04-JUL-C-6
THE ROAD TRIP
TO
WHERE WE
DELIVER SUPPLIES, TOUR THE FACILITIES,
AND LEAVE
NOTES FOR BOTH PAUL FARMER AND LOUNE,
AND THEN
RETURN FOR AN IMMEDIATE RETURN TO A REMOTE MARMONTE OUTPOST CLINIC AT SAPATERE,
FOLLOWED BY
OUR FINAL WRAP-UP AND TESTIMONIAL SESSION FOR EACH PARTICIPANT AND
WHAT THE
EXPERIENCE HAD MEANT TO THEM,
BEFORE OUR
FINAL CELEBRATION
IN ANOTHER
HUDA BIRTHDAY PARTY
In the usual scramble to get everyone ready to
go at least an hour late, we packed up the duffel bags and all the surgical
supplies I had kept in the shed and also from my recent PSS shipment off to
As before,
we seemed to have arrived unexpected, if not unannounced. The message3s we had exchanged by email had
suggested a visit Tuesday through Thursday since Friday Farmer was out of
This keeps
my record intact: I have met Paul in
multiple locations on the road, but not in
We made it back along the horrible roads and got just to Delva’s Guest house named Cilina after hi smother, when the plans changed. I thought we were doing a clinic at the Thumonde Dispensary where a few folk were supposed to have come to see us, but abruptly it was now that we had people waiting for us with a notice that we had planned to arrive early so now it was not possible to get out early since we had not even got back by noon, and the patients would already have been staked out in the hot sun missing whatever they might have planned for meals and the complicating factor is that I have insecure freshmen clinicians who do not handle surprises well, and who lack any kind of stamina or enthusiasm for obligations since they figured they had already had a full day. The women were found lying down and were rebelling. Before they would go anywhere they wanted to have lunch prepared for them. We rousted them out, and had a bit of bread and fruit, and then packed the cars under protest, to take off for a clinic in a church at a place called Sapatere. When we arrived over the rutted roads, sure enough, there was a parking lot of burros with their straw saddles on, and a large crowd of people under the few trees we could find to have them find some shade. There was listlessness on the part of most and a weariness on the part of a few of the stalwarts like Laurie who had been feeling poorly so she sat in like a trooper, propped up as all of us perspired in the heat. As I tried to make the best of only three translators and three teams one of them moved outside so as to get the sparse shade at the side of the church and the little breeze that was out there, and while I was reviewing patients inside, Neely came back in and singled me out to help her move benches outside—as though I were the most expendable fellow present.
The last of the patients came just as the darkening sky preceded the rain, and we pulled out wearily to get back to the Delva’s Cilina Guest House. We were getting some early dinner when I announced hat the final wrap up session would begin in fifteen minutes to which there was again a ripple of rebellion-yet it turned out to be the most rewarding of their sessions yet. It also was the recap for the review of our Haitian experience at the four clinic sites and a few scattered patients in between. I had opened the evening up to them as a review of the whole experience, and many took it as a time to give a testimonial of their reaction to the whole experience and the way it was going to change them. I had passed out the evaluation questionnaires part B, and had hoped to have them filled in and returned before the flights were over, but a number reported losing this paper, so I had to make out a few extra copies as a way of getting the closure on this experience.
A lot of good cases were also reviewed for the sake of the medical learning event, but also a chance for each to hear what the experience had meant to each. I will try to attach a few of these reported reactions to the experience.
But, we also all knew that it was going to be party night, sine we were going to celebrate Huda’s birthday yet another time, as it was coming up the following day on our day of travel back home. We did not know that this entailed total darkness with a very high decibel boom box DJ belting out a jazzed up version of Happy Birthday—yet we all got into it in time to cut the cake for Huda from the only baker in all of Thumonde. I tried to check on email when the generator had come on just after the heavy rain, and the thumping of the nearby boom box shook the computer screen to lose some of the messages, but I did see a few of the messages that might make for changes in plans upon my return.
The wrap up session was interesting for what a few people said in their reaction to this experience, and how it might change not only their practice but also their lives. So I will report the mix of their reports, including the few case reports and overall patient reviews and the context of the community health and development in which these patients are necessarily going to have to continue as we leave the environment, for which there was a fair amount of whimpering and whining, today especially.
For the final wrap-up of the didactic medical program of intensive medical education de-briefings that has followed each or our clinic days in trying to integrate the experiences of each team and allowing them to fit the pieces into a unified whole for their careful medical review, I turned them loose to make any statement they felt each would like to make. This was at the time of the distribution of the Appendix B of the post-trip questionnaire to be filled in upon completion of the trip and during the return flight. They were free to present a case for discussion as before, or to make comments on the overall experience, even testimonials as to what this trip had done to change them or make a difference in perspective on their lives and careers here or back home. Many chose a bit of each, but all chose to give a statement, some with emotion, on what the experience had meant to them personally.
Vesta: She stated she had been nervous about the trip since she did not know quite what to expect, but also that there would be some hardships involved. She is now well-motivated and eager to try a similar experience, having learned a “ton.” She said that before the trip she was a “spoiled brat”; now she said, “I am still a spoiled brat but I see that other people have far less than I do and get along with it.”
Anisha: “I learned a totally ridiculous amount of medicine and a whole lot more.” Before this, she said, she knew she had to put in many hours of memorizing facts, but now knew they had some significance in someone’s life evident right before her eyes, and in some cases, the small missing piece of knowledge might have life/death importance. She may have been overwhelmed by the amount of clinical knowledge necessary to practice medicine, but said that she had come to see the point of my suggestion of “pattern recognition.”
Anthony: This has been “ a very positive experience, both medically and culturally.” He was at first overwhelmed, and was embarrassed about starting off on the wrong foot coming to the airport heading to two foreign nations without a passport. He was often the butt of good natured jokes, as in “Are we ready now?” Well, first, where is Anthony!” But, I assured him that the practice of medicine in general and in this kind of environment did not require a genius (although it would not hurt): what one needed to know to practice effectively is simple: “Always a bit more than you know right now—which is why this is such an intensive learning experience, particularly in the context of your first clinical encounters, and especially in the setting of an extreme poverty and cultural difference.”
Michael: He had preferred to present a case so as not to miss the opportunity of taking advantage of the leader’s special expertise in one area, and then gave an impression of his entire stay. A 29-year-old woman with a swelling in the midline of the neck had a freely mobile mass. It did not move when she stuck out her tongue. She was seen in contrast to the dozen or so goiters we had also seen in our stay. I pointed out the origin of the thyroid as a mesodermal gland induced from the foramen cecum at the junction of the posterior third of the tongue along the “V” of the circumvallate papillae, which migrated as the heed and neck evolved in embryology, so that “ectopic” positions of the thyroid could be a totally “lingual thyroid” or along the “thyroglossal tract” including the center of the hyoid bone (for which reason the “Sistrunck Operation” for removal of the “thyroglossal duct cyst” requires resection of the hyoid midline to avoid recurrence) down to the two lateral and pyramidal lobes of the thyroid, to the sub-manubrial position of a substernal goiter in the anterior mediastinum. This nodule was a simple colloid cyst, which would be of no consequence except cosmetic, and would be low priority for removal. Mike went on to add what an incredible learning experience this has been with an experienced international leader, and if the first year medical students think that they were learning a “ludicrous amount of wisdom”, this was no less true for the seniors.
Sarah: The juniormost participant, now that 15-year-old Gregory had been left behind in the DR, stated that she had been terrified about coming even though she very much wanted to, knowing she would be entirely over her head all the time. She said she was surprised at how she adapted knowing that this was a lot of information and many actions with consequences for which she would not be immediately responsible as though unsupervised and her fears were decreasing and confidence increasing, figuring she might even be able to do this with further help in recognizing and interpreting patterns.
Laurie: {Hands down, the winner of the group, in seasoned judgments and good patient clinical skills, in my opinion} also wanted to make a comment and present a case and then a summary judgment on the experience. She thanked those who had helped her in the last days when she was not feeling good—a characteristic gesture on her part, since she was propped up in clinic and still reviewing patients, despite GI distress! She stated she has always wanted to make a trip with me and had tried previously and knew she would go no matter where when the senior elective time had become available, but only as the weeks progressed did she realize how valuable this experience was and is not eager for it to be over, but is very enthusiastic about doing it again, and soon!
This was real medicine without the labs and X-Rays and an immediate feedback in improvement or worsening that conditioned the responses in handling these very sick and poor patients. She is uncertain about her future in Ob or FP, but she wants to make this kind of experience a regular part of either she will be entering and hopes to apply to go out with me again, as soon as the next African mission I am preparing.
The case she presented was that of a three-year old who made a very dramatic presentation to clinic with the historic complaint of cough. In a very classic display of croupy forced inspiration with laryngeal stridor, she gasped and coughed and vomited a mucus secretion and had such a swollen larynx she could not complain despite trying to cry soundlessly. The differential diagnosis of the emergency of acute epiglottis and its Hemophilus Influenza basis was further detailed against the kind of upper and lower respiratory infection she had. I may be the only one who has seen the darkened thick membranes of necrotic mucosa being coughed up in diphtheria which is also life-threatening, but this was like that without the darkened membranes. We diagnosed URI and LRI and treated her like a DOTS patient making sure she got the first doses of Zithramax while being observed. Her epiglottis was not visible in the cherry red swelling that would make her a high risk for airway occlusion.
Zeb: In testimonial to the efficacy of treatment, Zeb came forward to report that he had been groggy and sick for several days with a cough and consolidation as confirmed by his team captain Duc and the group leader, and that after 18 hours on the same medicine, he felt a crisis and an improvement back to normal now. Just how sick he had been, and how quickly he recovered made him a believer in the power of modern medicine, and he was interested in trying to be a part of this as an applicant to medical school, for which he hoped this experience would be a positive contributor!
He stated his experience was memorable for several reasons, “For one thing, I almost died, but recovered quickly and completely; I want to be part of this kind of transformation.” He regretted that he could not save someone’s finger, since the lack of a ring cutter or a bolt cutter meant he did not have the tools that are normally redundant in a society that has too much of everything. He wishes everyone he had encountered could have the same nearly miraculous response that he did, and is sorry if any did not, because of a lack of their own resources or those we are able to bring, but he is sure we had helped an amazingly lot of people,
Sonbol: She thanked each of the members of the team of which she was a part. One of the freshman had pointed out the hopefulness she also repeated, saying that as each of us starts out in profound ignorance, and in comparing the knowledge we have against what we will need to know, it is good to see that there is a progression through the medical school years and that others have assimilated the huge load of information expected of us and can actually come out the far end and do something with it to make someone else better. She stated how deeply appreciative she was of the experience form the perspective of a public health student, and is somewhat in awe of the additional medical and clinical capacities to be built up further.
Neely: She stated she was hesitant about being here, not knowing any medicine, but found that other people around the teams helped her so that she would not feel constantly overwhelmed. She has a greater appreciation of public health as a big puzzle, with the component pieces she had witnessed here not being amenable to quick and easy fixes, but each worth the long and arduous start. She stated that knowing what little she could do and seeing what could be done had made her pause to consider that she might apply to medical school (the third of such responses by those not already in medical school—and such an experience can only help!)
Lindsay: “This was an
awesome trip.” She wants to use this introductory
experience to motivate her now to be eager to get back to school in the fall
and learn in detail what had just come at her so fast. She thought the idea of fourth year students
as team captains was encouraging not only for the camaraderie, but also the
hope that she could mature in the four years to be less flappable in
confrontation with the unknown, as she had seen a few of them had been. She says she wants to go with me into “the
deep end of the pool”—to
She presented a patient, a forty-year-old woman who had a complaint of abdominal pain. It was an unknown until I had got her into a semi-sit-up to show the protuberant epigastric hernia. I was chastised by the team by immediately reducing this, which “hurt the patient” who would recur again when she had intensive contracture of the abdominal wall muscles. We spoke of the conditions that might cause or exacerbate a ventral hernia—and then also presented an acquired direct inguinal hernia in an older male, pointing out its protrusion through the Hasselbach’s triangle near the epigastric vessels, and asking the critical question, “What three conditions do you have to rule out before this hernia is repaired to prevent its recurrence?” They are prostatism, (straining to pass urine around a BPH) constipation (straining to pass stool around an obstruction, such as a sigmoid colon cancer), and chronic cough, any of which increase intra-abdominal pressure and may cause the recurrence of such an acquired hernia if the underlying cause is not addressed. In this case in point, the man had a chronic productive cough from undiagnosed TB, so that his presenting hernia was not his most significant problem to be treated.
Siayavash: He stated that he came to GWU on a choice between two
medical schools since he had found my Home Page web site and was a “wannabe”
who wished to take on the kind of medical adventures world wide that he had
seen described. He had eagerly signed up
for the Haitian medical mission in the spring vacation period earlier this
year, since he knew this would be his chance to experience the kind of
international medicine first hand and was very disappointed when the civil
uprising that overthrew their President Aristide for the second time gave rise
to the State Department Travel Advisory that made GWU Trustees forbid students to travel to Haiti
considering the dangers. As I went off
to the Horn of Africa with only senior medical students and arranged the
clearance and MAP packs for
[He may not yet appreciate just how much every single course he will be taking in pathology, pharmacology and microbiology has been facilitated by this experience—if he did, each of the freshmen might be able to take the next two years off and accompany me on these trips! As one of the seniors from last year stated, if he had just taken the medical school curriculum as a correspondence course, and had gone on the for trips with me in international missions as graduated as they were in his experience from general outpatient clinics in Ladakh, to OB/OR in Malawi, to the “deep end of the pool” in the Horn of Africa in Somaliland, his time in medical school would have been spent more efficiently and rewardingly, and he would have come out on balance with three times the knowledge and four times the wisdom in perspective!]
Duc: He stated that he had known a bit about
Huda: She thanked by name each of the principles, including BRA and
Project MediShare and Marie-Cherie and Bryan and said flattering things about
the leader, in whom she has such confidence now, that since “she has now seen
him in action in his element, she will gladly go anywhere with him world-wide
into any setting.” I had quoted Skip
Williams’ statement, that there are but two reactions possible to a deep
immersion experience in Haiti: 1) You cannot wait to escape and get to a clean
A/C shopping mall and shake the filth of the poor off you, to forget the
experience as only a worst nightmare come true, or 2) to love it and
immediately make plans to return and to join in to share their lot and hope to
improve them. I would hope that this is a
self-selected group of the latter persuasion, and the Muhammad Akter quote on
my own view on “commiseration” I use to describe this is: “It is a wonderful
and glorious thing to joyfully share in the miseries of the poor.” That wonder
is often reflected back manyfold from the side of what had been expected to be
the beneficiaries of our efforts in
Huda said “I am one of those people
who found myself falling in love with the people of
Martha: Martha said she was especially thankful for the trip to
Cange, since we have been dealing with filed work in destitute areas, and it
was good to see what had been possible when good will and concerted efforts
tried to make something happen against considerable odds—whatever
sustainability it might have. She was
encouraged by Cange, to believe that the people of
Adam: “Inspirational” is what this experience has been to Adam, since before he came along, he knew “nothing about Haiti,” but he had always wanted to try to participate in a medical mission—and here was one made to order. He had participated in each activity to the fullest of his limited skills and knowledge which he would now like to expand. He was in awe of some of the ready diagnoses that could be made and treatments offered with no more than fingers, ears, eyes, and some neural interconnections directed by a heart that could care. He recognized that the rapid clinical telegraphic communication was necessary, but never obscured the primary motivations for why we were there.
Marie Cherie: On behalf of Project MediShare, Marie Cherie thanked each participant for coming and helping. She stated that this was the first time there had been public health students joining in and at first she was unsure what contributions they might make and had been trying to make sure they felt like participants in some of the extra meetings she had had with them. But, she said it is also fortunate that we have a leader who has been her before and has credentialing in all three areas of clinical medicine/surgery/ tropical medicine, public health and anthropology; now if only we could recruit several more of him to spread out the heavy obligations to supervisor of junior participants in the tasks we have taken on as GWU has committed to continue in caring for the whole Marmonte region.
Loren: As an anthropology graduate student, Loren was glad to get a chance to witness the people in the clinics to learn more about the birthing practices and the kind of information she will need for her thesis. She said she was not a physical or biologic anthropologist, so she found fascinating some of the concepts in the didactics about adaptation to the natural and cultural environment in this and other extreme marginal lands. She stated that it was especially exciting to see the Haitians bonding so well with their unusual outside guests in the kind of intimate settings provided by concerns for their health and their children.
Suzie: “Of course, I have done all this before.” She cited her single experience in
After this series of final wrap-up discussions, which were entirely directed by the participants with only reflection by the group leader allowing each to say what was important to them upon reflection on this experience, we adjourned for party time. This was yet another of Huda’s birthday celebrations with a cake from Thumonde’s only baker, and a high volume woofer and tweeter disco for dancing in the dark. During this period of celebration, several of the participants came to me individually and some seeking privacy to reflect gratefully on what this experiences had meant to them, and in some instances to react to comments made by some of the others, almost all of them positive