Tap taps and Hypertension

More often than we would like we see patients who need to be sent to the hospital for immediate care. This usually means we pay for a tap tap to take them there (not a problem at all and with more fundraising I am hoping we can have some money put away to send those who truly need care to the hospital) and then have them come back with any lab results so we can treat appropriately. Since we have a little to no hypertension meds on hand (we are always accepting donations!) we usually advise them to purchase this at the pharmacy. Sadly, there is a large proportion of the population who cannot afford the medications and with the rates of hypertension we are seeing here it is apparent there needs to be more free care. It is not uncommon for us to see a BP of 200/90 (120/80 is about normal) and some can even go as high as 250/120. If this occurred in the US the patient would be admitted to the ER immediately as the risk of stroke and or heart attack are immanent if the pressure remains elevated. We do what we can regarding pushing for patients to seek care at the hospital, the use of medications (it’s funny that everyone thinks Naturopathic physicians are completely opposed to the use of pharmaceutical drugs, personally I am opposed to the use of inappropriate and incorrect use of pharmaceuticals but I have the utmost respect for the advances we have made in treatment options for patients who really need the care. But I digress…) and discuss dietary modifications that can have long lasting effects on their health. We also have some amazing supplements that we use daily with great results, things like magnesium and high dose arginine are essential to the treatment of hypertension in patients who warrant that particular kind of care.

With all the treatment options there are often patients who come to see us who are in need of a higher level of care than we can provide. Today I had a woman with new onset headache and a BP of 220/106. Given the symptoms she needed to go in and have her hypertension taken care of stat. Again, if we had the medications to use we could alleviate all the other unnecessary steps (finding money for a tap tap, making sure she would go seek the care, having her come back with her medications so we can follow up etc) and just prescribe her an appropriate med without worrying if she is going to stroke out on the way to the hospital. I wish I could say this was uncommon but I have referred many people to the hospital for care since I have been here and I am sure it is not something that will cease anytime soon. Hopefully with our nutrition classes more and more people will begin to adopt some of the fundamental ideas surrounding health which will lead to great overall health but also lowering BP tremendously! 

Follow up care

By popular demand I have decided to write an update about the woman I spoke of in my last blog (sorry for the delay, the power has been less than friendly the past week.) She came to see us at a village clinic last week and I followed up regarding our treatment protocol, we had given her some supplements to help repair the lining of her stomach as well as some probiotics, a mineral blend and some multivitamins as she was eating only once per day.  She was not in any acute distress this time and stated that she was having less severe reactions to food than before but was still having a cramping in her lower abdomen which was better with hard pressure. The latter symptom is a keynote of a particular homeopathic remedy so I gave her one month’s worth of the medicine and made sure she had our phone number to call us if she did not feel better in a few days. In the US we would have referred this patient out to the hospital for some imaging and lab work immediately however here in Haiti most people cannot afford to go have these procedures done. Basic blood testing might be an option if she had money to take a tap tap (think pickup with a canopy and seats bolted to the inside) and then money for the consultation plus whatever medications they might prescribe for her. Though the fees would be considered nominal in our world, for most Haitians this is not something that would happen easily. Most reserve their visits to the hospital for severe illness and traumatic events, otherwise there is simply no justification for spending weeks’ worth of money just because they feel “ill”… a feeling that for most is not a foreign concept.

 As for the patient, I awaited her call and compiled a list of alternative treatment options in my head but I never heard from her. I know for a fact she would have called if she had not been feeling well as she sought us out at a clinic in the middle of another village just to tell us she was doing a little better, compounded by the fact that close to 90% of our patients have cell phones so getting a hold of us is not a difficult task. I have found that patients do quite a bit of follow up here and are not afraid to come back and let us know that our treatment was unsuccessful. It is a great way for us to learn what is and what is not working here and it is also comforting, I imagine, knowing that if you are still ill after treatment all you need to do it go back to the doctor and they can provide you with more care, free of charge. I often tell patients I am immensely worried about that they are welcome to call or come by at any time of day or night if they need anything, and a few even take us up on that offer which really makes me feel like our clinic is becoming a safe place for people to come when they need care and that the community is aware of this.

Knowledge does not only come from reading books.

Yesterday we saw a 60 something woman who was having abdominal pain and headaches. She was eating one time per day, cooking for 16 extended family members and seemingly ashamed of taking time to come to seek care when there was so much work to do at home. We offered her a glass of water which she promptly drank and subsequently doubled over in pain. To her, this was another episode of abdominal pain but for us, this was not an average every day event. We kept her for observation while we ran through differential diagnoses…peptic ulcer, gastritis, biliary colic, cancer, pancreatitis, bowel obstruction.  In my mind, the point was that this woman experienced this pain every time she drank water without food as she did so often because food is so scarce. She lived through the pain so she could continue to care for her children and grandchildren; taking care of hesrself was the farthest thing from her mind. 

The dedication to caring for one’s family I see daily here amazes me. Not only to your own family but to the family members who cannot care for themselves and even for other children who have lost their families to illness. The matriarch of the family puts her needs aside to make sure her family is taken care of, most likely until the day she passes away. It really makes me think about how we treat the elder generations in the United States. The inadequate treatment of those living in care facilities has always caused me much distress. These are the people who should be respected for being the wisest; those who have been through wars, catastrophes, historical events, multiple presidents and have witnessed the changes that have shaped our current societies views and beliefs.

I think one thing I have always loved about traveling is learning from the elders or hearing stories passed down from generation to generation. Recipes, medical treatments, home remedies, understanding of the culture and common misconceptions are all examples of things we can learn from the elders in our communities. It makes me wish my grandparents were still alive so I could ask them all the questions I was too young to know I needed to understand back then. There is so much for us to learn in our lifetime, I don’t want to miss out it. Knowledge is power, this I know for sure.

Hope and Perseverance

Clinic day 3 with the students ended with many of the same feelings as the last two…hope being the overriding of the two but perseverance was also present.

Today was a children’s clinic and we saw about 40 patients, these students are some of the hardest working I have ever met. I know this experience will shape their future practice in ways they do not understand yet and has also touched so many lives. The patients love all the extra attention, stickers and new faces that the students bring to the table as well as the best care possible when you have so many people working together. There is not nearly as much chaos as I would have guessed would be present with all these people in one building and the relative lack of clinical experience most have. If you were to look in on an intake you would see professional compassionate men and women dedicated to patient care. I could not have asked for a better group of students to come, I am hopeful for the future of our medicine and those who benefit from it.

Emotionally it was a difficult day today as there were many challenging cases diagnostically, children with painful infections and the worst case of failure to thrive I have seen.  A young mother brought her one month old child in to see us as he was “not happy”. The students did their best to elicit what this meant and mom noted that the child had seemed to be less apt to cry, wiggle around and fuss. As most babies are when they come to us, this little guy was all bundled up in blankets with only the top of his sweet little head visible. As the lead clinical student began to undress the baby to listen to his lungs I noticed his clavicles were very prominent (lack of anything but skin and bones is a better actually an adequate description). As we undressed him we were horrified to find an emaciated, dehydrated 2.5kg baby. The baby was listless and we could not elicit a good response from him, get him to nurse or take sugar water. The midwife came down and confirmed my decision to send him to the hospital. We made sure to let mom know she had done the right thing by bringing the baby to the clinic when she noticed he was acting odd though in the back of my mind I still wondered how a parent could look at a child this sick and not know something was wrong. Education. It all comes down to lack of education. This was a young mother who did not know any better. She had seen a doctor two weeks ago at a hospital and the baby had weighed in at 3kg, presumably healthy as the doctor did not make any other recommendations.

 Perhaps a little more time spent with a young mother to discuss how often to feed would have been enough as this mom was feeding only 2-3 times per day. It is probable that if she had learned the signs of malnutrition and dehydration before she gave birth she would have been more apt to come in promptly. Of course, this is all speculation. This was the best case scenario as we were there to make the referral and to insure proper care of this child. What would have happened if our clinic was not here? The answer scares me as I know what happens when there is not adequate care…you end up with statistics like you see here in Haiti, the worst in the Western hemisphere.

But we ARE here and things WILL get better, one day at a time.  We will persevere and so will all the patients like our little guy today, if given the chance to have access to adequate medical care.

Little pieces of string...

Sometimes I feel like all of the stories that come out of Haiti and care for those in Haiti tend to sad and depressing. Some would say ‘obviously’ as there is so much despair, sadness and disease how could there be a plethora of happy stories. Well, as someone in the field I understand the depths of sadness and diseases here in Haiti though I also have come to love and respect the ability of the Haitian people to laugh, smile and joke around. Children with enormous smiles and the adults with their boisterous laughter, ready to lend a helping hand whenever possible. Today the pastor at the orphanage where we completed a village clinic brought all 16 of us coconuts from his tree (that he and the older children harvested and cleaned for us) as a thank you for seeing his patients. After 6 hours working outside seeing patients, fresh coconut water has never tasted so sweet.  I laugh here so often that sometimes I need to remind myself that I am in a country in which 54% of the people live without sustainable water sources and less than 50% of children are able to go to school. The future is promising as there are many effective NGO groups here in Haiti that are beginning to band together with the same goal in mind; creation of organizations and other sustainable projects to help Haiti help themselves.

We know that the best outcomes occur when organizations have clear outlined goals and are of the understanding that coming into Haiti for a short period of time to “help” really causes more harm than good. What are needed are groups who are here for the long haul. Groups committed to empowering the local Haitian community to be able to stand on their own two feet. Groups who can aid current organizations or appropriate infrastructure as well those willing to find out what local communities want and need and helping them to get it. I am happy to be part of an organization that strives to reach these goals while keeping the most important goal in mind, we are here to help not to take over and run the lives of a community in need.

I will be honest, this blog has taken quite a turn as I began speaking of the joys of living in Haiti but hopefully the above rant will give a little insight into what it feels like as a foreigner living in a country with so much need, so many aid workers (Haiti has close to 10,000 NGO groups working here) and so much headway still left to make.

 As my anatomy professor would say after an intense lecture, “you have a million pieces of string in your brain; you just need to figure out how to tie them together”. 

When a cough is more than a cough...

Another day, another patient who touches your heart…one reason I love my job so very much.  Today, not once but twice I felt like everything I have sacrificed and all the support from my family and friends really went directly towards saving a life.

My first patient was a 2 month old baby with a cough accompanied by grandma and mom. As I began to inquire more about the health of the baby and the symptoms of the cough I learned that breastfeeding was an issue as mom had some of her own health concerns and that the baby was being fed teas and flour with sugar mixed in as it was all the family could afford. As I proceeded to check the baby it was clear that this child was severely malnourished and was hungry beyond belief. We mixed a bottle of formula immediately and began to feed her. She weighed in at less than 6lbs. She is lucky to have a family who cared enough to bring her to see a doctor even if it was for a different concern. Although too weak to breast feed she is quite the fighter with a solid cry and no other signs of impairment.

 She will survive.

For each one of these success stories there are plenty of unsuccessful outcomes and patients who never even make it to our clinic in the first place. There is an immense lack of education surrounding newborn care and childhood nutrition as well as limited access to care. More than ever we need to reach out to these communities and help them to be able to stand of their own feet and regain their health. I am hopeful that when the students come and we are able to open the clinic up every day we will get the word out to more and more people in the community. The more people that know about us the more we decrease the incidence of untreated illness and even death as we are at least a free, available option for people to utilize. Even if we can’t treat them, we can refer them out.

What Haiti needs more of are available options that lead to sustainable health. They need educational materials and classes and they need appropriate affordable health care. On top of all of this they need people who are willing to do all of these things without any ulterior motives; providing care because it is the right thing to do.

I love my job and I love Haiti, I am honored to be here helping these fantastic people. I hope to be teaching them at least as much as they are teaching me along the way. Every day I grow stronger in my ability to diagnose and treat disease as well as in my ability to take in what I am seeing and use it constructively. I could spend every night crying about the horrible situations I have seen or I can find a way to make the situation a little better. I guess you could say I am a fixer…and I am ok with that.

Proper health care for everyone is a must!

This morning was ‘adult day’ at the clinic. As our main priority are children and pregnant woman throughout the week we only have the ability to see non-pregnant adults on Saturdays (another reason to have more docs and more translators! This will hopefully become a reality in the future). Today was relatively slow as Dr.’s Sean and Sarah had to make a trip into Cap Haitien to speak with a local Haitian OB-GYN who runs a clinic near here; we only saw 13 patients. The last was a couple who had brought their children in earlier this week for care. The father had cut his hand I was told and was unable to work so we were going to give him some of the rice a local Pastor donated to us…when he sat down I noticed he had the most amazingly calm, soothing eyes I had ever seen, as well as what appeared to be a stiff left hand. He and his lovely wife sat down and we began the consult, they had come for her and so I listened as she told me of her symptoms. The entire time I could not push the desire to know what happened to her husband’s hand out of my mind as it seemed to just ‘sit there’ on his lap. I finished my exam with her and we got her on the road to optimal health, then I turned my attention to her husband’s hand. I wanted to make sure there were no signs of infection as it appeared to have two visible 3-4 inch healing lesions on the dorsum of the hand. They looked well taken care of and as I turned the hand over gently I asked what had happened.

 Rule number one in medical school, the poker face is hands down one of the most important tools.

 I am glad mine has been perfected by many hours of clinical practice because the palm of this man’s hand appeared as if a dog had taken a bite out of it. The thumb was contracted medially and there was a hole large enough to put the tip of a pencil in, directly in the middle of the palm. The skin was pink and tender with some of the previously exposed deep structures now healing. Apparently the machine he works with caught his hand and pulled it through a series of gears. I asked where he had it surgically fixed and he told the translator he had not had it fixed.

Wait, what!?! You had your hand severely mutilated on the job and never saw anyone for it; this is what my inside voice was screaming while outside I asked politely if he had any cream for it and then proceeded to get him some ointment when the answer was no.

I try not to be shocked and horrified by things like this as I should be thankful that this kind man is doing so well, he may not have full use of his hand back but at least he still has his hand. This is a stark contrast to a woman we saw last week whom I had to tell that her fingertip was gangrenous and needed to be removed asap if she wanted to save the finger; all this from washing some clothes with bleach, stream water and a probable open sore.

 I cannot begin to count my blessings and be thankful for my health and for the health of my loved ones. I know there are some things that are inevitable however I refuse to believe that going without care because you cannot afford it is one of those inevitabilities, regardless of where you live. I am also thankful for MBH and the other doctors I work with who are here working to facilitate health and healing here in Haiti. Without their visions and hard work there would be no clinic. Without a clinic people would not receive care. I like to think I am doing my part in taking the initiative to help others, as I would hope others would do for me.