutrition, but I never once saw a sad look come from her brother’s face. He is a quiet young boy, but certainly not incapable of emotions. As Dr. Anne-Marie explained to me, “The people of Passe Catabois live in a perpetual state of the unknown.” Therefore, they never consider – the way that we do in developed countries – tomorrow to be a sure thing. People, material things, and even their own lives could be taken from them at any moment, so there is little use for any emotional attachment. This skill that they have of avoiding grief could very well be interpreted as a survival instinct and a necessary part of the Haitian psyche. It makes visiting a psychologist a taboo, and shortens the grieving process to only a day-long affair, at most.

There was a moment of panic on a very calm afternoon. The nurses and doctor had left for the day, confident (as we all were) that the day would end uneventfully. We had good reason to believe this. All of the patients had received their medications, the two malnourished twins, Nerline and Nerland had been given their formula, no surgeries were on the horizon and all of the due diligence had been performed on each and every patient. Things were calm. Until they weren’t.

Jessica and I were the only ones on the floor that night. She comes running towards me with a worried look on her face, speaking of a pregnant woman (of which there were none at that time staying in the hospital) who appeared to be having a miscarriage in a bed, out on the front lawn of the hospital. She did what needed to be done, and ran up the hill to fetch one of the nurses. I ran to see what I could do to help the woman.

Out on the dirt lawn, next to the tractor, and perched on top of one of the cholera beds that had been cleaned and set out to dry was a young pregnant woman surrounded by a mob of loud and concerned people. As I approached the scene, their voices grew stronger and more anxious as they struggled to tell me what was happening to her, in Creole nonetheless. The pregnant woman was hunched over a bowl. My first instinct was to reach for my set of latex gloves and stethoscope. As soon as I did that, the crowd grew quiet. Their mob-like voices were reduced to a murmur and finally to a silent halt as I touched the patient and began osculating her stomach. I stepped back, her face was pale. The crowd roared with questions to which I could not answer. And then, the young pregnant woman began seizing. As they say, “The shit hit the fan.”

Eclampsia was not a good sign at all. I asked them to be quiet and to hold her so that she would not fall off the bed. They did one of those things, and took the initiative of sticking a sock in her mouth. It seemed like a good idea, so I helped. I would later learn that doing this is actually traumatic for the patient and not advisable since it may exacerbate the seizures. I wanted the crowd to stay calm, for the sake of the patient, and for my own sake as well. Never in my life had I felt more ill-prepared to treat an issue, and their panicked voices were only making things worse for myself and the patient. I reverted back to the osculation technique. As the woman writhed on the bed, I began listening to her heart. Every time I set my stethoscope on a part of her body, everyone grew quiet. I would pull away from the patient, give a stern look of contemplation, check her pulse, and really play up the idea that I knew what I was doing when I really had no clue. This pantomime was the only way I could get the crowd silenced, and the only way that the patient’s nervous system could go from a state of over-excitation to a more relaxed one. That is about all I could do at that moment while we waited for nurse Jacqueline to arrive. A few minutes of this felt like a few hours, and my patience grew thin for our beloved nurse. My instincts told me that I should bring her into the hospital, away from such a noisy crowd. I began preparing a bed for her transfer in the empty cholera room. At that moment, Jacqueline showed up like an angel sent from that Baptist church on the hill.

Jacqueline directed the men to lift the woman and bed into the hospital. Only family were allowed to stay in the room with us as we struggled to take her vitals and set an IV. After a few hours of work, the patient was considered stable enough to be moved to the main hospital in Port de Paix. The ride would be rough for the eclamptic woman, as she had to travel via a pick-up truck known as a tap-tap, given the name by the sound the trucks make as they hit pot-hole after pot-hole on the unpaved, hour-long ride. We received word back the following day that she and the baby were safe and in better health.

L’hôpital de Passe Catabois gave us all the chance to see tropical diseases that we would not have seen in our future clinical rotations. After being there for only ten days, we all had learned how to diagnose cholera just by the smell of it, to spot tuberculosis and know the importance of following the two-tier 8-month antibiotics regiment, how to spot a patient with HIV and TB just by the texture of their hair, and what to do when a patient dies: you learn from any mistakes that were made and tread forward to treat the next patient. It was also in the operating room of L’hôpital de Passe Catabois that I confirmed my passion for surgery. Dr. Anne-Marie allowed me to perform a cystectomy on a patient’s elbow. This was immediately followed by another cystectomy on another patient’s thigh. To top off the day, the surgical assistant allowed me to make the final sutures in the scrotum of a man who had just gone through hydrocele drainage. It was a very eventful day, and one that I will always remember as being the day that I found my calling.

I plan on continuing support for this and any other well-run, non-profit hospitals in underserved areas. My next venture will be in my home country of Colombia, where torrential floods have made a bad situation even worse.

We approached Haiti with the intention of making valuable and lasting changes in people’s lives. I am not sure that we accomplished that. Rather, I learned that our only job is to aid in the continuation of life, not to change it. As singular doctors, we should not be looking to cure world hunger, nor change how much faith a community of old-fashioned and distrusting people put into Western medicine. These kinds of goals are unrealistic for any one doctor to accomplish. Our job is to proliferate life. To give that dyeing baby a chance to survive up to adolescence. To treat the abscess on an old man’s rotting leg so that he can walk again, even if it is only for a very short distance. To make the last days of a patient dying from AIDS and tuberculosis as fun and fulfilling as possible. Simply put, doctors need to ignore the prospects of a tomorrow and treat the symptoms of the there and now. Medicine does not have to have a greater purpose than to just provide one more day of life. Sometimes, that is all you need to focus on. Sometimes it’s healthier to discount tomorrow, and take on a more Haitian perspective of the future.

Photo-blog in chronological order (somewhat):

		Haiti Spring 2011 VIEW SLIDE SHOW DOWNLOAD ALL

A petición del público … A Windows Live photo album with high-res versions of the photos in this blog post … Querida familia y amigos, espero que lo disfruten!  Sepan que los aprecio mucho!!!

Waiting for our puddle-jumper to start boarding in Port au Prince.

Part of the Port de Paix shoreline

The airplane that cost me my lunch…. That’s hyperbole, it really wasn’t so bad.

Tortug’ Air’s waiting room

A family-sized tap-tap

Dr. Anne-Marie was gracious enough to give a guy a ride back to town

The river crossing

Akosua, myself, Jessica and Daniel (from left to right)

The hospital’s main entrance.

Our beds: Daniel’s is the one with the princess-style mosquito net.

Where Daniel got his start as a paparazzi.

The new 16-year-old mother after her C-section.

Even so, the hospital was still short on some vital medical supplies.

The 78-year-old man with an abscess on his leg. Witch-doctor treatment was sought before coming to the hospital, so there was a lot of swelling and infection throughout his body.

This is very interesting.  It’s a cholera bed, used for the early stages of infection.

He survived, but his story is unfortunate. His parents had admitted his little sister because she had severe diarrhea associated with cholera.  They waited a week before bringing in the brother who was showing the same symptoms that she had.  By the time he arrived to the hospital, the boy was unconscious and they had to install an emergency catheter into his tibia, and a central line in his external jugular vein.  We don’t know why his parents decided to wait so long to bring him in, but my guess would be that they did not see the value in the procedures that we were performing on his little sister (administering intravenous saline to fight off dehydration).  Educating the community is taken very seriously, so you can bet the parents received a lecture from the doctor.

Nurse Jacqueline visits the Passe Catabois hair salon conveniently located in the hospital

There’s something real special about this picture

I could hear that she was congested, so I aspirated her nostrils and out came exactly what you would expect to come out…snot.

That’s definitely Nerline, the only one of the two twins that would take to the bottle.

Nerland and Nerline (from left to right).  Nerline was usually the more active one and the strongest of the two.  She had enough strength to throw the bottle out of my hands a couple of times.

Dieu Bon and I

This is what is given to patients with signs of malnutrition. One bar contains 6 serving at 400 Calories a piece. That’s 2400 Calories per bar, or a day and a half-worth of food.

My first surgery… It would have been perfect if I had followed the dermatomes.  The second one (performed by Akosua and I) was much better, but unfortunately undocumented.

Our impromptu suturing workshop

Getting silly with our esteemed Dr. Anne-Marie.  This woman truly deserves the respect and adoration that she receives.  Not only is she a bad-ass on a motorcycle, but she’s also one of the best doctors I have ever had the pleasure of knowing.  Also, her willingness and ability to teach us during those ten days is something that we will cherish and take with us in the remaining course of our career.  I for one will never forget that day in the OR and my first canalization.  Thank you, Doctora.

Kate (one of the Baptist missionaries) and Dr. Anne-Marie

Madame Odette (right)

 

 

Jacqueline’s b-day party. Comando ensued soon after…it was intense! (From left to right: Myself, Jacqueline, Tom [one of the Baptist missionaries], Jacques, Joanne and Daniel)

On our way to the Monday market

Coocoo and his goats

Taking a hike down to the dam located by the guest house.

Trying, unsuccessfully, to avoid touching the river of cholera

Trying, successfully, to dig my sandals out of the mud that had enveloped them.

The walls of the valley that lead to the dam

Fred and I

Overlooking the dam valley from the guesthouse.

Nurse Joanne’s bonsai tree, accompanied by Jacqueline’s butt.

 

This is one of their landfills.  It smelled better than you would expect.

On the tap-tap…

…that day we had to transport a few of the HIV patients to the main hospital in Port de Paix so that they could receive their state-funded medications.  There has to be a less detrimental way of getting them their meds. 

Saying some good-byes…

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The sun rose as we rode the moto-taxis to the airport at 4AM.  This would be one of the most unique and fun memories of our trip.

Joanne and I on the moto-taxi, plus three bags and my carry-on luggage strapped behind me to the motorcycle. 

The mode of transportation

That’s Jacques in the background, the handyman for the hospital and the reason it is able to run so well and efficiently.

Knocked OUT!

A well-earned respite in Port au Prince’s nicest hotel

The only thing that could make the following 29 hours of plane rides and lay-overs bearable.

A few beers and a childish mentality made this the funniest sign ever printed… As a matter of fact, I still find it funny.

Our savior, Nadar!!!  We love you man!  I hope we tipped you well.

Happy to be in MIA International, at last.