My mother has OCD. And 12 cats. This combination was responsible for the nightly ritual known as “counting cats”. We were a family of five in a standard three-bedroom ranch style home in El Paso, Tx. My two sisters and I dreaded bedtime. I, for one, had been known to slink off to bed early just to avoid participating. Before you judge, let me describe the scene to you:
”Bedtime!” my mother announces. We all know what that means. My sisters and I crowd into the one full bathroom in the house to brush teeth, wash faces, apply moisturizer, and whatever else our toilette entails. The cats, of course, scatter to the four winds.
Everyone changes into pajamas, and it begins.... each cat must be located, it’s location reported and confirmed. Don’t even try to pretend you’d found one when you hadn’t. If your veracity was at all in question, someone would be sent to verify your claim. Woe be to the prevaricator! Not only would they be punished (lying was the greatest evil in my mother’s mind), but when the cat you said was inside was actually left out all night, suffering a cruel death at the mercy of the elements and/or the coyotes, upon your shoulders is where the blame would firmly rest.
Those of you who know cats will understand when I say I’m convinced they took sadistic glee in finding impossible hideaways at this time of night. The cat who sat on your homework all evening, the one continuously howling for cream in the kitchen, the one snoozing peacefully on the sofa, the one biting your toes under the dinner table, the one who’s so old and fat it lays in the same spot in the hallway twenty-three hours a day- all disappear.
“None in my room!” cries Tammy, the middle sister. Her room is neat and tidy- nothing out of place. A cat could not go unnoticed in there, even under the bed or in the closet (Standard Search Protocol).
”I found Juby in my room!” reports Tara, the youngest. She and Juby have a special bond. They’re each the youngest and the smallest of their litter. Make of that what you will.
“Prince is in the bathroom,” says my mom. Prince, an affectionate, languid, long-haired Persian mix who’s favorite hiding place is the towel closet, is the reason every time I get out of the shower and dry myself, I’m covered in fur.
Four cats down, eight to go. The search continues.
“I’ll check the laundry room,” I announce. Just then, Katie, a shy calico we found living in the woodshed with her newborn kittens (whom we obviously took in), leaps down from the shelf above the washer, narrowly missing my head, and darts past me. “Katie’s here!”.
The only kitten of Katie’s we were unable to find another home for was Marilyn. Now a full-grown, cotton-haired white cat whom we suspect is deaf, and who is perpetually covered in mats due to an aversion to self-grooming, resides primarily under my bed. She’s called Marilyn in honor of Miss Monroe, due to her lush white fur and habit of lounging about and gazing provocatively at anyone who passes. Don’t try and touch her though; she bites. I spot her (without touching her) lying in the far corner under my bed.
Someone has located Kelly, a large, fluffy, motherly calico, asleep amongst the couch cushions. That leaves only “The Boys”, who are likely outside.
Once my mother is convinced every room has been thoroughly scoured, she heads for the front door to round up the stragglers.
“Heeeeeerrrrre KittyKittyKittyKittyKittyKitty!” she calls.
And again. “Heeeeeerrrrre KittyKittyKittyKittyKittyKitty!”
Nermal comes sauntering in. He heads directly to the kitchen, expecting a treat. Tara obliges him with a saucer of milk.
My mother continues to call for several minutes, then enlists me to take over.
Reasoning that perhaps they simply couldn’t hear her well enough from the doorway, I venture out onto the porch. Standing under the porch light, I begin to call.
“Heeeeeerrrrre KittyKittyKittyKittyK.....AAAAAHHH! Stupid bugs! Heeeeerree KittykittykittyKITTY! Help!!!”
The porch light has attracted the usual array of moths and June bugs, and now there’s a June bug entangled in my hair, buzzing frantically near my right ear, its creepy little legs crawling on my scalp. I’m generally considered the least squeamish and the boldest of the family, but June bugs are my Kryptonite. As I dance around yelling for help, Keaton ducks past me and scratches at the front door. Tammy opens the door and he runs in. She manages to get the bug untangled from my hair and takes over the cat calling.
Back in the kitchen, I trip over Nala. “Where did you come from?” I ask him. He mewls at me, indicating the empty milk dish.
“All right,” says my mother as she comes into the kitchen. “Who’s not here?”
I run down the list with her: Juby, Sugar, Pepper, Prince, Kelly, Katie, Marilyn, Nermal, Keaton, Nala. Only two missing.
Momentarily, Tammy opens the door for Shadow. “Just Cowboy left to go”, she reports.
Cowboy is a rogue and a rambler: a large, lanky, orange tabby who prowls the neighborhood from dawn to Last Call. There have been a few nights we finally gave up and let him stay outside (against my mother’s better judgment and ability to sleep). When he does come inside, he sleeps in my bed- curled up on my pillow just like when he was a tiny kitten. I feel a particular fondness and a responsibility for him, so I volunteer to brave the porch again, thinking maybe he’ll come for me if no one else. This time, though, I avoid the June bugs by turning off the light. Cats can see in the dark anyway, right?
After another twenty minutes of calling with varying tones, pitches, and ululations, he appears. I scoop him up in my arms, kissing his head and scolding him for causing so much worry.
My mother announces it’s now truly time for bed. All is well. Until tomorrow night......
The pager went off at 6:42 pm. "Full Trauma -- ED 6"
I hurried down the stairs and into the Trauma Bay. Several team members were assembled around the room
"What have we got?", I asked.
"24 year-old male, GSW to the chest. CPR in progress". (GSW = Gun Shot Wound)
"Get the thoracotomy tray. Have we called Blood Bank?"
"A box of blood is on the way. EMS three minutes out."
We heard the stretcher coming down the hall. A moment later, the unconscious patient was lifted onto the gurney. Nurses and techs went into action: placing EKG leads, starting additional IVs, stripping off blood-soaked clothing.
"What has he had?", I asked the medic.
"This is liters two and three of lactated ringer's. We've given epinephrine twice. He's in PEA."
I felt for a pulse at the carotid artery and there was none.
The monitor showed an electrical rhythm but there was no pulse, likely because there was insufficient blood in the vascular system to generate an adequate blood pressure.
"Rapid infuser is ready," said the trauma nurse. "How much blood do you want?"
"Hang a unit of cells and keep it coming, alternating with plasma every two units."
Meanwhile, I had opened the surgical tray and grabbed the scalpel. With one long, smooth stroke, I made an incision along the upper edge of the fifth rib from sternum to armpit, slicing through skin and fat down to muscle. I traded the scalpel for scissors, cutting the muscle between the ribs to enter the chest cavity. I could see pink lung tissue inflating and deflating with every squeeze of the AMBU bag.
The chest compressions were obscuring my view of the pericardium, the tough sac that contains the heart. When they stopped, I could see it was distended with blood which was crowding out the heart so it could not fill and pump. I cut a hole in the pericardium with the scissors and blood rushed out- over the lung, out of the chest, off the gurney, and into my shoe. There was clearly a large hole in the heart or one of the large vessels associated with it.
"More blood! Keep it coming!”
I took up the scalpel again and extended the incision across the sternum and onto the right side, an exposure known as a "clam shell". I now had access to the entire chest cavity, which was held open by a Medieval-looking instrument called a "rib-spreader".
The heart was not beating, and it was flaccid and flat- EMPTY. Blood was pouring out of a hole at the junction of the inferior vena cava and the right atrium. I put a finger over the hole. The heart filled and began to beat weakly.
With my left index finger on the hole, I took the suture in my right hand and started sewing. Meanwhile, the nurses continued pumping warmed blood into the veins. As I completed closing the hole, the heart began to beat more strongly. The monitor showed a rapid but normal rhythm. Blood pressure rose. A sigh of relief went around the room.
"Call the OR- we'll have to take him down and get him closed. Do we have an ICU bed ready? Let's get a set of labs. Warm blankets, please. He'll need a Foley catheter and a nasogastric tube."
We'd done it. Life saved.
"Family is in the consultation room," said the Chaplain.
I looked down at myself. I was a mess: arms smeared with blood to my elbows, scrubs soaked with blood from chest to knees.
"I'll have to change before I talk with them."
Someone ran to get me a clean set of scrubs and I set about washing up at the sink.
"Pressure is falling again!", announced the trauma nurse.
I turned from the sink.
“Check for a pulse. Give epinephrine. How much blood has he gotten? Do we have labs yet?"
The respiratory therapist read off the numbers. They indicated sufficient blood volume and oxygenation, acceptable acid/base balance and electrolyte levels.
I looked back at the heart. The sutures were intact and there was no bleeding. The heart was full, but barely beating. I began rhythmically squeezing the heart between my hands to augment its contractions. Soon, they ceased. Medications to stimulate heart activity were administered, I kept pumping, and we spent another twenty minutes working with no recovery of spontaneous heart function.
"We've lost him.", I said.
I continued manually pumping the heart while verbally running down the list of what had been done so far, what the current status was, then polled the room.
"Is there anything more we can do? Can anyone think of anything we've missed?"
No one could.
"I believe we have reached the limits of what we can do, so I propose we discontinue resuscitative efforts. Are there any objections?"
There were none.
"Time of Death: 7:51 pm.”
"No Theatre today."
"What do you mean? We have six cases scheduled." I was standing in front of the scheduling board with Farada Ali, the intern who would be operating with me that day. Samuel, our anaesthetist, had just joined us.
"No Theatre today."
Samuel pointed to the pole that held the power lines to the small building that housed the operating rooms. The pole had fallen over during the night--its complete collapse prevented by the water tower. There were two men busily digging around the base of the power pole, and I was assured they should have the problem solved by the next morning.
The next task for me was to determine how to reschedule the two semi-urgent operations and the four outpatient procedures we had planned for the day. I was most concerned about a nine year old boy who had been admitted during the night with appendicitis. He looked rather ill, and I feared he would be far worse by morning.
As we puzzled over the particulars and possibilities, Husnity, the intern assigned to Casualty for the day, came running up to us.
"Dr. Tracy, you must come to Casualty immediately!"
Casualty is what we in the U.S. would call the Emergency Department. We all followed him at a jog across the courtyard, through the crowd of roughly sixty people who had queued up in hopes of seeing a doctor that day.
Casualty was a ten-by-twelve foot room equipped with a rickety stretcher covered with a torn sheet, a small metal table on which sat a half box of gauze and a stethoscope missing an earpiece, and a wooden chair. The nurse on duty was standing over the stretcher where a nine month old baby girl lay. She was semi-conscious, covered in dirt and scrapes. Her mother stood nearby, wringing her hands. She explained they had been on a motorcycle taxi and there was an accident on the main road just outside the hospital.
The infant's left foot had been amputated completely at the ankle. The resourceful intern had tied a latex glove around the baby's calf as a tourniquet to prevent blood loss, and in doing so probably saved her life. There was nothing more he could do then but come find me, as she would certainly require surgery.
Though barely conscious, the baby's heart rate and breathing were normal, so I was a bit reassured. I examined the wound, complimented the intern on his quick thinking and actions, and turned to Samuel.
"I'm going to need to tie off the vessels, debride the wound, and apply a dressing", I told him.
"No power to the Theatre."
"Yes, I am aware. But I can do this without power. It will take less than ten minutes. Can you give her a sedative and we'll just get it done? She'll need a formal amputation and wound closure, but that can wait until tomorrow."
"OK", he conceded.
Samuel started an IV, and we took her to the operating room. I removed the tourniquet, ligated the major veins and arteries, trimmed away some dirt and damaged tissue, cleansed the wound, and applied a dressing.
The next morning, I was delighted to learn that power was restored, and we could proceed with surgery as planned for the day. My first priority was the nine year old boy with appendicitis. He had indeed worsened overnight, with high fever, chills, vomiting, and severe abdominal pain. I was sure his appendix had ruptured and that he was developing peritonitis and sepsis. He needed surgery right away.
As the nurses prepped him, I went to see the baby girl from the day before and was pleased to find her actin more like a normal baby and nursing from her mother. As the intern interpreted for me in Swahili, I explained to the mother that more surgery would be needed. I would amputate higher up on the leg in order to provide good closure of muscle and skin over the end of the bone. We agreed to do that the next day, as the present day was already full of cases we'd postponed from the day before. Some of the outpatients had walked for hours to the hospital the previous day, only to be turned away due to the power outage. They had been instructed to return today.
We performed the appendectomy, and as expected there was widespread infection in the abdomen. With several days of antibiotics, the boy recovered and was able to return home.
The following day, we returned to surgery for amputation of the infant's leg. It's customary to immobilize the leg after surgery, so I asked for plaster to make a splint. None was available. I was told by the intern that such materials must be purchased by the patient or their family from a pharmacy, and he assured me he would write the prescription for the mother to take to the pharmacy. I instructed him to apply the splint as soon as the plaster arrived.
When we made rounds the next day, there was no splint. The baby's mother explained to me that she had no money for the plaster, the cost of which amounted to less than $2 US.
I later gave the money to the intern, he went to the pharmacy and purchased the plaster, and we applied a splint. The next day, the child went home with her mother.
The pain began suddenly last night, woke her from sleep. It wasn't the first time, but was worse than before. The ER physician diagnosed a gallbladder attack, and that's where I came in. Surgery is often indicated for recurrent gallstone problems.
"L" was surprised to hear the diagnosis. She had assumed it was yet another pelvic infection caused by an STD, just like last time.
As as we talk, I notice the pasty texture and pallor of her skin. Her eyes are bleary and bloodshot. Innumerable scars and scabs cover her body. Her sparse, greasy hair is pulled into a messy ponytail.
"I need a cigarette."
I've seen the medical chart: opiate overdose, methamphetamine use, anxiety disorder, history of sexual abuse, migraines.
I glimpse broken, discolored teeth through cracked lips as she tells me she's feeling better now and wants to go home. I explain the nature of gallbladder disease, my recommendation for surgery, potential complications and likelihood of recurrence.
"I don't want those scars on my belly. And I'm fine. Just let me go."
It's her choice, her decision. I feel hopeless. Her gallbladder was the only thing I could fix. I take her hand and wish her well. Her father is waiting by the door. He thanks me for my help.
I write the order: Discharge to Home. All I can think of is what "home" is for her.
She's twenty-eight years old. She looks fifty. I doubt she'll make it that far.
Esther is sixteen years old. She is dying. For the last year, her father Charles has taken her to clinic after clinic looking for a diagnosis and a cure. She has lymphoma. The only hope for a cure is chemotherapy and a bone marrow transplant. Neither is available nearby or affordable elsewhere. Esther and her family live in a mud hut with no electricity. She is the eldest of six--soon to be seven--children. She lies in the bed she shares with her siblings. It is an agony for her to even turn over. She is bone thin, and developing bed sores on her hips from lying too long on her side. She doesn't eat much, but when offered rice and lentils today, was able to take a few bites. She does not complain, but the moans she cannot always suppress keep the family up at night.
Sandy is a farmer, and a resident missionary. Charles works as a laborer on the farm, and through him Sandy has come to know of Esther's plight. Sandy senses Esther's end is nigh, and comes to me for help. She is hoping to ease the pain and suffering of these final days. I agree to prescribe and administer medicine for pain.
Pablo, a surgical technician on the team, hears Esther's story and asks to accompany Sandy and I on a visit. We walk the half mile or so, Sandy greeting neighbors along the way. On arriving at Esther's home, Charles and family usher us inside. Esther is grateful for the company, and puts on a brave face. I examine her, confirm the diagnosis and prognosis, and explain that we have brought medicine to ease her pain.
She cringes when she sees the needle. I reassure her it will only hurt for a moment, then her pain will subside. She submits. Her father holds her hand as I inject the medicine into her shriveled thigh. I explain that we have brought several doses, and will return to administer them each evening so that she and her family can rest. Pablo says a prayer, and we depart, having done all we can for her.
The next two days are consumed with surgery, but Sandy keeps me updated on Esther's condition, as she has been making regular visits. Another, more effective medicine is added, but it causes itching. I give Sandy my personal stash of Benadryl to combat this side effect. On the evening of the third day, we learn that Esther has died. This is the reality of life here.
The housekeeper returned for the third time since 8 am. It was now 11:20 and I had slept in, exhausted and sunburnt and maybe a bit hungover with wine. Since his previous visit, I had risen at last, showered, and made a cup of tea.
"Are you OK?"
"Yes. I'm good."
"Are you needing anything?"
"No, thank you."
"Did you get the water?"
He'd left two bottles in the porch earlier.
"Yes, thank you."
"Do you need more?"
"I have enough, thanks."
"So everything is okay?"
"Yes. Everything is ok. Sawa sawa."
"Hakuna matata. One thing only: do not leave the door open. The monkeys are so many and they do not fear you. They will come inside looking."
He left, closing the glass door firmly. Moments later, she appeared. I watched her climb the door, rattling it in an attempt to open the latch. Her fingers searched the cracks at the edges. She scrambled up to the top where the window screens foiled her efforts.
Dropping down to the ground, she sat and gazed at me through the glass. I sat on the floor and gazed back. Her right ear was torn, her teats sagged, and the skin of her hands was wrinkled. I had no way of estimating age, but I knew at least that she had seen injury and childbirth. She was indifferent to my presence-- neither afraid nor curious, affectionate nor antagonistic. She was simply looking for food.
I remembered a small bag of almonds in my suitcase. I took out a handful and dropped them through the crack of the door frame. They scattered on the porch. She gathered and ate them one by one, looked around briefly for more, then left.
She is forty-two years old. She knows she will die soon. Even from the end of the hall, I can see how pale and frail she appears. As she draws closer, I notice the smell. It's the odor of death and decay. The chart indicates she was diagnosed with Stage IV breast cancer last year and it has metastasized to her bones. She understands there is no cure at this point. "I just want to be able to not stink so I can go out in public", she says. When I open her gown, the source of the stench is evident. Her right breast has been replaced by a tumor the size of a cantaloupe, and areas of the tumor are necrotic. She is literally rotting away.
We enter the operating room and she climbs onto the table. I hold her hand while the anesthetist puts her under. The surgical nurse cleanses her chest with Betadine. We are all near to gagging from the smell.
I remove the cancerous mass, but doing so has left a large open crater of a wound on her chest. It takes me nearly two hours to devise a way to close it by incising and rotating nearby tissue into place. At last, the bandage is applied, she awakens drowsily and is taken to the recovery room.
The stink is gone. It's all we can do, and it's enough.
The driving distance from Nairobi to Migori, Kenya is 371 kilometers or 222 miles. I'm traveling with a team of 15 other Americans, divided into three vans. We will spend the week in Migori, providing surgical services to the surrounding communities which do not have local access to such specialized care.
The road winds through city, town and countryside for nearly seven hours, providing an overview of this land and a glimpse into the lives of the people here.
A man shovels red dirt into a wheelbarrow, with no one and no structure anywhere in sight.
Small boys clad in colorful shawls of woven wool tend a herd of goats along the roadside.
A gaunt steer saunters past a row of ramshackle shops, pausing for a moment in front of Dimples Butchery, Bar & Restaurant.
Two young girls walk along, talking and laughing. Each carries a large bundle of sticks on her back.
A father walks hand in hand with three small children, past a group of donkeys nosing for food amid the roadside garbage.
Traffic creeps behind a long line of laden trucks, struggling up a steep hill. A family of baboons, including a mother with a tiny baby clinging to her back, gather at the edge of the road, hoping for scraps of food to be tossed from the trucks.
A teenage girl runs, laughing, to hide behind a shed as a boy of four or five looks around for her in an apparent game of hide-and-seek.
Acacia trees, with their distinctive silhouette, line the road and dot the distant landscape.
Birds pick at the bloated corpse of a cow lying in a ditch.
Groups of school children in scarlet uniforms smile and wave, shouting "How are you?" before bursting into giggles.
A family of five speeds past on a motorcycle.
Sheep wander between pieces of furniture for sale in front of a small cement building labeled FIVE STAR HOTEL.
Higher up in the hills, it is market day. Bunches of green bananas and bundles of sugar cane are piled high in makeshift stalls of sticks and cloth. A man selling chickens dangles them by their feet through his fingers, three to hand. Women sell vegetables from coarsely woven baskets piled high with potatoes, peas, tomatoes, and squash. Shoppers haggle over produce, testing mangos, avocados, and melons for ripeness. Small fires covered with metal grates provide a means of roasting ears of corn which are sold as a snack to passersby.
The rainy season is just beginning. We pass through showers here and there which turn the dirt portions of the road to thick red mud pocked with deep pothole puddles.
Shortly after dusk, we arrive at our destination. Migori is home to approximately 30,000 Kenyans from several different tribes. It is located 4500 ft above sea level, in the southwest corner of Kenya, just north of the Tanzania border.
Tomorrow will be spent touring the facilities, getting a crash course in how things are done here, and organizing team and supplies for the work ahead.
The roosters begin to crow around three thirty a.m. There are hundreds on the island, as they are used not only for food but also for entertainment. Cock fighting is popular in the Philippines, and on this island of 11,000 people it competes only with karaoke as the favorite pastime.
Besides the roosters crowing, I hear rain falling on the clay roof. I've slept well, exhausted by two solid days of travel by air, land, and sea. The eight-by-six foot tiled bathroom is dimly lit, the ceiling bulb powered weakly by the hotel's small generator. Central power for the island is shut down from midnight until ten a.m., which means the fan in my room has no power. It's 85 F with 95% humidity, and I'm in need of a shower.
In one corner of the bathroom is a water spigot, and a drain in the floor. On the floor sits a blue plastic bucket. I turn on the spigot to fill the bucket with cold water-- the only option. A scoop floats in the bucket. There is no tub, and the shower head yields a scant trickle, so I employ the standard Filipino bathing method of soaping up then rinsing with the water collected in the bucket.
I wash the clothes I wore yesterday in the bucket and hang them over the balcony outside my room, hoping the rain will stop during the day. Across the street, an elderly man is sweeping the roadside in front of his shop with a bundle of straw fashioned into a broom. It's not yet daybreak, but all around I hear the sounds of the townspeople beginning the day.
The guesthouse where I'm staying is clean and well-maintained by the owner and her adult children. The five guest rooms are small but comfortable with private bathrooms and television. A small shop downstairs sells beer, water, snacks and sundries. The building is of concrete construction, in contrast to the plywood, cinderblock, and corrugated tin structures in which most of the islanders live.
Back inside, I pour the wash water into the toilet to flush it. I have yet to see a toilet on the island that is plumbed to flush any other way. Most do not have a tank attached. Toilet paper is not commonly used, and can never be put into the toilet. Instead, one washes with the scoop in the nearby bucket then pours the remaining water in to flush. It's bad manners not to fill the bucket again before leaving the bathroom.
Today is the first day of surgery. I'm assured there will be sterile instruments to use today, though the autoclave is currently not functioning properly so cleaning them for use tomorrow will be a challenge.
We have scheduled surgical procedures for over 200 people for the next ten days. People come from the larger neighboring island of Northern Samar, traveling several hours to have surgery they otherwise would never be able to access or afford. The local clinics and hospitals provide general medical care, but not surgery, and a trip to Manila where a full range of services are available for a fee requires a day or more of travel by boat, car, and plane. Those scheduled for today will arrive at the hospital by seven a.m. and wait their turn for surgery. The order of procedures is determined by which patients show up, the availability of sterile instruments, and manpower considerations. Some people will wait for hours.
Before going to the hospital, the team meets for breakfast at an outdoor dining pavilion next to the police station. Food has been prepared for us by volunteers from the community. Today we have a soup of cabbage and macaroni noodles in coconut milk and chicken broth, SPAM rice, and scrambled eggs.
The hospital is a ten minute walk from breakfast, and we are greeted there by patients, families, and staff including Dr. Alex, the resident canine. So it begins...
I am awakened at 4:35 am with an urgent call from the Emergency Department. An eleven month old baby has arrived in respiratory distress, and a chest Xray reveals a pneumothorax. Without prompt intervention, he may die.
I'm there in ten minutes, arriving to find a team gathered around the child, who is pale, listless, and fighting to draw air into his lungs by using every muscle in his chest/neck/abdomen. In children, this is called “retracting” and is a very bad sign. I glance at the chest Xray and see that the left lung is nearly collapsed.
“Let’s get a chest tube set up.”
“I need an 18 gauge angiocath.”
I insert the needle between the second and third ribs on the left side, just below the clavicle. As the needle enters the chest cavity, there is a rush of air through the catheter. The child’s breathing immediately eases, and oxygen saturation improves. This is a temporary measure, sufficing to relieve the pressure on the lung until the chest tube can be inserted.
“He’ll need to be transferred to the children’s hospital. We should intubate him first then insert the chest tube.”
The Emergency Physician agrees. We administer medications, perform further Xrays, draw blood, insert a breathing tube, connect it to a ventilator, and insert a chest tube. Within an hour, the Pediatric ICU transport team arrives to take him to the Children’s Hospital in Portland.
FONDE BAPTISTE, HAITI
An eighteen month old baby girl comes to or clinic with her parents. She’s had a cold and cough for several days, hasn’t been eating or sleeping well, and they believe she has worms.
We’re holding the clinic in an unfinished concrete building in this village in the mountains above Port-au-Prince. Two days before, we came up the mountain in a pickup truck, and had to get out and walk several hundred yards five different times while the driver eased the truck over rocks and ruts. The distance is about nine kilometers, but the trip took us over four hours. Locals make the journey on foot or on motorcycles, which can navigate the rocky, rutted terrain more easily than larger conveyances.
There is no medical care available on the mountain, but the community is hoping to change that by building a clinic to provide basic treatment of common problems. We have come to administer what care we can, assess the medical needs of the community, and assist with strategy/planning for the future clinic. We don’t have much in the way of equipment/supplies/medications, but are able to provide diagnosis, relief, advice, and reassurance to many of those who come to see us.
It is a disheartening endeavor. For this team of six Americans, the daily reality of the villagers is appalling. The community is poor, and living conditions are primitive. Lice, scabies, intestinal parasites and malnutrition are endemic. We see children who are shockingly underdeveloped for their age, and who suffer from a host of chronic illnesses related to malnutrition.
The baby girl with a cough is typical: she appears at least six months younger than her stated age. We administer de-worming medication, provide a sample of over-the-counter decongestant, and instruct the parents on the importance of hygiene, clean water, and how to use steam as an aid for cough/cold symptoms.
An hour or so later, they return with the child, who is having a coughing fit. The mother reports the baby started crying and then began to cough. This has happened before, as recently as last night, and usually subsides in a few minutes. I listen to the child’s lungs and determine she is having an asthma attack. I have brought along an inhaler, but they can be difficult to use, even for adults. For children, it is nearly impossible to use an inhaler correctly. We need to add a spacer-- a closed chamber which affixes to the inhaler and has a mouthpiece or mask on the other end, through which the child can breathe the misted medication mixed with air in the chamber.
We do not have a spacer.
Looking around, I see an empty plastic water bottle. By cutting the bottle in half, I create a mask. I connect the mouthpiece of the inhaler to the mouth of the bottle with the finger of a latex glove, then place the mask over the child’s mouth and nose. The mist from the inhaler fills the mask chamber, and as she inhales it, her wheezing subsides. She drifts off to sleep in her mother’s arms for the next hour. When she awakens, she begins to cry and her respiratory distress returns. This time, the inhaler treatment is not helpful. Her breathing becomes more and more labored. We have no further diagnostic or treatment resources, and I advise the parents she needs to go to the hospital in Port-au-Prince as soon as possible. A motorcycle taxi is arranged, but they have no money to pay the driver, nor to pay the hospital once they get there. The team takes up a collection for the trek down the mountain, which will take about an hour and a half. The temperature is dropping as the sun goes down, and the father wants to go home to get a blanket for the baby. Delay is not prudent, so I wrap her in my sweater and the family heads down the mountain on the motorcycle.
The next day is Sunday. We are invited to church, the hub of the community, and there we are informed that the child reached the hospital but died during the night. While the community is saddened, no one is surprised. Children die often there. Two other children had died that week. The parents of the child we treated had lost another child last year.
Two weeks later, I walk through a cemetery in Edinburgh, Scotland. The graves date back to the late 18th century, and many belong to children. There are several family monuments to multiple children. I'm struck by the fact that the death of a child was such a common occurrence back then. It seems so strange in this era of modern Western medicine.
As I stand over the baby boy in Oregon, I see the baby girl in Haiti before me. One child lives, another dies. It’s nothing new, only new to me.