Last week we had an awesome experience—in the midst of our last weeks of preparation for our mission to Haiti, we are continuing to open our Oakridge clinic. Pretty hectic—clinic by day, boat work by afternoon and evening, and computer work late into the night…but totally worth opening the clinic not only because we had a full patient list right away, but also because we had some very welcome visitors to the Oakridge clinic on Wednesday.
Optometrists from Manteca Rotary Club in California’s Central Valley came to our clinic
and provided prescriptions and eyeglasses to 40 or more people in one morning’s work. They were cool—came in, knew exactly what to do, had obviously done it before and saw as many people as humanly possible in the time allowed. Exactly the kind of group I love to work with; the maximum effect with the minimum fuss.
One thing that made their work really efficient was the little device they had with them—it was a Welch-Allyn device for scanning and identifying patients’ eye prescriptions. When I heard optometrists were coming, we pulled out and dusted off the traditional optometrist machine sitting in the clinic building we use, but the device they had with them made it
look like a piece of obsolete medieval torture equipment. Fred, the optometrist scanned patients, gave them their prescriptions, and Renee (the former club president) gave them their glasses—both reading and distance.
If one of those were on station somewhere for a month, I think it could do about 2,000-3,000 patients. That is an INSTANT, huge increase in someone’s quality of life. Apparently the units are affordable, easy to learn to use, and of course small and portable. We have GOT to try and get one of those.
It was great being back in clinic—plus, we have Dr. Holly with us as well. We picked her
up at the airport in San Pedro Sula on our way back from Copan. She is an Accident and Emergency Room doctor and Tropical Medicine specialist from the UK, and will be working with us for 3 months before joining the Flying Doctors in Africa. It was wonderful to have so much help in clinic; Donna from Roatan Rotary was with us, Sky was running the front desk, Noah was doing his Thursday physio sessions. I love it when the clinic is humming; ultrasounds and minor ops, consults…love it.
Our container from Direct Relief comes soon…can’t wait to distribute it among the clinics (and pack the 350 cases of IV fluids onboard to take to Haiti for the cholera relief). So much to do in these last
weeks…just like the first time, we went, except this time we have already done it and have substantially continued to rebuild our ship ever since we set sail. We are better equipped and more experienced than our first trip, and that was a success.
I am confident, a little scared (if you aren’t scared of the ocean then you have no business going out on it), and excited to return to Haiti. It’ll be an 800-mile, uphill (upwind and up current) trip but with the right weather window we can do it. Still have a lot to do first, but it is getting done every day…and probably will be right up to the day we leave!
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.
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.
On Wings Of Angels
A few days ago we did a house call from the RBC Center to a lady who was 6 weeks post stroke. The family’s house was at the top of a 35-foot steep slope, and she had pretty complete right sided paralysis. Her speech and cognition were affected badly; she seemed unable to understand questions and had no speech. She had a permanent indwelling catheter, and could eat and drink when fed but her swallow was affected and she seemed to be aspirating a little bit (saliva or fluid entering the lungs). Like most elderly or infirm family members in the developing world, she was being cared for at home.
There was not much I could do to help her improve, although her stroke was so recent that it was impossible to say how much spontaneous improvement she might experience over the coming weeks. We told the family to interact with her as much as possible and Annee demonstrated passive motion exercises the family could do with her to help prevent contractures and blood pooling, and discussed turning and bedsores. We talked about signs of urinary tract infection (always a danger with permanent indwelling catheters). And the folks from the RBC center are going to try and help out. Overall, the prognosis was not good, but there is one thing this lady had going for her that many elderly patients in the US and Europe never enjoy.
In the US and Europe, the general tendency is to stick elderly family members in nursing homes and visit them occasionally, usually out of some kind of guilt or obligation. I worked in Care of the Elderly in Ireland and I saw it everyday. The first time I did a house call on an elderly woman in Africa, who coincidentally had also had a stroke, I was ashamed of how we treat our elders in the developed world. Here in Honduras, as in Africa and Haiti and everywhere I have been, older people live with and are cared for by family members in their homes. They do this for two reasons—first, because they have no choice; there are few nursing homes to deposit and forget elderly family members. The second reason is because the culture in most developing countries has much more respect for the older generation, and elderly people get home care and attention from their families simply because that’s the way it is.
The granddaughter of the elderly stroke victim hovered over her grandmother, stroking her hair and talking to her. The family washed her and cleaned her, emptied her catheter bag, fed her and talked to her and interacted with her. Lying there paralyzed, she received the most tender care and inclusion in the life of the family. There may have been no advanced tech available but this lady was being wonderfully cared for. And a week later, she got some of her comprehension and speech back, and some control over her right side mobility. With love and more care, hopefully she will recover enough to regain some measure of independence, but if not I have confidence in the care I know her family will provide if she remains permanently disabled.
The RBC Center, para los ninos con incapacitados, is staffed and run by people who have extended the kind of care they would provide a family member to the kids and people in the community who have cerebral palsy, have had a stroke. Ashleigh has been there nearly every day she was with us, providing Occupational Therapy and Physical Therapy and helping the clinic workers learn new techniques of therapy.
I am amazed, and very proud of what Ashleigh has accomplished at the RBC Center. She and Annee started a Yoga class for the mothers of the handicapped children, many of whom have bad backs and joint pain from carrying their immobile grown children everywhere. The women who come to the center love the class; one 57 year old woman said it was the first time she had ever exercised, and she was so proud of herself. Peggy from Clinica Esperanza gave us a couple of children’s walkers, and a few days ago a 7-year old boy walked for the first time, and a 9 year-old boy wrote his name for the first time.
Ashleigh does movement therapy, sensory therapy, passive massage; pretty much everything—Supertherapist! Fridays are my favorite day…on Fridays I always go to the RBC Center and see patients, young and old. I treat a lot of gastritis and arthritis there; the moms of these kids have lots of stress and physically challenging lives. But on Fridays, when I am there seeing patients, I get to see what Ashleigh and everyone is doing—giving attention to the children, giving the mothers a desperately needed rest from the constant care they have to provide, helping people get their mobility and independence back. Annee, Sky, Noah, Sirin, Rachel, and Nick have spent many days working with the people at the RBC., and I love when we get to all work in the same place.
It is wonderful what can be achieved when you are helping somewhere long enough to learn the lay of the land and what the real needs are, and make the friends and connections necessary to undertake more ambitious projects. Of course, you also need outstanding individuals like the volunteers that have come out to help us. Ashleigh was amazing in action; when she went home it was a sad day for us and also for the clinic staff and patients and families.
The clinic closes for an hour at lunch, and we usually walk down the road to our friend Sherman Arch’s Iguana Park. Sherman is caracol, meaning of white descent but an islander who speaks the patois of the island. He is second generation here, and on his property iguanas are not allowed to be killed, so over the decades they have congregated. He takes in rescue animals, including monkeys and coatimundis, and does turtle rescue. He often feeds us at lunch and sometimes gives us rides back to the boat in his truck or the 37-foot skiff he made himself. He has been enormously kind to us, esta un bueno hombre, another angel we have met.
High in the air during a night flight across the dark ocean a week or two ago, I suddenly remembered a story I read years ago that seemed appropriate for the moment. It happened on the way back from a patient transport in the helicopter to the mainland, and I was sitting in the back thinking about what Floating Doctors became after starting so long ago as a decision made on the plains of East Africa, when I decided to go back to the developing world with more help. I contemplated the path we followed to make Floating Doctors a reality; I thought of all the heartbreaking setbacks and the glorious triumphs that were achieved by the goodwill of people who seemed to come out of nowhere to help pick us up when we fell, and encourage us to keep going, and who worked side by side with us.
The story I remembered is about a man climbing a tall, steep mountain in his dream. After a desperate struggle, he makes it nearly to the top…then falls. The story says that when it comes to the dreams perched high atop the mountains of your mind, it is sometimes a mistake to climb to reach them—but it is ALWAYS a mistake never even to make the attempt. If you climb, you can either succeed or fall. And sitting there in the helicopter, thousands of feet above the dark, luminous, serpent-haunted sea, I understood in a very literal way the third option mentioned in the story: sometimes, when you fall during the climb to reach your dreams, you find out you can fly.
There have been many angels who caught us when we fell and who helped Floating Doctors continue forward. I know I talk about it a lot, but I don’t care. I wanted to thank you all again very much, and to know how much it means to me that you believed in us and helped us and worked with us to make Floating Doctors fly—both in spirit and, riding the clouds over the gulf of Honduras, in literal fact.
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
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.
June 4, 2010. Petit-Goave, Haiti.
At long last, my dad and I got to practice medicine together! Dr. George La Brot, was just with us for ten days working in the clinic alongside me. This was a big deal for me; ever since I was a child and I knew that I wanted to be a doctor, I dreamed of working with my dad. Over 25 years have passed and here, a continent and an ocean away from where we started, we saw patients side by side in the clinic and in our mobile clinics. It was a wonderful experience to consult with my dad, and to be consulted by him when we had troublesome cases to figure out. I really wanted to show him what all his and my mom’s support and encouragement on the path to medicine and then to Floating Doctors had wrought.
I talked to my dad on Hughes’ phone as they were driving from the airport; my dad said that PAP looked like a lot of places he had been, but with more rubble—the wholesale destruction is much more striking in PAP because that’s where the biggest buildings were. He is right—anywhere I have been in the developing world, many things are exactly the same. As different and unique as each place is, there is always a strange sense of déjà vu that accompanies walking down a dirt road through an impoverished neighborhood watching children bathe in the gutter or a woman cooking something over a small wood fire. When he arrived at the clinic, we worked that first day, and in the afternoon all of us headed into town to run errands. We had to go to the bank, get bread from the bakery, get some produce from the market, get laundry detergent, get gas for the skiff, get some phone credit for our Haitian cell phone (indispensable for anyone planning to work in Haiti), exchange some glass soda bottles and collect our deposit, etc. For the afternoon, the clinic had arranged for us to have a driver with a beat-up old pickup truck. Continue reading Wherever You Go, There You Are
April 27, 2010. Petit-Goave, Haiti.
At long last, phase one of our project is complete! We have completely rebuilt our ship, found and loaded all our medical supplies, sailed our vessel over 800 miles from Florida and arrived safely in Petit-Goave, on the northern coast of Haiti’s southern peninsula.
Our last port-of-call in the US was Miami, our jump-off point for the long transit southeast to Haiti. Miami Beach Marina and Epic Marina donated dockage for us while we provisioned, continued stowing and securing our supplies and waited for a weather window to cross the Gulf Stream.
Moving from Miami Beach Marina to the Epic Hotel dock was a bit tricky. The Epic Marina is on the narrow Miami River. It had a ripping current flowing into it when we came in, and we had a strong wind blowing behind us, pushing us along the current. When they gave us the docking instructions, they told us, “You can’t miss it—the spot where you guys should dock is about 200 feet long, right between the two mega yachts; be careful because the one in front of you just had a 2 million dollar paint job!” We parallel parked without incident and spent two days provisioning and waiting for the weather to clear.
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