Sak vid pa kanpe. (Empty sacks don't stand up)

A portable Haitian pharmacy.

Alan and I had lots of car trouble the last day. He valiantly came to the rescue, while I valiantly documented his efforts with my photojournalism.

Alan and I with our amazing Haitian resident class.

Yes, that's my lecture in French.  I was so proud of this idea!

In explanation of my title, it is a Haitian proverb. Literally, it means "Empty sacks don't stand up." It reminds people that a hungry nation is usually not a productive nation. But I also like it, because it implies that you need to be a person of substance to make your way in the world. I love Creole- so succint, but with such impact.


Sorry for the big delay in blogging. We had electricity issues my last few days, and car trouble on top of it, so my internet availability was very limited.  The night we were without power was actually one of my favorite nights in Haiti. All the lights went out around 7 pm. Emmeline and Gerald, the Haitian couple who hosted me, (or my Haitian mama and papa, as I liked to call them) brought out a few flashlights. We sat around the table with the few lights and swapped stories. We all told our craziest stories from our nights on call as medical students and pediatric housestaff. We talked about Haiti from the inside out: the people, the politics, the poverty, and how those things are are related. We shared our hopes for Haiti, and also our fears. Something really special happened to me, in that kitchen, on the quiet night illuminated by a few small beams of light. A part of my heart will belong to Haiti, forever.

I have had a lot of touch moments in the past week. There are times in all of my trips where the sadness of the children I see hits me. It is hard to see children suffer, and it is especially hard when I see children who are beyond my help. I have seen many babies with severe birth injuries. I have seen 2 adolescent girls with rheumatic heart disease, who need surgical repair. I am not sure if there is a way to get it for them. These trips always challenge me on every level.

The teaching I had the opportunity to do here was pure joy. I had a bit of trepidation about teaching Rheumatology in Haiti, because I was not sure how useful it would be. But the residents were so enthusiastic about the topic. They took notes avidly and asked really sharp and insightful questions. all of them spoke English, although most of their lectures are normally given in French. Towards the end of the week, I started using Google translate to get my lectures into French for some of those students whose English was not as strong. I had my Haitian host family briefly review them for me. It was a new experience lecturing in English while my slides were in French! At least I couldn't be accused of reading directly off my slides during the lecture.

At the end of the week, the chief resident stood up, and gave a thank you speech. She told me that they deeply appreciated my lectures, because they had never had a lecture in Rheumatology before. They loved having someone to see patients with them, and answer their questions on the subject. I'll be honest, I had a big lump in my throat. It is really invigorating to teach such a bright, engaged group of learners.

I am now back stateside, safe, sound, and cholera free (which is a vast improvement over my first trip to Haiti, when I arrived home safe, sound, and cholera-ful.)

As I reflect back on my time in Haiti, I only wish for more. More time to teach the residents, and learn from the residents and attendings. More time to discuss the management of HSP in the developing world with the bright young residents on rounds. More time to take care of the kids, who are really sick. More time at the bedside with the Haitian mothers, who are so caring, and so strong. I am grateful for the opportunity to work in Haiti, and I hope I can return for more.

Haiti from a mountain view.

As a pediatrician, I work towards helping families raise healthy children every day.

A home of many of the Haitian children.

In Haiti, the challenge of this is great. There is so much working against the health of the children here. It starts with maternal health. The mothers of these babies have poor access to care, medicines, food and water. They may deliver at home, and the child may be sick for a long time before they come to the hospital. Once in the hospital, all of the major illnesses, such as pneumonia, diarrheal illness, and malaria, are much harder to control and cure in a severly malnourshed child. When I think about a typical well child visit in the US, I remember asking about childproofing, locking away medicines, keeping water temperatures safe. When I drive by tent cities, and see dangers at every turn. There are long iron rebars coming out of the ground and rubble. There are large piles of garbage and refuse adjacent to most tent cities. The government has crews constantly out working to collect and contain the trash, but it is a losing battle. There are open fires right next to the tents. When I first saw these things, I was shocked. When I saw two youngs boy splaying soccer, kicking a ball back and forth between piles of trash, it really hit me: this is their home. They have been here for so long, this is their average, day to day reality.

Beginning to work to fix these problems is hugely complicated, and I am certainly glad it is not my job. When I see healthy children in their school uniforms walking down the street, I marvel at the miracle. "How did you make it through, little one?" I ask, silently yet incerdulously. When I see the effects of these living conditions, such as babies with such severe malnourishment that their little bellies are round and swollen, and their skin begins to breakdown, I get motivated to do more. We cannot forget about Haiti. The journalists have moved along, the cameras have stopped rolling, but the need for help remains. I am very happy to be part of an ongoing effort to help make a difference in the lives of these kids. There is no quick fix here.

I continue to be impressed by the work of the Haitian physicians. November 12 was world pneumonia day. They organized many efforts to help the parents of Haiti prevent pneumonia, and seek treatment quickly if it does arise. One powerhouse pediatrician created "The 10 commandments of pneumonia " for mothers. She and her colleagues developed 10 basic tenets, including using clean water, getting immunizations, and recognizing respirtory distress. It is a very clever outreach model in an almost enitrely Christian nation.

On a personal note, I have been so blessed on my trip here. The Haitian family I am boarding with has been overwhelmingly gracious. On my first trip here, it was during the elections, and there was a lot of concern about political violence. I did not leave the clinic compound except for one day when I drove to get a cell phone. This trip has been like a sneak peek into Haitian culture. They present me with a new Haitian food to try each and every meal. For those of you who have traveled with me, you know I love nothing more than to sample the wacky and the weird. I have had my favorite from my last trip, soup joumou, or pumpkin soup. The peanut butter I have with breakfast is manba avec pimien, or with hot peppers. I don't think I will ever be able to go back to plain peanut butter again. And yes, concerned readers, I have been avoiding the street food.

The side of a tap tap- Haitian public transportation. They often have Jesus and Beyonce hanging out together, amid the bright Haitian paintings.

Little lives

I am always overwhelmed by the littlest lives.
We had quite the day today. In the NICU there are two babies who are in the 700 gram range (that's about 1 and a half pounds.) It is an attestment to the amazing work of the doctors and nurses here. They have limits to the resuscitation measures, labs, diagnostic tests, and medicines, yet they have kept these two fragile little lives going strong. The babies themselves are Haitian through and through- beautiful, brave, resilient, right from the first moments of their lives.
I also spent time on the malnutrition wards. Even after many trips to many poor countries, and taking care of these kids day in and day out, something about them still grabs me. I see babies who have thin, bony limbs where they should have cherubic limbs with roly-poly thighs and dimpled knees, and something gets stuck in my throat. Every time. There is a deep, intrinsic drive to FEED the baby that pumps through me when I see them. They inspire me to continue to tell their stories, to continue to work for the change that would allow them secure access to food. I try my best to take care of them in the short term. I worry about them once they go home, whether they will continue to grow, if they will have the strength to fight off infections, how they will do their first year in school.

The toddler ward

I brought the first batch of coloring books to the wards; they were a huge hit. Thank you to everyone who contributed to that project!

Heroes in Haiti

I have arrived safely in Haiti. The trip was unbelievably smooth. The 5 hour layover in Miami was tough- getting in at 11 pm and having to be back in the airport at 4 am was almost ridiculous.The man who worked the desk at the airport hotel said, "What's the point of checking into this hotel?" Wise man.
 I arrived Saturday morning. I met my host family, two wonderful Haitian doctors. They are amazing people: bright, engaging, and gracious. I am so lucky to have the chance to meet them.
I am here with a neonatologist, Alan Picarillo. We went to the hospital today for rounds, and a teaching session. Rounds was somewhat abbreviated as it is Sunday. I was very nervous about teaching. Pediatric rheumatology is a subject that can be difficult to teach. English is not the first language of most of hte residents, and my Haitian creole is getting stronger by the day, but still not up to lecture giving performance level. But the teaching was great. The residents were engaged and interested. They asked so many great questions and kept the talks going with their enthusiasm. I am so excited to teach the rest of the week. We have already had a few challenging cases presented to us. we are working hard to try and help take care of these beautiful children.

I spent most of the day with a pediatrician. She has worked in Haiti her whole life. We spent a lot of time talking about our work, and what drives us. We had a lot of shared passion for serving underserved populations, working in situations which challenge us, and providing social justice. These doctors could choose to leave Haiti. They could head to the States and live a protected and comfortable life. But they work tirelessly every day to improve the health of Haitian children. Their dedication blows me away. There are angels on this earth, and sometimes you find them in the most unlikely places.

Alan teaching the residents-I can't make it upload in the correct orientation. 

I like this picture of the smushed mosquito on my journal article. Stamping out malaria, one mosquito at a time.

Haiti, Here I Come!

I am preparing for my second trip to Haiti.
I was invited by Dr. Coliman to travel for a week to Port-au-Prince. I will be travelling with Dr. Alan Picarillo, an all-star neonatologist from UMass. I am so excited about this trip because I will have the opportunity to do a lot of teaching, and I find that to be such a rewarding part of my global health work. We will be working at 2 sites, HUEH and St. Damian's hospital.
I have been trying to practice my Creole;  I had a blitz session with a Haitian rheumatology fellow this past week at a conference. I can now ask about joint pain and morning stiffness, so I should be prepared for my rheumatology patients!
I depart tomorrow, and I am really excited to be back in Haiti. The patients and families I met on my first trip continue to inspire me every day.

Rollercoaster ride

     Sorry it's been so long since I have posted anything. We had major rain the past 3 days, which puts a big damper on my ability to access the wireless internet. Time is flying by here- today is my last weekday. I can't even think about leaving yet- there is just too much to be done.
     We have had some ups and downs this week, as always. The NICU has had some sad cases. We had a 4.6 kg infant delivered at 44 weeks with severe asphyxia. We also have an infant whose mother was in labor for 48 hours before she sought medical attention. These babies have such severe anoxia. One of them passed away last night, the other is in critical condition. The importance of maternal and child health supervision is evident everywhere you turn. Access to care is still a major issue here. And it is a hard, hard thing to be a baby in the developing world.
     We also have had some malnutrition admissions. One is a 3 month old girl who has a cleft palate. She is unable to breastfeed due to her cleft, and her mother cannot afford food. Breastfeeding failure is a major cause of malnutrition here because when mothers are unable to feed they often do not have another option. This poor little sweetheart just grabs your heart. She weighs four pounds, so she even infant clothes are baggy on her. She was really irritiable when she came in, but has improved after being fed. I went on a quest for a Huber nipple, which is a specialized nipple used to feed babies with cleft palate. As you can imagine, I was not successful. I could barely find a place that sold baby bottles at all. I am hoping Dr. Okoh can bring a few back from his trip to the states.
     We have had an interesting challenge on the wards this week. A few children from local orphanages have been brought in for various complaints. One of them has unbelievable splenomegaly, but nobody knows how long he has been that way or any family or medical history. The staff from the orphanage were interested to know if we would be interested in making field trips to see children at the orphanage for them. Apparently now they have 500 children they are taking care of.  If they had asked me before today, I would definitely have gone. Maybe next trip.
     We discharged one of the tetanus admissions this morning. He has been here the entire three weeks I have been here. He walked out of his room today(albeit stiffly) and said "I'm ready to go home." We all clapped for him- it is so good to see him well again. It is really uplifting to see a boy who was so sick walk out smiling today.
     Hopefully I will have internet access so I can publish some reflections before I leave.

Tryin' small

     Liberia is a place that never fails to challenge me. Sometimes the challenge is mental, sometimes emotional, almost always extreme. In Liberia, instead of saying someone is hanging in there, they say they are tryin' small.
     This was a brutal week. we lost two young girls. The first was the young girl who died of tetanus. The second was a lovely ten year old darling who died of respiratory arrest from pulmonary edema. The morning she died was one of the moments I was pushed by the demands of this place. I was trying to coordinate her care when she arrested. I ran to her bedside and she was breathless and pulseless. I started CPR, having the intern bag her while I did chest compressions. Ten seconds in we got a call that there was a critical infant born in the maternity ward.  Then I was informed that our baby with neonatal tetanus was having obstructive apnea from secretions and that her bedside suction wasn't functioning. Trying to triage 3 acutely ill patients while running the code and doing chest compresstions was an extraordinarily trying moment. I definitely prayed for grace. The intern had to step out and I gave a medical student a crash course in the proper seal and bagging technique. I gave another instructions on where to look for some suction supplies for the infant with tetanus. I did everything I could think of to save these children's lives. Two hours later, the babies were both doing well, and the girl had passed away. I was covered in sweat and saddened by the loss of a life ended too soon.
     There is always such inspiration here, though too. Last week I was called to the NICU to see a baby with birth asphyxia. She was seizing by the time I arrived. We gave her IV glucose and I ran around procuring her some phenobarbital to quiet her seizing brain. It took less than 10 minutes as I ran between hospital floors investigating emergency cabinets, but that is a long ten minutes. Every second of a seziure can seem like it is lasting for days. The baby began to breastfeed, slowly at first, but then increasingly well. She became more active and vigorous with each passing day. She was discharged home today with a happy mother. The NICU nurses asked if I was considering moving here, and told me I take good care of Liberia's babies. Hard to have dry eyes when you hear something like that.
      I have had the challenge of working as an attending here for the first time. Emmanuel has had other commitments for the past 2 weeks, so after the first half hour, I am leading rounds by myself. I had to switch gears fast from the medicine I am used to practicing to the resource limited setting. I have enjoyed the teaching immenselyand I have 8 medical students and 2 interns on my team. I also gave hospital wide Grand Rounds on Monday. I almost died when I opened the talk on my flashdrive and 1/4 of my slides hadn't been saved, but somehow I mustered through. I presented a tetanus case, and discussed the pathophysiology, current treatment recommendations, and public health issues of the disease. It led to a fascinating discussion between the Peds, OB, Internal Medicine, Surgery, and Anesthesia departments on the disease and management. It made me wish we sometimes had a forum like this back in the States!
       It is also my responsibility to give the students Friday afternoon lectures. I had prepared a talk on fluids and electrolytes, and one of the students was assigned to help me set up the projector and connect the power cords, etc. Since the projector was locked in Emmanuel's office, he had given me the key. I arrived ten minutes early to have ample time to set up. I was quite surprised to see the projector up and running. I asked the medical students if they had a spare key. Turns out they couldn't find the key (it being in my pocket) so they called the carpenter and had the doorknob and lock removed so they could set it up for me. Talk about overly enthusiastic medical students. I mean, you all know I love the nephron, fluids, and electrolytes, but busting down doors for my talk was a bit over the edge.  Luckily they have repaired the lock so I don't have to feel too guilty.
      I can't explain the passion I have for working here. It is brutal, it is hard. I have to work harder with sicker patients and less diagnostics and medications to treat them with. Yet I am always inspired by the strength of the patients, the beauty of the children, the community of families that rally around the family member in need. The people of Liberia know adversity, and that in the face of adversity, you cannot quit, but must keep trying, if only "small-small."