Heartstring

I don’t look at her or get too close because I will make her cry. She already feels awful and I don’t want to make things worse. She is suffering from malnutrition,such skinny skinny arms and legs, with a huge taunt belly...which is complicated by the fact that she has diarrhea, worms, maybe malaria, maybe Tb, maybe is HIV positive….maybe maybe maybe…we will do the tests, we will treat and we will start her on the milk formulas F-75, then to F-100 and then to plumpy nut (ready to eat mix of fortified peanut nut butter), hoping we got her soon enough…all the while giving her deworming medicine and as prophylaxis a broad spectrum antibiotic…and once she starts feeling better….we will be friends and she will smile and play with me, let me hold her…. but right now, day one, I’m too scary and she is too sick.

I hate to make them cry but it is inevitable and rare that I don’t….on day one….or two or three…but it is also rare that I don’t fall over and over again in love. Who knew? Certainly not me…I would have been the last to have predicted such an incredible pull on my heart for malnourished babies and children. I was never much for working in the Pediatric wards in the States. I love my kids to pieces, but other people’s? and sick ones at that?…not for me. But here, in the malnutrition ward in Kigutu, Burundi, I am like a moth to a flame…who knew?

She is sitting on my lap and I start the Village Health Works Waka Waka video and she starts singing along, this little voice...filled with such joy! Her face is lit and I am in awe. They are all special but this one has me wrapped around her little finger. She is so smart, so independent, an old soul with such a fighting spirit.
I tell Crystal all about her and she asks…”Mom, are you going to adopt her?” That is apparently how transparent I am. I do hesitate, I do imagine and then say, ”No, no I’m not.”

I will be leaving soon, far too soon, not enough time…which as I knew even before I came, that it would not be enough…but all that I can do is be present and enjoy the moments, the precious moments as they unfold.

and Haiti....again

I have been back from my second trip to Haiti for 2 weeks and am already planning another one in June. To say that Haiti has a strong hold on me is an understatement and yet a hold I cannot explain. Haiti is not a place I would have ever chosen for myself to spend time. It is so incredibly hot and humid and I am not a hot and humid kind of girl. I live at 7000 ft and when it gets in the upper 80's we think we are having a heat wave of monumental porportions. So melting in the moist furnace of Haiti is not somethng I relish. However, I did notice this last time that I did better than the first...either that or I have short memory:)
Be that as it may my last trip was eventful, beyond anything I could have imagined.

We arrived late in Haiti...around 9 pm and we had figured out who was working the night shift while we waited at the airport in Miami. I won! Actually it made sense for me to work it having done so on the last trip.
The first night went pretty well, Some of the translators remembered me and gave me big hugs...yeah, pretty wonderful feeling. I worked in the adult tent and we all got a row of patients. Our charge nurse had been there for a few days and did a great job of orienting everyone and helping. Things are the same but different. A little more attempt at organization, but the execution still is tough and you have to be realistic in what you are able to accomplish. I ONLY had 15 patients this time!
Sleeping the next day was a challenge...a very HOT day even with AC in the tent and I actual sequestered a bed in the day sleeper section. I woke up at one point and felt like my skin was burning. Quickly remedied that with a shower in my clothes and went back to sleep. The second night really started out nicely everyone with their same patients and feeling very comfortable we actually thought we would have a smooth night. Boy were we wrong. The evening started out with a torrential rainstorm, thunder and lightening right on top of us. The rain was blowing sideways and flooding in the tents, ankle deep in the sleeping tent. Apparently we got a direct strike that shorted out the contol panel at the back of the pediatric tent. We evacuated the whole tent outside amidst billowing smoke. Then just after we moved all the ICU patients into the wound area of the adult tent the adult tent also had an electrical fire and we hauled cots w/patient s outside as well. This sounds much more controlled and orderly than it actually was...people were ripping out the sides of the tent exiting into the mud. Eventually all patients and family and staff out, shut the power got some sleeping volunteers up to help out and we settled outside. We were outside for several hours. The adult tent was put back together (floor even got washed!!!!) and we ALL moved back in peds, and adults...yep, interesting but we all fit, plus, of course, families. I have respect for the Haitians, I can't even begin to explain....At one point the army showed up and helped make the move. Our goal was to get everyone in by dawn and we succeeded.
All are still in the adult tent but making progress with the return to normalcy...whatever that is.
Then no AC in the sleeping tent so most of the day sleepers moved to peds tent (still no patients in it) to sleep because it did have AC and there were several volunteers dropping like flies, getting IVS etc.
A small group of us did manage to go into PAP the next day. We rented a tap-tap. We visited a tent city...again humbling. I don't think I could live in those conditions and be as gracious and smiling as the people we met and shared a little bit of time with. In fact I am doubtful I would even survive.Try living in a “home” made of, if you are lucky, a blue tarp for a roof held up by sticks with pieces of plastic and sheets, dirt for a floor, jammed right next to another of similar construction, shitting in a filthy portapotty, limited water, limited food, no money to buy food, no job to earn money, injured in the quake, some if not all family dead, friends dead, dealing with unbearable heat and stifling humidity…I could go on and on and I only just got started that would be just one of….get this…… 1.3 million Haitians. Yes, that’s “million”
Being in Haiti is sad and challenging and yet feels so right.

And then there is Haiti

Four days after returning from Burundi I am heading to Haiti with a group of 30 other health caregivers (doctors, nurses, etc) from Flagstaff. We arrive at night at the University of Miami/Medishare large tented field hospital situated alongside the Port-au-Prince airport runway for a week stay. It is hot and humid and it remains hot and humid, day and night
The first day I find out I am assigned a 12 hour night shift in ICU, so in order to pass the daytime hours and be useful, I go and work in the supply tent, trying to sort through the mountains of donated supplies (which is a whole other story…lessons need to be given to people and institutions who donate) for several hours until I get too hot and decide it is perhaps best if I cool off and try to get some sleep before I have to stay up all night. I am less than successful at the sleep part and head to the Pediatric/OR/ICU tent at 7pm to start my shift. Fortunately I am working with a real ICU nurse, Kristi, so all is not lost (I can’t remember how many years it has been since I last worked ICU). We have 4 patients, one on a ventilator (with a trach), two also with tracheotomies, and one with a closed head injury who has to be restrained (soft)and his bed is on the floor because he is so restless. Incredibly it is freezing cold in the ICU.
We spend much of the night suctioning the trachs and trying to keep the man with the closed head injury calm and keep him from pulling out his IVs, at which we fail. We get a pediatrician to start an IV in his foot and finally get him somewhat settled. By about 4 am I am struggling but the cold helps me stay awake.
I try sleeping during the day but have the opportunity to go out into the city at 10am so get little sleep. . My brief 2 hour sojourn out into the city reveals a mess, I really have no words but controlled chaos, is perhaps the best way I see it in my mind. It is apparent that even before the earthquake, things would have been tough in Haiti and especially Port au Prince, so overpopulated but certainly functional to some degree. But now….one building will be completely intact on a street, the next one absolutely leveled to the ground, nothing but a pile of dust and bricks. In some places the sickly sweet smell of human remains hangs in the air. It seems that anywhere there’s open, flat land in Port-au-Prince it is covered in makeshift tent cities, which are huge, beyond comprehension …shelters cobbled together from whatever people could find on the street. However I am so impressed with the Haitians resiliency. To see people moving about trying to establish some semblance of normalcy is inspiring, traffic fills the streets, the street vendors are out in force, and clean up efforts are very apparent. From big rubble moving machines to individuals with shovels….I observe one man with a hand saw cutting rebar!!!!! You have no idea how much twisted mangled rebar there is….infinite…thus mindboggling, yet there he is diligently sawing away.

I return and try again unsuccessfully to sleep, (the heat being one factor, the noise being another in a tent with about 400 volunteers) because I have again been awarded the night shift, this time in the adult ward that houses approximately 180 patients give or take a few. It is hot in the tent. I am assigned about 25 patients, although I’m not really sure, and have a hard time keeping them straight. They are a mix, of amputees, broken bones with external fixators, diabetics with ulcerated wounds, a 32 week pregnant woman experiencing preterm labor, a post op abdominal surgery pt...etc. Fortunately their charts remain on their beds (cots) so I am constantly referring to their charts mostly to see what meds they get and when. I have a translator come with me and I go down the line and have him introduce me to each patient and ask them if they need anything. Most want pain medication and something for sleep. I go to the “pharmacy” which is at the front of the ward, a simple row of tables with some shelves behind loaded with medications, fortunately in categories, and for a few hours it is manned by a pharmacist and so I learn where what is so that when he heads to bed I can get the medications I need for my patients, myself. I work nights in this ward for the rest of my stay in Haiti, with me being the charge nurse for the last two nights. Getting around in the ward is tricky. The cots are in long rows , but are close together with a narrow space in between each one, and at night that space is filled with one and often two sleeping family members, lying usually on a piece of cardboard, or sleeping in chair. It’s hard not to just let your heart break. The patients and the families are wonderful, gracious and thankful, and it seems apparent that they don’t really get just how sick and injured some of them are, which perhaps on some level is a blessing. They just are doing the best that they can, and so….so do I. I work with a few of the Haitians translators who are amazing, such willing good kind smart people with hearts of gold, so helpful, so patient, with the patients, ah yes.... and with me. I can’t thank them enough and even though I give them some money when I leave, I certainly feel as though it is hardly sufficient.
My last night is the toughest. I am given the resonsibility of a young man, Jeremy (30 y.o, married with a 2 y.o. son) who is dying(advanced leukemia ,TB, ALL), and we (the docs on call and I) make him as comfortable as possible in one of the outside isolation tents,(which takes from 7pm till 1130pm to clean and set up for him) start him on a morphine drip and he dies quietly and I am hoping comfortably around 2 am. His wife is completely distraught and we give her a sedative to calm her and let her sleep on one of the ER exam tables, as there isn’t any other appropriate place for her. After spending the majority of the night with Jeremy and his wife, I return to the ward at 3am to find two of the Haitian/American nurses assigned that night are nowhere to be found and have been missing for about an hour. So I take over their 50 or so patients, restart lost IVs, cath patients, give meds..etc. They reappear about 530am…they were tired (oh really?) so they went and slept!!! (one even changed her clothes!) I’m so frustrated (and angry and tired) by this point that even though I know they are leaving on the same plane that we are that day, and so it is a moot point, I tell them that they should be ashamed of abandoning their patients, they aren’t special, that all of us are tired, and that they placed a big burden on the rest of us, me specifically, and that I thought they were selfish and disrespectful….which essentially falls on deaf ears....but I feel better.
My day in Haiti ends on a really positive note in that I see Bazile, a Haitian doctor that I worked with in Burundi, who is in Haiti for a couple of weeks seeing and helping his family. He stops by a few hours before I am to leave Haiti and I meet his parents and one of his brothers. It is so good to see him, and the time spent is too short. He will be returning to Burundi and it is clear that he is conflicted….which I understand.
Leaving Haiti is, for me, conflicting, I feel as though there was so much more I could do (nothing big, I know better, just the ripple effect) and I am not ready to go and then on the other hand I am exhausted and very ready to leave in that sense.

Continued thoughts of the monumental problems that lie ahead for the Haitians and the patients I leave behind.
The homes of the patients who fill the wards are mostly gone. Their livelihoods may be gone for a long time as well. How do you discharge amputees, and people with cranial and spinal injuries, to the destruction of their old city? And if you don't discharge them, how do you maintain them in an overtaxed hospital. It has to be a dilemma facing the whole country.
How to impose continuity of care? The surgeon who labored to save a crushed limb is gone after a week. The nurse that started and maintained the IV, administered antibiotics, cleaned and dressed their wounds, emptied their bedpans and explained to the families the gravity of their condition, is also gone. Who follows? Will help continue to come to Haiti? Will it be enough? Only time will tell.
Eventually, beds now occupied by recovering, but homeless people will have to be cleared for more serious cases. Eventually, the challenge of kidney damage and the need for dialysis caused by the tissue death and circulatory problems of crush injuries will have to be addressed. There are mountains of problems with no clear solutions. What will be sustainable?
I can only imagine the work that lies ahead, but what I do know is the first person served by the service is the server and that I hope to return to Haiti in the future...and do the best I can.
.

Halfway

The time has flown. Quiet weekend only three admissions to the malnutrition ward, all with malaria, anemia,malnutrition...it is a vicious cycle. They are malnourished they get malaria which makes them anemic, which prohibits them from absorbing any nutrients. We attack the malaria and also try to build them up multivitamins, iron, and special formulated milk. But the good news is, is that they come in very sick, sad, listless, miserable, crying,withdrawn and (so far)go out of here soooo much better, acting like kids should, playing, laughing, and interacting,...and of course still some crying but not nearly as much.

I smell like F-75, and F-100 (the malnutrition milk formula), multivitamins, liquid iron, quinine and amoxicillin suspension, all mixed together, to say nothing of pee...or at least I think I do because that is what I have been smelling and dealing with all day. It takes getting used to.

Today the two older boys who have been here for a while and will continue to be here for a while more, one with a significant leg wound on his thigh, and the other with peritoneal TB,went to the local school for the morning. They seemed to enjoy it and when Helen and I went to fetch them at noon, we were quite the distraction. It is good to get them out of the hospital setting

to have the opportunity to continue with school.

We went to watch the drumming on Saturday. Two of the VHW employees, Peter and Mandela, along with several other local boys have formed a drumming group. They are amazing. You can watch a video of them on the VHW website. http://www.villagehealthworks.org/ They practice Tues, Thurs, and Sat evenings, and it is a teaching session for several of the younger boys, some of whom are not even as tall as the drums.There is also a girls singing and dancing group that I watched practice on Friday.

We spent last weekend emptying a storage area of medical supplies and sorted through them all, finding lots of very useful stuff...I was able to put together two complete OB delivery kits...much needed, and then tons of not so useful stuff, like 3 ancient IV pumps for which there is no tubing to fit them, a whole box of dental impression plates(?), all kinds of specialized lines for monitoring patients but no monitors, a whole total hip surgical kit (which can and probably will be cannibalized)...doing surgery here is not possible, and probably won't be for several years. It is odd to see some of the things that have been sent here, certainly from people with good intentions but with no clue as to how useful they might actually be. ..or not.

Only two weeks to go.... it will be hard to leave.

Up most mornings by 6, this morning 5:30, the sky just starting to lighten with a faint pink blush. Clear view of Lake Tanganyika and the Congo this morning although there is a moist haze over all. Days are equal length as we are so close to the equator. This is the rainy season, so it rains at some point pretty much every day. The good news is that there are also periods of sunshine as well. Very humid, my hair is curly.

Went to pick up the 5 babies and one adult that we had sent to a nearby (two hour drive) hospital for blood transfusions. Unlike most hospitals in the states it is not just one big building but several small wards, most with the doors to the patient rooms opening to the outdoors. The maternity ward being the exception which had an inner corridor with patient rooms on either side. The buildings are made of concrete and metal bars and are in obvious disrepair. As we (Elvis, one of our translators, and I) were walking down the corridors heading towards the pediatric ward I saw one of the moms of one of the babies. She saw me as well and came running towards me giving me a big hug. Very excited to see me knowing that I had come to get her, and very anxious to leave. Elvis said that they did not like the hospital. Getting out turned out to be a three hour process. It was Sunday and the doctor who had to discharge them was no where to be found. After asking several people we found out where he lived, drove there, found out he was in church got his phone number, which he didn't answer for an hour, and met him at a hotel for coffee to ask him to discharge the pts. He drove back with us, by now it is pouring down rain. He discharged the babies, and because they were all under 5 years old, we did not have to pay any bill for them...however none of the moms/fathers/parents/grandparents had any sort of documentation to that fact but with the promise that they would get that in the near future we were given permission to take them. The adult woman was another story. She did not have proper documentation saying she was indigent (if she had she (actually we meaning VHW...she has no money) would have only been responsible for 20% of her bill) so I ended up paying the full amount to get her released. If I had not had the money she would have had to stay. If patients can't pay they can't leave...! The billing process seemed pretty random, not sure how they came up with the final price but I paid $38,700 Burundian francs =about $26.00US for her 5 day hospital stay which included 3 units of blood...and that was considered expensive!
On the way back stopped at a market in Rumonge and bought 50 lbs of flour. We have a hot pot (a solar cooker) that I want to try out...baking, so wanted to have enough flour to experiment.
I ended up making banana bread and it turned out great. Took about 2 hours to bake and was delicious.
There is somewhat of a food focus here....because of the lack of variety. We usually get chipatis for breakfast (1 each) coffee or tea with sugar, lunch is rice, beans, sometimes, french fries or boiled potatoes, cooked cabbage or some sort of cooked greens and water, then dinner a repeat of lunch....everyday. So the banana bread was a welcome addition. It is good food, filling and I am thankful but I have to admit, I miss salads and fresh fruit. We can on occasion get mangoes, bananas and pineapples, so that helps. Oh and one night we had chicken. OK enough food talk. We have it good compared to the Burundians. Their staple food is cassava....and it is pretty much void of nutritional value. The do eat rice and beans but the fact that cassava is their main source of food is very telling in their state of health or lack there of. There is a food program in the works here to really concentrate on teaching the people other choices of nutritional food to grow. An agronomist from the states, Will, arrived recently, and is busy getting it organized. There is a large two acre garden already in place but the things planted in it are not plants that the Burundians are familiar with or necessarily want to eat. So the goal is to have some staple crops that grow well here, have high nutritional value and that people will grow and eat. The need for better nutrition is vital.

In the thick of it....

I am not going to even try to remember as to what has happened when, but just to ramble about some of the events to try to share a sense of this place. It is lush and green, green, green. Hot and humid when the sun is out and sort of cold when it is raining. Torrential rains, at times, just pounding, with mini rivers running everywhere and a lightening strike the other day so close that it caused the oxygen machine to spark????

Have been in the malnutrition ward all week taking care of malnourished children (marasmus and kwashiorkor cases) and some really sick kids, with malaria, pneumonia, severe anemia...and ??? The lab tech's newborn baby just died so he isn't here, plus I don't know all the things we can or do test for here, plus often it is the shotgun approach to treating people. You can assume that all the kids are somewhat anemic and have worms and are malnourished to some degree and then they get malaria or something else and they can be pretty sick. We sent several babies to get blood transfusions (we can't do those here) but they haven't returned yet.

The families stay with the patients, sleep in the beds with them, yes really, help take care of them, and often help some of the other patients. They patients take their own meds and the moms were doing the feedings and medicating their kids...except for the IVs, and the first day I figured out that they weren't exactly measuring the correct amount. I then taught the moms the correct amounts and we had a staff meeting and it was decided that the nurses needed to be giving giving the meds. We are getting there. It's like nothing you would EVER see in the states. Confusing to say the least and the first day I couldn't figure out who one of my little babies was because her mother had left her with the mother of another baby and I thought she belonged to that mom and wasn't a patient. Lots of noise, babies crying, moms talking, babies peeing on the floor, or on their bed...diapers do not exist...their version is a piece of cloth tied around the butt and then like a plastic bag wrapped around this...if that. I have gotten over the smells pretty quickly as they are rather permeating. All the commotion doesn't seem to stop anyone from sleeping if they want to. The babies just get covered completely and are just this little bump in the bed.

I am having the time of my life...really, some the babies are sooo cute, I am in love.....filling my heart for sure. The kids as they get stronger start to play and wander outside. This evening all the moms and babies were out sitting on the grass and they started singing. They tried to teach me as well....with mixed results...they certainly had a good laugh, as did I.

I also went out with Alex, the computer guy to do some GPS plotting of the homes of accompagnateurs in a village about a two hour circuitous drive and then another hour walk up,down, up down...some of these people live 3 to 4 hours away from the VHW clinic. They help take care and distribute medication (for TB and HIV infected people) and educate people in their community about the diseases. Most of the accompagnateurs came to Kigutu this morning and Helen and Brad gave them a power point presentation about malaria, signs and symptoms, prevention and treatment and distributed ponchos and bags.

The Burundians in this area are very poor, live very simply, have very little, are very proud, yet humble, and continue to amaze me..

In Kigutu

Arrived in Bujumbura day before yesterday about midnight...flight from Brussels delayed by 4 hours of sitting on the runway...cargo door problems,snow, deicing, losing departure slot, but pleasant flight nonetheless. Arrived in a substantial rainstorm and picked up by Nestor, the in country director, Cory the new (has been here a week) site coordinator and Daniel the driver/?. Had a great nights sleep (sound of rain helped), cold shower (get used to it:)) coffee and bread, and then a quick trip to exchange money, buy some Nido (full cream powdered milk...manna from heaven...really...wish it were available in the States) and then attempted to drive the normal route, along Lake Tanganyika, south to Kigutu. Totally foiled by a rock road block...some sort of land dispute...lots of police, shots fired, cleared the road...attempted again but almost got caught between two road blocks...got out and took a much longer route. Took 6 hours instead of 3. Beautiful, lush green country...pictures to accompany this post. Arrived in Kigutu at 3pm, had a quick tour of the residence, the computer room, the clinic, pharmacy, depot (storage room), and then the wards. There are 8 or 9 adult patients, with a variety of illnesses...Malaria, TB, HIV, shingles, fungal infections, pneumonia, weird skin leisons, and then several kids in the "malnutrition" ward, some malnourished, others with malaria, HIV positive and I can't remember what all else. Then lunch and then a visit to the baby goats and a gigantic garden. Harvested lots of radishes, mustard greens, carrots and onions. Dinner of rice, beans, french fries,cooked cabbage...which is pretty much what we had for lunch, substituing potatoes for rice...and which will pretty much be what we will have every day. Good thing I like beans and rice. Helen and I did a show and tell of all the stuff we hauled over and then to bed. Read from my Kindle (jury still out) for about 2 minutes then to sleep. Slept well, awake by 6:30, shower (yeah cold) then breakfast of a sort of chipate/crepe and tea.

Then rounds which are a little tricky. Most of the patients only speak Kurundi, occasionally a little French so they would talk to the doctor then someone would translate for our benefit into English. Most of the staff speaks French, so I am reaching into the depths of my brain to pull that out....and when in doubt I say it in Spanish, which noone understands except for Brad (an RN who has been here 2 weeks and will be staying for a month)and Alex (the computer guy, who has been here for 3 months and will be here another 3 months). I am going now to help in the wards with Hilary (a Burundian nurse)...will post more later.