John Heimerl's Last Week In Haiti

The following post was written by John Heimerl, M.D., 3rd year pediatrics resident at University of Minnesota

Most days at Saint Damien's begin with 7 AM church service, and most days there are several bodies nicely laid out on the church floor to receive a final blessing. On this day there is a small group of family members in attendance. One woman wails, and Father Rick takes time to explain to the foreign visitors that she is the mother of a 12-year-old boy whose body is in one of the caskets. This day also happened to be Ash Wednesday, which marks the beginning of Lent on the Catholic calendar and where ashes from last year's Palm Sunday palms are applied to attendees' foreheads to remind us of our eventual mortality.

I have been attending Ash Wednesday services my whole life, but never before had it coincided with a funeral mass; therefore the homily hit home all the more. Father Rick warned those in attendance that the caskets would be opened and the family would have the opportunity to see their loves ones for the last time. Visitors in the past have found it difficult to watch, so we were all free to leave following the final blessing.

Chapel at St. Damien's.

Also in attendance at mass is a group of fundraisers from California who I think, judging by their clothing selections, appear more prepared for a day of shopping in San Francisco than a day in Haiti. It is yet another example of a form of tourism that occurs daily in Haiti: people traveling to see how bad the conditions "really are", but never taking time to fully immerse themselves in the lives of the local people.

I, too, have been part of this.

A couple weeks ago I toured Cité Soleil with the sole purpose to see one of the poorest parts of the city. We were not there to provide help, but there to satisfy our own curiosity and photograph the conditions for others to see. The photographer and journalist I accompanied recently published their experiences in a Chicago newspaper. You can read the series of articles and view pictures here.

Having been present for part of these photographers' trip to Haiti, it was interesting to read their experiences and compare it to my experience of the same event. Much like a witness to a crime, we each view events from different perspectives.

A couple of days ago I was given the opportunity to visit the dedication of a new district clinic. The drive was about 3 hours from Port au Prince. We left before dawn and made good time. I spent a majority of the trip riding in the back of a pickup with Dr. Phil, a dentist from Vermont, who has been coming to Haiti since 2004.

We drove by the coast and could not help but think that in other places the sand and beaches would be lined with massive hotels and tourist attractions. Instead, the sand was littered. The last hour of the journey took us down a dirt road, and before reaching our destination we had to ford a river with the truck. I hear the crossing is much different in the rainy season when the river is much higher.

On the drive to Fonds des Blancs 

Crossing the river on our way to the new district clinic opening ceremony

The new clinic is freshly painted and is largely empty, but beautiful. There is space for a pharmacy, dental office and multiple exam rooms.

A local man named Farell who had grown up in the area financed and organized the building of the clinic. He has been finding ways to give back to his community now that he is financially set. His thought was that if he built the clinic, patients and doctors would come. The clinic is built, but no one is there yet to work or run the clinic. He asked me to work in the clinic on my next trip to Haiti, which would be a nice change of pace from the city.

Clinique Sainte Joan Margaret, the new clinic at Fond des Blancs

The dedication service included a mass and a plea to the community for nurses and a physician to work in the clinic.

Then there was music, dancing and food for the 100 people in attendance. When the music and dancing started we took the opportunity to head further up the road to Fonds des Blancs, where Farrel is from. We saw his parent's house, his construction business, a bakery he was instrumental in establishing, a potable water filling station, and at the end of the road, the Fonds des Blancs Catholic hospital. We arrived unannounced and toured the facility. The Haitian physician in the Urgents spoke amazing English, and as it turned out, had attend Dartmouth for a time (as had Dr. Phil).

A Fonds des Blancs physician

A washing station at Fonds des Blancs

Me and Dr. Phil at the bakery in Fonds des Blancs

We made it back to the clinic dedication in time for the recognition of the 50 people who had helped ensure the completion of the clinic. Sister Judy (of St. Damien's, where I have been working these past six weeks) was given a plaque for her part of the project. I had taken a couple of pictures and asked Sister if she wanted any. She only wanted the picture of her with the plaque to remember the day. I believe that it was not so much the plaque she wanted to remember, but the positive impact that day will have on the community.

Sister Judy received a plaque in recognition of her efforts toward establishing the new clinic

Children attend the opening ceremony at the new district clinic

I had initially planned to get two posts out this week before I headed back home, but it is now 14 hours before I start my journey back to Minnesota. As I type this, I hear the screams and moans of another woman giving birth to what is hopefully a healthy baby.

This has been a rough week for me.

When you come to do a rotation, you have a return flight and ending date. This week it became clear that I was nearing the conclusion of my trip. I had been looking forward to this week for many reasons. A big part of it was getting Kesley back as my interpreter. He is not only an amazing interpreter but exceptionally smart. Today I asked him if he makes good money and he replied that he does this work for the opportunity to learn better English (he also has been accepted to start a master's program at Washington University this year, if he can fund his living expenses). To the others, their work may be just a job, but to Kesley it is a chance to learn better English.

There have been some interesting patents this week. Unfortunately the interesting patients, due to their pathology, are also extremely difficult for me to deal with on a human level.

Yesterday, a boy presented in the morning who Doctor Augustin wanted me to see. He told me that since the age of 6 months this boy has had lesions on his face. He is now 6 years old, and the lesions now are everywhere. This child has been to other doctors, but nobody has been able to fix the lesions. I had no clue what this was. It was clearly a chronic process and looked both infected and inflammatory at the same time.

When in doubt, phone a friend.

I took a couple pictures and sent them to global health faculty in the states. I got some good responses, but it was not until I returned to work yesterday that Dr. Augustin told me one of the brilliant HIV attendings thought it was xeroderma pigmentosis. I was not completely convinced, so I Googled it.

Sure enough, it was as if I was seeing this patient in the pictures. Thankfully the initial email had been forwarded to a couple of dermatologists who felt it was consistent with XP.

A biopsy still needs to be done, but then again we are in Haiti, which means a trip to the general hospital. I have heard numerous stories about this place, and some are not so
positive. Jamie, my roommate for a couple of weeks, told me about a shootout he had witnessed on a trip there, but the general hospital is the teaching hospital and likely has one of the only dermatologists.

I got an email from Dr. Mike at Brown who forwarded the email to the dermatologists there, and apparently there are some philanthropists who are interested in possibly paying for the patient's treatment in the States. This remains a long shot, as the diagnosis is not confirmed, and if this is XP, it means he has skin cancer on his entire face. (I will not enclose his picture, but if you google XP and look for the worst image you find you will see something similar).

Yesterday I was working an afternoon Urgents shift when a nurse asked me to see a patient because his heart had stopped. There was no code blue alarm or code team, only me and two nurses, and twenty parents looking on. No pulse, so CPR was started after one cycle, there was no pulse, I examined his eyes and there was no pupil response. Pneumonia and severe anemia had claimed another 6-month-old.

No sooner had I finished his death certificate when I was asked to see another child, a newborn with pallor and clearly severe anemia. His labs were not back and until the labs are back one cannot go to the blood bank to get blood. He had some respiratory distress and poor perfusion, but otherwise looked well. I sent my interpreter to the lab to ask about the sample. They had received it, but could not be run it until the morning, as the machine was not functioning.

I again ordered blood STAT O-blood hoping that if it were ordered multiple times that it would happen. In the meantime I made him NPO and gave him a small bolus. He looked decent, and I thought he would make it till he was able to get blood in a day or two.

Today Dr. Augustin informed me that this infant had died due to severe anemia. Unlike back home, there are no continuous monitors and infants are not checked routinely. A third child also died, which Dr. Augustin was upset about, as that child had been doing well the previous day. What a way to start the day.

Fortunately, my attention turned to a 9-month-old who was carried in by the security guard. He had been seizing in triage, but had now stopped. I did a history and exam and, for the first time, actually thought his neck was stiff on exam. I did a lumbar puncture, and when he was getting an IV he had another seizure, which we were able to stop. Before long he was tucked in for the day. I have been working on a seizure management protocol and followed the protocol exactly as I had written it. Ironically, I would be presenting the protocols to the staff in a few hours.

The next patient was a 10-year-old who weighed 30 pounds and was severely malnourished. It was almost too much to bear on my last day. There are so many levels of complexity in caring for each patient--cultural, financial, transportation logistics, etc.

Around lunch I was able to excuse myself. I had a presentation to prepare for and had seen enough pathology for one day. I spent the evening with a couple of volunteers at a restaurant as my final goodbye. Haitian food sure has a spice that I am going to miss.

Just prior to heading to the airport, I was able to go to a celebration at the nearby school. They had completed construction of a gymnasium, and a celebration and dance followed mass. The children were super cute dressed up for the occasion.

Children at Father Watson Angels of Light School (FWAL)

As I complete this letter, I am nearing my arrival to Miami.

My first trip to Haiti was an adventure. It was the international experience I had been looking for: a diverse patient population and resources to treat them with. Prior to leaving today, I stopped by the Urgents to say goodbye to Dr. Augustin. I gave her my Pediatric Emergency Drug Reference Card from Amplatz. She thanked me for my assistance and for the "very useful gift". I already miss Ayati! Hopefully, I will be able to make it back next year.

When I told Sister Judy I would have to find another niche, her reply was that I could work in the New Saint Mary's hospital in Cité Soleil with her or work in Fonds des Blancs. Both of those options sound amazing, and I look forward to my return trip.