Going Home

The following was submitted by Ben Trappey, fourth-year medicine-pediatric resident.

I'm leaving today. It's hard to believe that I've been here for nearly a month. Part of me can't wait to get back. I'll be glad to see Emily again. And to be back to the comforts of home. And that the vast majority of my patients will survive.

However, Father Rick likes to point out that despite the difficulties and trials and struggles he's encountered in his many years in Haiti, he finds that life is much simpler here. After just a month here, I must say that I agree. People are easier to understand. Motivations are less complex. People come to you for help because they live in poverty and you do not. They are hungry. They are sick. They need a job. They need money. They ask. They do not use passive-aggressive manipulation to attempt to get you to do what they want without asking. You are either able to do something to help them or you aren't. Life moves on.

Father also likes to say that evil is not subtle here. It is ever present and comes in many forms--illness, infection, corruption, kidnapping, theft, armed robbery, and murder. It is easy to recognize, and it nearly all stems from the one great evil here.

Poverty.

You hear stories from people who have been here for a while. Times when they were robbed or forced to pay bribes or prevented from being kidnapped by a sum of money which would seem laughable to most Americans. But throughout all of the stories, there is always a common thread. There is rarely ever a question of motivation. There are very few senseless or random crimes. People rob and kidnap people for the same reasons they ask for help.

They need something, and you look like you can afford to provide it.

Cite Soleil is the poorest slum in Port Au Prince. It's a sprawling accumulation of homes built primarily of sticks and stone and tin and tarp which appear to be ever on the verge of tumbling down. It is quite possibly the most poverty-stricken and dangerous area in the Western Hemisphere and is effectively governed by the gangs who inhabit it. Father Rick has been going there for years--building more stable housing, providing clean water, and setting up impromptu street clinics. He has just finished building a permanent clinic and a bakery on top of a landfill there, and is in the process of building a hospital there as well. The clinic sits about a hundred yards from the ocean. Outside the windows of the clinic, you can see children playing atop mounds of garbage and goats and pigs foraging through the detritus as it makes its way to the sea.

For now the clinic is staffed on varying days of the week by Father Rick, Sister Judy, and Dr. Charles (a Haitian physician). Father Rick, who is known as "Mon Pere" among the Haitians, is so well-known and liked there that anyone who is known to be associated with him is given privileged status by the gangs. It is not unusual for groups of young men with gold chains to go out into the street to stop traffic to allow the passage of any vehicle labeled with the decals of one of Father Rick's many projects.

Unfortunately for Dr. Charles, his car did not have such a decal when he first started working there. He was coming home from the clinic one day and was approached by a young man with a gun. He demanded Dr. Charles's wallet and told him, "My children are starving. If you don't give me your money, you will die, and they will die. If you do, everyone lives."

There is no subtlety there.

Dr. Charles gave his wallet to the man, who took the money from it and casually handed back the wallet with his ID and other belongings undisturbed. Dr. Charles now catches a ride to the clinic in one of Father Rick's vehicles, but he still goes back to Cite Soleil every day. Because people still need help, and the evil is apparent and almost understandable--"You look like you can afford to give me something that I need."

Despite the fact that this sort of very real danger is always in the back of my mind whenever I leave the safety of the St. Damien compound, I still wonder how I will cope with going back to the safety and comfort of my life in Minnesota, where I will face very different and much less weighty problems. I won't have to worry much about being robbed or kidnapped, but I will be plagued by the complexities of a life that some Haitians would literally kill to obtain.

I'm not sure how I'll adjust to that.

I imagine that for a few days I will be very aware of how very fortunate I am as I return to my very comfortable life and leave the struggles of this place behind. But I fear that I will slide back into the life I have spent my whole life living.

I'm afraid that I'll find my "First World problems" to be incredibly weighty. That I'll hem and haw over what restaurant to give the equivalent of several days wages for many Haitians in exchange for food which will slowly kill me. That I'll worry over how to afford more things I don't need. That I'll have anxiety over maintaining relationships I'm blessed to have. That I'll feel frustrated about some minor unpleasantness or some perceived slight at work.

I'm afraid that I will once again come to think these anxieties are all very natural and important, because I will lose perspective of what real struggle looks like--that I'll lose sight of what poverty and long suffering can drive a person to do. I fear that I'll fail to remember the beauty that lives inside of so many of the Haitian people, despite that poverty and the suffering--the patience of the families and patients sitting in the hallway of Urgence, the joy of the children playing in the orphanage, and the comfortable calm of the Madame Lazarus family sitting on her front step.

I fear that I'll forget the spirit of this place. And I'll complain.

Until I return here and am reminded how blessed I truly am.

Kenscoff Orphanage



Another group of residents and an attending from the U.S. arrived this week, and I was given the last two days off from work in Urgence. I used the opportunity to get out of the compound and see some of the rest of Haiti.



I was able to catch a ride to Kenscoff, the site of an orphanage in the mountains that Nos Petits Freres et Soeurs (NPH) has been running for the past 25 years. It's only about 20 miles from St. Damien, but it truly seems like a different country. I suppose it's somewhat fitting that due to traffic and the condition of the winding mountain roads, it takes around 2 hours to travel those 20 miles.

The orphanage, which is home to some 450 children and provides school to hundreds more, is located 6,000 feet above sea level at the top of one of the taller mountains surrounding Port Au Prince.

The elevation allows for a much cooler and wetter climate where the locals grow onions, cabbage, turnips, and other vegetables in a patchwork of small fields precariously situated on the side of the mountain. One of the long-term volunteers at the orphanage told me that it's been said that "Haiti is the only place where you can kill yourself by accidentally falling out of your field."







The guest house in which I stayed is at the far end of the orphanage and is, itself, perched rather precariously on the side of the mountain. From its balcony, one can see the small footpaths that crisscross the hillsides and valley below and allow people access to their fields.





Since it is such a small community on top of the mountain and so many of the people in the area have benefited from the orphanage, I was assured by those who live there full time that it was very safe to wander around up there. I was able to find my way down to some of the footpaths and hike for awhile. The view was stunning. The absence of dust and noise was particularly striking after having spent so much time "down below" in the chaos that is Port Au Prince.

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The presence of pine trees seems particularly remarkable for Haiti, were most of the country is barren and deforested due to the demand for charcoal, which remains the country's primary source of fuel and claims millions of trees each year. The area around Kenscoff is one in which the felling of trees is illegal. However, when I woke up to leave the next morning, I could hear the sound of someone felling a tree under the cover of darkness in the valley below.



In the evening, we walked a few hundred yards down the road from the orphanage to the home of Madame Lazarus, an incredibly joyful Haitian woman of indeterminable age, who sells canned goods, soda, beer, candy, and toilet paper from her front porch.

The long-term volunteers at the orphanage know her well, and we bought sodas or beer and spent the evening sitting around her charcoal stove on the front step of her small stone house. We watched motorcycles drive or people walk past on their way to Holy Thursday church services as she and her family regaled us with the news from the surrounding area--marriages, births, tales of disputes over the ownership of chickens (the Creole-speaking volunteers would translate for me when something was particularly interesting), and her smiling grandchildren sang/rapped for us and gladly finished off the dregs of our sodas.

It was lovely to be able to get a glimpse of the real life of a healthy and seemingly well-adjusted Haitian family, who would be considered indescribably poor by American standards, but seemed quite content as they spent the evening in the company of each other crowded around a little charcoal stove as the sun disappeared behind the mountain and night fell around us all.

The One About Kites

The following was submitted by Ben Trappey, fourth-year Medicine-Pediatric resident.

A mural on the side of one of the orphanage walls, which are made nearly entirely of metal shipping containers

Having other people here has given me the opportunity to get away from the hospital a bit during the day. Thursday afternoon, I got the chance to tour the school and orphanage that are down the street from St. Damien and are also funded by Nos Petits Freres et Soeurs (NPH).

Both were set up after the earthquake and have been growing since. From what I've been told, the school was initially set up to establish some sense of normalcy for the many children who had taken refuge in and around St. Damien. At first it was merely a collection of tents out in a field where teachers would teach to children sitting in folding chairs or on the ground. It has since grown into a collection of concrete buildings where 800 first through sixth graders go to school every day.


 
The school courtyard

 
Inside one of the school rooms

The majority of the children live with their families in the area surrounding St. Damien and walk to school every day. However, 130 children live in the orphanage that is connected to the school. It, too, was established in the aftermath of the earthquake. It's clear when you look around that its inception was of pure necessity, as the organization was inundated with orphaned children.

The orphanage is made almost entirely of metal shipping containers, which serve as both its walls and the dormitories for the children. Initially, there was very little ventilation and few comforts other than a safe place to sleep. Now the containers are surprisingly comfortable and spotlessly clean. Ventilation slats have been cut into their sides, allowing the constant breeze with which Haiti is blessed to blow through. Toys are neatly arranged in and on top of a chest near the door to each container. Vibrant murals painted by local artists have replaced the industrial motif that originally covered the makeshift walls.

 
More of the murals that decorate the walls of the orphanage residence and school

Not all of the children who live there are truly orphaned. In Haiti, if a caregiver is unable to feed her children, it is not unusual for her to seek out an orphanage that will take on one or more of her children. Some mothers simply must abandon a child at a hospital or an orphanage.

A young Haitian man with whom I've been working closely every day was the third of five children. When he was nine years old, his father left and his mother was unable to provide for all five of them. She found a woman from Detroit who ran an orphanage for Haitian boys that agreed to take him in. He lived there until he was 20 years old. His mother, brothers and sisters would visit a few times per month.

He admitted that he felt quite abandoned at first and would cling to his mother every time her visit would end, and that he cried every night for the first year. However, he now realizes that his mother giving him up gave him the opportunity to go to school, to learn English and to have the job that he has today. He now pays for his mother's medical bills and for his sister to go to school. He is the sort of success story that drives the voluntary orphaning of these children.

St. Damien/NPH does not take part in this custom, at least not voluntarily. However, it still happens, occasionally, that a parent in Urgence will ask another to watch a child while she uses the restroom and then never come back. These children end up in the Abandoned Boys or Abandoned Girls rooms upstairs in the hospital, and, eventually, in one of NPH's orphanages.

When I visited, it was clear to me that the orphanage has developed into a place of stability and refuge for these children who have lost so much, due to death, poverty, or both, at such an early age. Despite all that they have seen and all that they have lost (and the chicken pox outbreak spreading around last week), they come across as surprisingly happy (even when covered in calamine lotion).

 
These girls have calamine lotion on their skin due to last week's chicken pox outbreak

 
A boy in the play area of the courtyard

We came through for our tour in the early evening after school was out. In one corner, a group of boys was playing soccer with an under-inflated ball. They were using a bench as their goal. The smallest of them was making impressive saves, apparently unconcerned that he was diving onto concrete. In another corner, a mass of children was absolutely rapt by the television, which was playing Lady and the Tramp.

These children are rapt by Lady and the Tramp, which is playing on the TV in the corner

However, it was a windy afternoon, and the most fun to be had seemed to be in the construction and flying of kites. The boys were making them out of plastic shopping bags, sticks that they found on the ground, and strips of plastic for tails. They were using string like we in the U.S. might use to tether balloons and would wind it around short sticks, which were used as handles.

Talking kites

Posing with their kite

To say that these boys were adept at flying these kites would be a vast understatement. They were infinitely better at flying these handmade kites than I ever was at flying the kind you buy in a store. They were able to keep them aloft without actually looking at them, giving subtle and seemingly unconscious flicks of the wrist to keep the string taut, while simultaneously helping their friends make new kites or posing for pictures. When their concentration was fully focused on their flying, they had incredible control using the kites to dogfight against each other, attempting to cut the strings or break the frames of their friends' kites.

After 3 weeks in Haiti, it was nice to be able to see some healthy, happy children. To be able to realize that there is more than just suffering here. And to recognize the absolute resilience of these children who have lost so much but are still children. Still able to find joy in each other. And in the flying of kites.

This Too Shall Pass

The following was written by Ben Trappey, MD, fourth-year medicine pediatric resident.

Last week was tough. It seemed that death was everywhere. And I was all alone. Nearly every afternoon last week, after the Haitian doctor who works the day shift in Urgence, as well as several of the nurses, had gone home, and I was preparing to end my day, someone--a father, an aunt, a grandmother--would hurry in carrying an infant wrapped in a towel. I've learned to fear the sight of a small bundle wrapped in a towel.

It seems that most women in Haiti give birth at home. I suppose the majority of these home-births go well and the babies do fine.

I don't get to see those babies.

In Haiti, it's not easy to get anywhere quickly, and most people don't own cars. So when something goes wrong with a birth at home--the baby too small, too weak to cry--these family members make their ways to St. Damien however they can: on the back of a motorcycle or in the back of a tap-tap (the garishly-painted vans and pickup-trucks with seats in the back; the Haitian equivalent of a bus), holding their bundles wrapped loosely in towels, moving as fast as Haiti will allow.

But it's rarely fast enough.

The Haitian tap-tap

Last week, when I would look into the towel, I would invariably find a dead or near-dead infant--cold and cyanotic. Usually premature. All born hours earlier. If they had a heartbeat, I would give them artificial breaths and try to warm them up to see if they would start breathing on their own. Unfortunately, none of them did. Every day last week ended the same way. Any victories, any "saves" made throughout the day, any feeling of accomplishment over a child helped were wiped out at the end of the day by the crushing sense of hopelessness as I tried (despite being aware of the futility) to save those babies who had been so cold and so blue for so long.

This week has been much better.

A group of two residents and two attendings from the Children's Hospital of the King's Daughters in Virginia arrived on Sunday, and at least two of them have been in Urgence with me at all times this week. Fewer of these infants have come in this week, but we've had our share of very sick children, several of whom have died. Still, it has been different with extra people here. Extra hands to help with procedures. Other minds to discuss treatment options. Other souls to share in the joy of the victories and the grief of the failures.

Yesterday, an 8-month-old came in with severe respiratory distress, to the point of being unresponsive. Less than 5 minutes later, a mother brought in a 9-day-old infant who was also unresponsive, hypothermic, incredibly pale, and had been transferred from another hospital because he had been bleeding out of his umbilical cord stump for 2 days.

Luckily, we had enough people available for one to be able to stand there for 30 minutes and give the 6-month-old continuous breathing treatments, to which she, thankfully, responded, another to hold pressure on the umbilical cord and warm the baby, and another to run the 9-day-old's blood to the lab and insist that they check the hemoglobin and blood type immediately. The hemoglobin was 3.5. (Hemoglobin in a child that age should be somewhere around 12 or 13, and back home we typically transfuse before anyone gets much below 7.) We were able to transfuse her within 30 minutes of her coming through the door, and she quickly woke up and started crying.

Today, both children were alive and well. I have little doubt that if there were not so many of us there, at least one of those children would have died. So, those were saves. Victories. I'll enjoy them while I can.

From Dawn To Dusk

At St. Damien's, there is a mass every day at 7 a.m. It almost always also serves as the funeral service for those patients who have passed away at either St. Damien's or St. Luc's (the affiliated adult hospital across the street) and who do not have family to take care of their remains.

"The Destitute" are wrapped in cloth and lain in the center of the small chapel just next to the hospital. Father Rick, the Passionist priest/physician who founded and oversees St. Damien's (as well as numerous other projects throughout Haiti) presides. He does so with quite a flourish in a mixture of Creole and English, as the early-morning sun rises above the compound walls and light streams through the windows on the right side of the chapel.

View toward the inside of the chapel at morning mass

When mass ends, the bodies are carried out of the chapel on battle-field stretchers amidst the sounds of joyful Creole hymns and lain next to each other in the back of a flatbed pickup waiting outside. Father Rick and the Haitian men and women who helped carry the bodies climb into the back of the truck, still singing. The sounds of voices finally give way to the sputtering of the diesel engine as the truck disappears around the corner of the hospital and the morning sun fully emerges above the compound walls.

"Our every sunrise is someone else's sunset."

These masses have served as a stunning example of the contrast between life back home and life in this country. Death is much closer here.

The sky above St. Damien's compound at sunrise

This afternoon, a young mother showed up to Urgence with her baby wrapped in a thin blue blanket. She didn't have to unwrap him for us to realize that he was not doing well. He was very small and was grunting with every breath. When she did unwrap him, it was obvious that he was burning up with fever. Also obvious were his bulging anterior fontanelle and jaundice.

He had been born at home 4 days earlier. The mother had had no prenatal care, and the baby had not seen a doctor since he'd been born. He was so small that he'd not been able to figure out breastfeeding, so he'd not had any nutrition since the mother had tied off the umbilical cord with a string after cutting it with a box cutter. She finally brought him in today because he had stopped waking up and was having trouble breathing.

There were no beds available for him in the main area of Urgence, so we laid him on his blanket on the mint green countertop between the sink and the infant scale. We corrected his hypoglycemia with IV fluids and got antibiotics into him relatively quickly. When I was finally able to get someone to help hold him for a lumbar puncture, pus poured out of the needle. The nurse drew his labs, and I left him in the care of his mother while I went to work admitting another child just a few feet away.

About an hour later, he stopped breathing--the infection finally overwhelming the breathing center of his brain. We used a bag-mask to breathe for him for over an hour, stopping periodically to see if he would take a breath on his own. Back home we would have put a breathing tube in and put him on a ventilator until the infection was well enough under control to give him a chance to breathe again on his own. That wouldn't be an option here, since the only ventilator in Urgence is made for adults and cannot be set low enough for any baby, much less one his size.

Without us giving him breaths, his heart finally slowed and then stopped. He lay there on the green countertop, tiny and cyanotic, while his mother sat stoically at his side in a metal folding chair and the Haitian doctor filled out the death certificate.

It was only then that I noticed the 5-year-old boy who I had been seeing for pneumonia when this baby stopped breathing. He was sitting in his mother's lap a few feet behind us, staring at the tiny body on the counter. He and his mother were both looking on, not with faces of horror or curiosity, but with what appeared to be grim acceptance. I'm sure that the boy didn't really understand what had just happened, or the permanence that this tiny body represented, but his mother made no effort to turn him away. It was as if she were saying to him, "This, too, is part of life."

Death is much closer here.

Patience

The following was submitted by Ben Trappey, a fourth-year medicine-pediatrics resident:

Urgence is an amazing medical hybrid: part Emergency Room, part Urgent Care. Part short stay, part inpatient unit, part NICU. It consists of one long room with a smaller area sectioned off in the back and a hallway running the length of it where another 5 to 12 patients are housed. The main room holds 15 or so stretchers, where the sickest kids, ranging in age from a few months to 13 years old, are housed. Along one wall are another 15 or so newborn babies, many of them premature. (St. Damien's has a separate NICU, but it is open only to babies born at the hospital. Those born elsewhere are initially managed in Urgence.)

Outside the Urgence department at St. Damien's Pediatric Hospital

Each patient is accompanied by a family member who sits patiently beside him/her and provides much of the nursing care. The back room is home to 8 of the more stable children. The hallway holds the overflow of children for whom there is not room in the main or back rooms.

The other American doctors (if there are any) and I start our day in the back room, and when we finish rounding there, we move on to the hallway. The hallway is full of kids who had been seen overnight and are either waiting to be sent home or to get a bed in one of the main rooms. Some, however, end up staying in the corridor for several days. Their maladies range from pneumonia to seizures to severe malnutrition, and some of them would probably qualify for ICU care in the U.S. The hallway ward is furnished with a long row of connected metal chairs, a few moveable chairs, and one padded table. The sick children sit or, if there is enough room, lie on blankets or towels in the chair next to or in the laps of their family members. The table is usually occupied by the child whom the mothers somehow seem to decide needs it the most.

Inside the Urgence department at St. Damien's Pediatric Hospital

The patience of these families is, perhaps, the thing that I've seen here that astounds me the most. Many of them sit in this hallway for days, waiting for a bed to open up, for the doctors to round on them, for the one nurse who covers both the back room and the hallway to carry out our orders, for lab results that usually do not return for at least 24 hours.

And so they sit and fan themselves and talk to each other and lean upon each other for a nap, and watch each other's children while one of them takes a bathroom break.

What they do not do, apparently, is complain. In the four days I've worked so far, I've not had one parent express concern about the wait or about being tired or hot. Two have let me know that the antibiotics have not yet been given or the fluids have not yet been hung for their child, but these were the mothers of two of the sicker children, to whom I had expressed concern and stated that we needed to move quickly to get treatment started. Neither of these mothers seemed angry or put out.

Nor did the grandmother of the very small 11 year old girl who presented three days before I got here with low-grade fever and yellow eyes. Her fevers resolved quickly, but when her blood counts returned the next day (day 2 in the hallway), she was severely anemic. Her other blood counts were normal, as were the remainder of her labs. Her grandmother had been told in the past that the child was anemic as well. The most likely cause of her anemia was sickle cell disease, which runs in their family. She received a blood transfusion the day before I arrived (day 3 in the hallway), but when I saw her the next day, her follow-up hemoglobin had actually dropped. So we ordered another transfusion and waited for the results of her sickle cell labs.

Unfortunately, St. Damien's did not have any more of her blood type in stock, and the family had to find a family member to come in to give blood for her. On the evening of the fifth day she had spent in the hallway, she finally got the blood transfusion. We repeated her hemoglobin the following day. The result, along with that of the sickle cell test, finally returned yesterday.

She'd responded well to the second transfusion, and we were able to confirm that she has sickle cell anemia and to arrange follow-up in the sickle cell clinic here. She had spent an entire week of her life in that hallway.

When I was 11 years old, a few hours of not being engaged or entertained seemed an eternity. This child sat patiently on those metal chairs for seven days, while younger children beside her cried and coughed and vomited and had diarrhea and seizures. Every day when I would see her, she would grin broadly and tell me that she felt well. I would tell her and her grandmother that we were still waiting.

And they would smile and say "dakò" and "mèsi", which means "agreed" and "thanks".