Man, sometimes a week brings a flood of minor upper respiratory tract infections, fungus, and the usual small town clinic maladies…and some weeks, the dam opens and all kinds of situations arrive on the doorstep. We did a lot of small surgeries, mostly taking off cysts and dealing with minor wounds, and did loads of ultrasounds (lots of ovarian cysts, some gallstones and bladder stones); but we also had a few more unusual cases come in.
First, there was Missty (yes, that is how it is spelled). She lives on a sailboat with her mom and dad, and climbs all over the place like a wild child. She is the cutest little girl ever—she came in a week after getting her knee stitched up at the hospital; she sliced it about 4 inches across the front on a piece of sharp metal and then tore ALL her stitches jumping down onto her boat/home and landing in a deep knee bend. Then it started to get infected, so it was a green mess when I took off the bandage.
Tough as nails, she let me take out the stitches and debride the wound, then I steri stripped it together and rebandaged it and sent her home with some antibiotics and dressing changes… “No more running around like crazy on the boat for one more week!”
Then a guy came in unable to swallow or drink, and unable to lower his chin because his tonsils were so badly inflamed they were like tennis balls, with another tennis ball sized abscess in his
cheek. He was really dehydrated, so we gave him IV fluids and pumped him full of antibiotics. The next day he was marginally better, so we kept him on the antibiotics and after a few days he could swallow and take liquids. Only his cheek abscess remains, and it is shrinking rapidly.
We had a baby come in with a mysterious rash (see the photos below for the case details)…we did two surgical house calls for minor procedures at a shop run by two ladies in French Harbor. One of the ladies, from whom I removed a ganglion cyst, was in a hurry to get home so she could make dinner for her husband. I told her he should do it for her while her wrist has just had surgery, and she and her friend agreed…and both laughed at what a delightful fantasy it was, and how impossible. Still tough to have two X chromosomes around these parts.
Still, our clinic is seeing lots of patients. It was great to have Megan with us. She set up two of the clinic rooms for acupuncture and treated patients two at a time every day our clinic was open, and was always running all over the island after hours giving treatments in the community. Being able to combine acupuncture with western medicine was great—in the community we serve, there is a lot of stress and post-traumatic stress from abuse or violence, and mental health issues are somewhat of a taboo. These issues are often compounded with some form of chronic pain, usually in the knees or back or feet after years of hard living.
When patients I had treated medically and then referred to Megan came back for follow up, they raved about how much they felt the treatments helped, and I have seen acupuncture be effective way too many times for me to doubt that is has efficacy in a number of situations. I’m not sure I understand why it actually works, but although I would really like to know for my own interest, ultimately I don’t care—I really only care that it works! My dad always says that despite their frequent disagreements, there is one way doctors and lawyers are always in agreement: ‘Ultimately, both are only interested in results!’ Especially doing this kind of remote medicine, a doctor has to be ready to use any tool in the toolbox that can help, and I felt that of lot of patients got a good result from their treatments. A lot of them burst out crying after or during their treatments and shared all kinds of horrific personal tragedies with Megan…it turned out that often they were crying about it for the first time, even horrible experiences years ago.
I also think the patients were really, really receptive to the concept, too. Certainly, against the blend of bush medicine, Obia, and traditional home remedies in common use,
acupuncture probably didn’t seem too out of place, and there was also an element of the ‘well, the doctor has suggested this, it must be a good idea’ kind of thinking I often saw among older patients in Ireland and most patients in the developing world. Although in this case that attitude it made it easier to get patients to accept acupuncture treatment, that same outlook can sometimes put patients at risk of medical error. One way to bring people into more active participation in their health knowledge (i.e., questioning the doctor), is by empowering them with knowledge about their own health, and we spend a lot of time in consults drawing diagrams and explaining people’s physiology to them.
Sometimes, however, one of us becomes a patient…last night, walking barefoot on the deck, the side of my foot kicked the slivered edge of a cut pine board, and a giant splinter wedged itself into the bottom of my foot. It was wedged in deep and barbed like an arrow, but after I anesthetized it Noah and Sky got a scalpal and some forceps and pulled it out. Man, it sure is sore today…going to go soak it in salt water before showering tonight.
That’s when you know you have an awesome sister…an awesome sister is one who will hold the light for you when you have to inject yourself on the bottom of your foot, which is pretty much exactly like you imagine. So much is happening all at once—we just found out there is a possibility we will be going back to Haiti to help with the cholera outbreak, we are investigating ways to keep the Oakridge clinic operating on a permanent basis, we are coordinating containers of medical supplies and gear from California and Florida to Honduras, and in our spare time continuing to improve and strengthen Southern Wind.
With this much on our plates, I sleep a lot better knowing Sky and our crew are facing this with me.
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All patient photos used with patients’ express consent.
As we were closing up shop after a busy clinic day in Oakridge, we got a call from the Roatan Zoo—one of the new keepers had been badly mauled by one of the monkeys while cleaning the enclosure. Oh man…after a late night working on the computer and a CRAZY day in clinic I was looking forward to lying down for a while, but when the call comes for help, you have to help–so we grabbed our minor surgery bag and some antibiotics and headed over.
Apparently, the victim had been employed there about two months, and was working (as usual) with the main keeper, who had been with the zoo
for 5 years. They had been in the cages together many times before, and had no problems, but this time the head keeper stepped out to grab some additional cleaning supplies and one of the monkeys decided to challenge the new guy.
While with the head keeper, he had been safe—the head keeper’s place in the monkey society was well established (as boss), so the new keeper got a free pass. But when he was left on his own, one of the males just went for him. He was knocked to the ground and savaged, bitten and clawed all over his legs and his arms and hands; the monkey actually went for his face—all the wounds on his arms and hands are classic defensive wounds. Fortunately the head keeper heard the commotion, ran back and pulled the monkey off (the monkey immediately submitted to the head keeper).
The male in question had been horribly abused in its previous home; it had come to the zoo nearly dead…now it is in fine form; I guess it feels strong enough to challenge newcomers in its little kingdom. Everyone always looks at monkeys and goes ‘Awwww….how cute.” And it is true, with their little human faces and adorable antics, they are pretty fun—but they are also wild animals with motivations all their own, and with lots of strength, agility, speed and teeth and claws!
When we got there, the poor guy was a little shocky, covered in blood, dried monkey saliva, and dirt and debris from the bottom of the monkey enclosure. He was so filthy and crusted that we couldn’t even see where the wounds were. Pretty bad scenario from an infection point of view; monkeys have fangs that can bite pretty deep and inoculate your tissues with their raw sewage-like saliva (pretty similar to human saliva, probably).
I immediately gave him an injection of ceftriaxone and an injection for pain. We used a garden hose (the water at this resort/zoo is filtered and potable) to soak off the filth and dried blood as it would have taken more gauze than we had with us, and been more painful. The hose helped gently soak open the dirty scabs over the wounds, and let them bleed out a little to help clean them. Finally we could see the wounds—lots of them, probably around 40 bites and claw marks. If he hadn’t been wearing jeans, I think he would have lost half the skin on his legs, and if he hadn’t had his arms up in front of his face things would have been a whole lot worse.
After disinfecting and irrigating all the wounds, we salved them with antibiotic ointment, dressed them, and gave him oral antibiotics and painkillers, and fresh bandages for his family to change for him if he got wet. We also started him on acyclovir, an antiviral given as prophylaxis for monkey bites. The next day, all his wounds were clean and dry except for his right hand and left forearm, which were very swollen (and pus was expressed from the hand). We added a second, stronger antibiotic and got him to start bathing his wounds in hot soapy water a few times a day.
It worked—his swelling went down and his wounds are healing nicely. Never a dull moment practicing medicine in the tropics, but most of all I liked that we were able to bring care to his home. The house call is still my favorite consult.
When I was a kid I watched my dad do house calls in Los Angeles…practicing Alaskan small-town doctor medicine in a big city. In my folks’ house, as long as I can remember, there is an old print of a painting of a doctor, circa 1830ish, on horseback with a lantern and black medical bag in the dead of night, riding slowly through a driving rainstorm. There’s no adrenaline rush about the figure; the doctor is not flying down the road, coat trailing behind and sparks flashing from the horse’s shoes on the cobbles.
Instead, the doctor looks cold and wet—can barely see his face behind his upturned collar, peering head through the dimly lit night. He has the air of one doing a job that he is doing because he has no choice, because it is who he is. It would never occur to him that someone else should be the one to go out in the night and go help a sick patient. He goes, and gets cold and wet and more tired (he must be a critical care doctor), because to him, that is what a doctor does. It isn’t even a sacrifice, just a part of his core being. I always felt like that picture captured some of the essence of what being a doctor means to me.
All photos of patients are depicted with consent of the patients.
Wow, what a ride…a few days ago, Hurricane Richard passed almost directly over our position here on Roatan. For several days, we watched it approach, slowing down and gathering strength as it hesitated out in the Atlantic, almost as if it were undecided about whether to move northwest, as most hurricanes do, or to move directly west and sweep over the Isla de Bahia in Roatan. Naturally, we began to take elaborate pre-hurricane precautions, hoping that they would not be necessary.
We cleared all of our gear off the decks and lashed all the big stuff down tight, covered our bridge windows to protect them from flying debris, charged our batteries and filled our water, stocked up on food, added about a dozen dock lines and more fenders, and prepared to ride it out. These are the moments that are a true exercise in letting go; when you have taken all the precautions you can, and done everything you could–then whatever happens is beyond your control. The sea can be a very scary and intimidating place when you try to maintain the illusion of control on the water.
From the bridge, we waited, and tracked the storm on satellite imagery. As it came nearer to our position on the screen, the air felt heavier and heavier as the pressure dropped, and all of us–including Tweek and Giles, our ship’s dog and cat–started feeling restless and agitated…I guess it is true what they say, the waiting MAY not be the worst part, but it is surely no picnic!
First, the weather turned dead calm and still, the only change being the plummeting barometer…then came the rain, and then more rain, and then a LOT more rain…and then the wind. At first the wind wasn’t too bad, blowing at around 30-45 mph for the evening, but as 3:00 AM rolled around the wind began to pick up sharply, whipping the trees around us and surging the already full-moon high tide up over the concrete dock. Thank goodness we had had a chance to adjust and tune all our dock lines while the wind was still blowing only 30, since by the time the wind hit 79 mph it was difficult to move around safely outside.
The boat rocked and heaved amid the spiderweb of dock lines holding her out in the middle of the basin–one line snapped, but Captain Ed and Noah managed to get a replacement line around another cleat in time to keep us from being
pushed forward onto the seawall 8 feet dead ahead. As dawn brightened, the wind began to die down to gale force, and eventually petered out amidst a series of heavy showers into a preternatural stillness, and the first tiny patches of blue sky we had seen for days finally peeking out in the eastern sky.
Then all hands checked the lines one more time and turned in for some well-earned sleep–back at it in the clinics tomorrow! What did Graham Greene say about the sea.. “The ocean is an animal, passive and ominous in a cage, waiting to show what it can do.” The power of the Hurricane, this ‘little’ category one hurricane, gave us a brief glimpse at the forces that lie in wait under the deceptively calm waters and blue skies of the tropics.
The price of having even a chance of survival on the sea is eternal vigilance…when situations turn bad, they tend to do so quickly. Better to prepare thoroughly every single time than be caught out the ONE TIME you fail to take every possible precaution.
Live to sail another day!
Cayos Cochinos, Honduras
Today we voyaged to the Cayos Cochinos island group to do a mobile medical clinic among the Garifuna people living on theses scattered, isolated cays. About 150 people, mostly children, live on the Cayos with little or no access to health care except on the mainland–and for most of the inhabitants, making a bare subsistence living fishing and on the few adventure tourists who visit the Cayos, the 14-mile journey to the mainland might as well be a thousand miles away.
We were joined by volunteers from Clinica Esperanza and the Roatan Rotary Club. A dawn departure with beautiful weather for a crossing saw us
reaching the Cayos Cochinos around mid morning. Because the normally east trade winds were reversed, blowing from the Northwest, there was no place we could anchor in shelter, and Southern Wind had to stand off the island while our team went ashore for the clinic.
The local officials were kind enough to use their panga to run us to shore, and we set up on the beach and began to see patients. We saw adults and children, men and women, all suffering the diseases of poverty that we see everywhere there are people living at the subsistence level such as worms, skin diseases and fungus, poorly healed wounds, poor nutrition, anemia, malaria…and we also saw a lot of ear infections since the islanders spend a lot of time diving for food.
It is heartbreaking to see people living their lives with so little support from anywhere, and yet they laugh and smile, and the children play, and when they get sick, they either get better or they don’t, so it was a wonderful experience to bring care directly to their homes. We distributed over 6,000 vitamins, and treated almost all the residents of one of the cays for parasites, and managed to get some health education to the moms on the island. They have little or no access to health knowledge, and we always look for any opportunity to provide health knowledge that can help our patients get better and stay healthier.
Bad weather and a broken mooring line in the middle of the night forced our early return to Roatan, but we will be going back to the Cayos soon to do follow-up on the patients we saw, and to visit the families living on the other cays as well. Our goal is to provide care for every man, woman and child living on the Cayos!
Here in Honduras, as it was in Haiti, on any given day my crew are usually spread out at several locations, and when I find out later the details of what they have been doing, I am always astonished. Today we recognize the awesomeness of the work done by nurse and instructor Sirin Petch. By the time we had been here about a week, we learned that the single fire station on Roatan had not been given much formal training, and Sirin agreed to work with Maddie to provide training in emergency response. Nearly every day for almost two months, Sirin worked with the firecrews to provide training in airway management, scene assessment, lifting and immobilization, choking, and other techniques necessary for EMS response. Some of them had joined the department when they were 14, but few had been able to get formal training. The firemen are paid very little (they have to buy oxygen for the ambulance out of their own money), and they work hard.
Sirin first asked the Firemen what they would be most interested in learning, and looked at the resources that were available and would be the most useful instruction for work here in Roatan, and then provided training. Maddie was instrumental in helping communication, plus she is a naturally gifted teacher, and later they were joined by Zach, one of the pilots on the emergency helicopter, and Yolanda, a paramedic from Montana volunteering for a couple of months on the helicopter.
Sirin and her team trained the fire crews, went on night calls with them, and even after Yolanda and Maddie had gone home, Sirin continued with the firemen. Near the end of Sirin’s time with us (for now?), an incident occurred that says a lot about the relationship Sirin created with the Bomberos. I got a phone call to transport a patient on the helicopter to the mainland, so I made my way to the landing field, prepped the gear in the helicopter and waited for the Fire Department ambulance to bring a patient with suspected barbituate overdose. The ambulance arrived, the doors were kicked open, and out jumps Sirin and the firemen, who hand off the patient to me on the helicopter.
On the way back to the station, Sirin and the firemen got a call for a woman in full arrest. Sirens blazing, they arrived at a house surrounded by wailing family members. A larger woman in her 40s had a full arrest, in a house at the top of a 30-foot embankment. Using the techniques Sirin had taught, they put her on an immobilization board, inserted an airway, maneuvered her down the hill to the ambulance and raced to the hospital. They worked hard to resuscitate the woman, both in the ambulance and the hospital, but eventually had to call time of death. Sirin helped arrange the body and deal with the distraught family thronging the hospital corridor, then she and the Bomberos headed back to the Fire Station, only to be diverted to a brush fire. They gave Sirin a brush jacket and sped off to a banana plantation, arriving as it burned itself out. Scrambling up the smoking, scorched earth, they made sure the fire was completely extinguished, then returned to base.
Beyond the skills and training that she made available to the firemen, I believe that Sirin gave them something much more valuable. They looked at what Sirin knew, and her professionalism, and saw its value. She earned their respect (not always easy for female professionals in Latin America) and their friendship, and helped inspire them and motivate them to want more training and to seek it out. They have asked Sirin to send EMS instruction books and have increased their physical training (Noah has worked with them in the gym and done lifting and transferring instruction with them, and a few days ago I boxed with another).
I am very, very proud of the work at the Fire station, and very proud to have seen Sirin rise to such a challenge. Long after we are gone, I hope the knowledge and professional pride she left behind will continue to grow and help people.
July 8, 2010. Port Antonio, Jamaica.
I have time to think about some of the patients we saw in Haiti. I told my mom about a burn victim—a guy who had, 32 days before he saw me, fallen and been knocked unconscious for 7 hours, left lying on the metal deck of the boat he was working on alone in a Santo Domingo boatyard.
The HOT metal deck…cooked him. In Ireland, I used to see cases of elder neglect. Elderly people, especially over-medicated or with dementia, would fall asleep with their leg or body against a radiator. Overnight, they’d get terrible burns. This guy had burns on his right buttock, on both calves, his ankle and on the back of his head. Continue reading The Last Patient of the Day is Always the Hardest
July 5, 2010. Port Antonio, Jamaica
Well, our passage from Haiti to Honduras was briefly interrupted. Our first day sailing from Haiti brought fine cruising downwind and down current, but as we began to cross the Windward Passage between Haiti and Jamaica we hit heavy weather. A beam sea of 8-10 foot waves made for a miserable roll. After 48 hours of fighting the helm, driving through lightning and winds reaching 55 mph, we found ourselves passing north of Port Antonio on Jamaica’s NE coast.
With our generator overheating and crew exhausted, we turned south and arrived in Port Antonio just after daybreak. Errol Flynn Marina in Port Antonio has been giving free dockage to boats coming to or from work in Haiti. Only a mile from land, the seas subsided, and we got shelter. We cruised into the protected harbor and pulled gently up to the dock. I was at the helm, and I will never forget the enormous feeling of relief that washed over me as I heard ‘All lines secure’ called out from the deck. I shut down both engines and relaxed fully for the first time in over 2 months.
We lived at anchor, enduring squalls and gales and constant maintenance, for well over 8 weeks in Haiti with nowhere to tie up or deep water to try and anchor in. Once or twice in Haiti our anchor dragged on a windy night and we had to pull and reset. An hour after we tied up at Port Antonio, a squall came through with 40 mile an hour winds, and I paid zero attention to it; a luxury we never had the whole time in Haiti.
Captains Blog June 27th 2010
“Man is the measure of all things.” –Protagoras, ca 450 BC
Last night I watched Frank Capra’s great 1936 masterpiece ‘Lost Horizon.’ Set in a mystical land called Shangri-La, it is the story of a man who worked for peace in a world constantly at war. It is about a man, a diplomat, who dreams of a world run on compassion and dignity.
After his plane crashes en route from China, he finds himself far up in the Himalayas in the hidden valley known as Shangri-La. The valley is a community based on kindness and simple courtesy to one another. It is a paradise.
This is a beautiful story about what everyone wishes were true, but no one believes is possible.
When Frank Capra premiered the film, many snide comments were made about how silly it was. The movie that proclaimed the secret of a happy life is to “Be Kind” to one another was considered “Capracorn.”
That selfish cynicism nearly destroyed Frank Capra.
Almost everyone secretly wishes there were some place they could lay down their stresses and burdens and pains and needs. That place, as fanciful, exotic and remote as Shangri-La, can be wherever people practice kindness to each other.
And kindness is always a choice.
Before coming here—my first trip to Haiti—we had done so much reconnaissance (and I have already been to many places in the developing world) that I had a pretty good idea what to expect, but I also knew that there would be many things that would come out of left field and surprise me. From experience, I knew that for the first couple of weeks everything would be new and exciting, and that after a few weeks there would be things about Haiti that were chronically frustrating and upsetting. In this case, corruption in the government, the behavior of many other non-profits that are here, and human greed top the list for things that upset me in Haiti. But this doesn’t discourage me at all—EVERYWHERE I have EVER been, including places I love and would live in or revisit in a second, has things that I don’t like: the traffic in L.A., the lack of mountains in Florida, the cold in Ireland, the rampant HIV in South Africa, government corruption in Mexico, the mosquitos in Botswana. After a few weeks here, yes, of course there are things about Haiti that I don’t like, but I don’t care. No place is perfect, but as much as the challenges to rebuild Haiti seem overwhelming, there are still people here who have not given up, and neither will we.
If I am miserable and unfulfilled in one place, I’ll be miserable and unfulfilled when I go somewhere else, but I am doing what I dreamed of doing, after having (as Sky puts it) “frankensteined together this project that came out of your own head and watched it accomplishing everything you hoped it would and more.” At age 34, I am watching my dream come to life despite naysayers and constant challenges, with many hands reaching out to us to help us along our way. From childhood my dream was to practice this kind of medicine—the kind of medicine I watched my dad practice when he took me on rounds at the hospital as a child, and saw him provide in the homes of his patients and on the side of the road at terrible car accidents in Topanga Canyon where we grew up.
When your life’s dream is being fulfilled before your eyes is very hard to be unhappy and negative. The most common comment we have gotten, hands down, from older people who have met us, is “It is so great that you are doing this now, while you are young. You will never have to look back and have regrets about things you wish you had done and the places you have seen.” And when I look back down the years, hopefully many years from now, I want my halls of time to be lined with the faces of people whose lives I have connected with, however briefly, and in whose lives I left some kind of positive impact.
June 7, 2010
Time for a quick status check, and to update everyone about our plans for the next phase of our mission in Central America. So far, in seven weeks in Haiti we have:
• Treated over 1200 patients and over 250 dental patients in the DesGranges clinic with our current skeleton crew.
• We have had three more volunteers (a medical student, osteopathic physician, and EMT) and my dad join us in working here in Haiti.
• We have finished one schoolhouse, roof and all, and are nearly done putting the roof on the second building.
• We have worked in the DesGranges clinic for more than 30 days, and put in more than 25 days’ labor on the school.
• Hand-unloaded and transported in UN trucks: 20,000 pounds of material.
• We have treated over 300 people in our own mobile clinics in the underserved communities near our anchorage.
• We have provided health and dental education to patients.
• We have moved the clinic from tents outside back into the inspected and cleared building, reorganized the pharmacy and pharmacy stockroom, set up an infirmary and triage room, and restocked the minor ops room.
• We have distributed several hundreds of pounds of clothes.
• We have conducted our activities here for one tank of diesel and a total of less than $250 a week for all food, gas for the skiff, laundry soap, transport, etc. for a crew ranging in size between 7 and 11 people onboard. That’s just over the cost of three night’s stay in the hotel here for one person (no food, transport, etc), where many other aid workers have no choice but to stay.
• We have made many friends in the community—we play pick-up basketball at 5:00AM some days, our Haitian friends visit us and often stay on board, we chat with the town baker, Madame Fievre, about methods of making Haitian bread, people bring us small gifts by way of thank you (a few mangos, some plaintains or coconuts), we go swimming, eat, and work with many folks here who ask us for nothing (some do, but many do not) but have no work and would rather work with us than sit around doing nothing.
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