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maggots in a tunneling ulcer
Ah, the Asilo…one of the places we heard about here in Panama when we were still in Honduras. We found a unit seldom visited by a doctor (in a year), but with a wonderful staff of no more than a cook, cleaner and nurse on each of the two 8 hour day shifts and 2 on the night shift. There are 27 patients there, all elderly, ranging from totally mobile to totally bedridden, some without sight, some without limbs, many with varying degrees of dementia—they all have to be fed, bathed, many changed, floors cleaned, meals prepared and cleaned up after…the fact that the floors are clean and the patients are clean and fed is an extraordinairy achievement, but the patients need more attention.
When we got there I thought they were totally medicated…so many of them looked so catatonic…it turned out almost none of them were medicated,
They seemed so catatonic when we first were working there
or where very occaisionally medicated. They were just bored and unstimulated, almost into catatonia. It was months before some of them spoke; I came back from 5 weeks in California to find patients that I thought had no power of speech actually talking with me. It was like awakenings, and it isn’t because of medication, it is because of all the time our volunteers and people in the community have spent with the patients there. Many had not been out of the grounds for years, and now walk in town weekly—our friend Javier, a Colombian physiotherapist in town who also works at the Asilo, brought his four horses and our elderly patients dressed up and rode like kings and queens through the streets, looking down around them as if to say ‘So…this is Bocas, you say.’
one of 3 trucks of trash we removed
The mayor sent three trucks and we removed several tons of rusted metal and trash from the grounds and landscaped a little (more to go), repaired two broken washing machines and plumbed 3 in total (the only working one had been filled by bucket), installed handrails in the common area for walking and physio, changed the showerheads to removable handle versions, put a commode chair in the bathroom, created and update charts for the patients, provide medications, and have done our best to provide the additional more advanced care that the staff are sometimes not able to provide.
When we arrived, there was an elderly stroke victim, immobile and unable to communicate, and terribly emaciated and contracted with bedsores
emaciated, rigid, and covered in bedsores
all over. We worked for weeks, doing wound care and working with the staff to use advanced wound dressings we provided and creating turning regimens—our goal not to extend his life, but to allow him to die with more dignity and in greater comfort. At one point he got a chest infection and we stood by to administer oxygen and midazolam and buscopan to make him comfortable as he passed, but he rallied…and subsequently gained 12 pounds and the ability to focus and speak a little (very, very little) before he died quietly one night in his sleep a few months later.
ulcers spreading in a deteriorating body
And he died with not a single bedsore on him…that was a victory to me, at a personal level. I hate it when people die with their bodies disintegrating externally around them as well as internally. It is unnecessary, but totally natural for birth and death to be so awkward and difficult…the first time doing ANYTHING is usually awkward and difficult: the first day of school, first kiss, first great loss, first great love, first great adventure, the first and final sunset cruise, and finally, the end of the voyage.
Any ship, no matter what storms it has weathered and what damage it has sustained in a long life of navigating unknown waters, wants to look its best when it pulls into harbor for the last time. There should be dignity at the end, as much as can be wrenched from an unfeeling universe. Not always possible…but always a betrayal not to even try.
My cousin, a physical trainer, just arrived here for a few months…I have another patient in the Asilo who has not walked for 9 years after his stroke. He stood up the other day after exercising on his own, ferociously, with some basic exercises we showed him after we applied a difene patch to his paralyzed knee for knee pain, and he and we found out the immobility was more pain-related and he could move it a little. He freaked out an dhas been exercising like a fiend.
Our friend Bolivar snapped some pics in the asilo while we were working there one day
I came back from California and he collared me from his wheelchair and looked me in the eye and said ‘Yo Puede CAMINAR!’ And stood up, giggling like schoolgirl. Sometimes things are too much for me to process when they happen…later at night, especially when I’m writing a blog or making a facebook album of the day, I start to process…thinking about that patient a lot. I want to go for a walk with him before he dies—and he might live for many more years, so if he does, I’d like him to be able to walk, and he REALLY wants it, more than almost any patient I’ve ever seen. I feel tiny beside the strength of his determination.
Matt and I changing a suprapubic catheter blocked after 11 months of neglect
I tell all my incoming student volunteers (I have my little speech about this prepared): “You are so lucky we have the Asilo for you to volunteer in. Not only does every second you spend there interacting with some of the loneliest people I have ever seen benefit them beyond what you can know, but care of the elderly—and especially in this setting—is where you find out if health care is for you.
Eve and Sarah doing wound care on tunneling ulcers
“Yes, it’s challenging, the medical issues are very complicated, the patients may have dementia and can be challenging, and you have few resources to deploy except what you can somehow manifest…but beyond that, its where you learn things like ‘are you the type of person who is thoughtful enough to throw a corner of a sheet at least over the exposed genitalia of some bedridden shell of a human during some procedure that leaves them all exposed?’ Or ‘When you lift a frail contracted foot off the bed, do you automatically support the knee out of awareness (to avoid torqueing the knee)?’
walking the patients
“It’s a good place to learn PATIENT CARE…not something everyone can learn, because some aspects of it I just don’t think you can teach. I feel like I have to practice at it constantly…people are afraid of old people…can you learn to look past the rotting shell of their failing minds and bodies to ressurect in your mind’s eye when you look at them the glory of their individual histories? It is like looking at old ships tied up in the scrapyard and neglected, never to leave again…remember that those ships voyaged 70 or 80 years across 2 or 3 of your lifetimes…can you see who they were and what oceans and storms they have passed, somewhere inside the wrinkled, frail bodies awaiting their final voyage?”
I love the Asilo…my volunteers go more frequently than I (I only have 2 hands) these days, but I love going in and seeing my friends there. We need people in the community to each give 30 minutes once or twice a month…come on…an hour a month, that’s pretty good…want to walk patients with us? It is awesome—email us or (better) contact us on facebook if you want to go for a walk with us and be checked out to walk patients on your own. One hour per month…you saw the walkway we all built in La Solucion; a miracle happened because everyone showed up and made it with their hands and time.
giving time
Make a miracle happen at the Asilo…everybody give an hour a month, and every patient will be walked several times a week instead of never. They’ll get stronger and be more fit (less pain), and be more mobile (and they HAVE to be, the ones that are bedridden have the worst time of it). Let’s make it happen Bocas!
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Cap Haitian, Labadee, Shadda, Milot, Coco (east of Bayeux)
Norwegian Crusted Scabies
Today is the 1 year anniversary of when we first set sail from Florida to Petit-Goave. Returning to Petit-Goave after a year and seeing our old friends and patients (and meeting new ones) was an incredible experience, but after a week working in Petit-Goave we weighed anchor and headed north to Cap Haitian. After the Windward Passage, it was great to ride across the smooth glass of the Bay of Haiti, but as we approached Cap-du-Mol on the western tip of Haiti’s northern peninsula we entered the edge of the Windward Passage and had a few rough miles before turning east along Haiti’s north coast, arriving shortly after daylight and pulling onto the commercial docks in the port of Cap Haitian.
We were met by Hannah from the Cap Haitian Health Network, and after several days of
trash river in cap haitian
paperwork and meetings we unloaded our medical cargo onto the docks, onto a truck and got it into the CHHN warehouse, where it will be available for distribution to the clinics that are members of the network. While we were waiting to unload at the dock so we could move to our mobile locations, we took the opportunity to visit a couple of other health centers, meet the minister of health for the north, do a mobile clinic in Shadda—Cap Haitian’s worst slum—and see a steady stream of patients at the dock the entire time we were there.
holly hefting an instrument of war...
It took us almost 4 days to get our material cleared in, which gave us time to visit Milot hospital, the primary center for major or specialist surgery (staffed year round by local and visiting teams) and get a schedule for the next few months of that doctors and specialist teams will be visiting there; that way when I am further afield I can write referral letters and give the dates and doctor’s names to patients I encounter who need specialist care. Above Milot is the Citadel…the largest and most impressive castle I have ever seen, perched on a mountaintop above Cap Haitian. Built after independence, it was made to hold 12,000 troops and be able to fight a devastating guerrilla war from the mountains should Cap Haitian have been re-taken by the French. I liked the raincatchers built into all the roofs, but mostly I was shocked by the size and scale of it. “My name is Ozymandias, King of Kings…Look On My Works, Ye Mighty, And Despair…” The castle was never really used or completed but it has been well preserved as a UNESCO site and SHOULD be a huge tourist draw for anyone visiting Haiti…just plan to bring $10 for a horse if you don’t want to walk all the way up (3,000 feet in 3 miles…I made it but I wanted to have a coronary at the top).
Cap Haitian was not too badly damaged in the earthquake and is quite prosperous in
infected and necrotic burn from hot oil
comparison to other places I’ve been in Haiti, but Shadda, its central slum, was awful. We saw a ton of scabies, which always tells me an area is really poor, and some half-done operations (like a colostomy that has not been reversed though it was supposed to be). A toxic river draining sewage, agricultural and industrial runoff and storm drains from all of Cap Haitian flows between two dykes made of garbage, medical waste and sewage…Donna was saddened to see three children: one standing in a huge pile of garbage, another simultaneously defecating on the pile, and another simultaneously picking a can out of the pile and checking it for scraps of food. The general health of the population in Shadda reflects the surroundings.
a river of sewage, garbage, agricultural and industrial runoff flowing through shadda in cap haitian
By contrast Labaddee, where we moved and dropped anchor to work from this protected fjord, is one of the more prosperous-looking little villes I’ve seen in Haiti—pretty much 100% because of the jobs and income that come with Royal Carribbean Cruise Line’s destination here. RCCL run a school, help support the small clinic in Labaddee, and have extended themselves to us by providing fuel at cost and allowing us to get water from their dock (thank you Peter and Dave!! Lifesavers!!) and do laundry (16 continuous hours of laundry when we first went over there). I
It is important to remember that Labaddee’s prosperity is relative to places likes Shadda,
meeting his first white person, and unafraid
so we still saw loads of bad injuries, poorly healed wounds, a LOT of major operations with little or no follow up (we asked Hannah from CHHN to come do a day of physiotherapy and she is planning to try and come regularly), and some unusual cases also—I treated a little boy with a knee wound all septic with ripped apart stitches (almost all healed now), we ultrasounded nearly every pregnant woman in the village of 6,000, and after only two days people started coming out to the boat, night or day, for emergency care.
You never know what will arrive paddling up in a canoe at 10:00 at night—a guy came by
wound care for the skarkbite victim
the other night and I saw the blood-soaked rag wrapped around his left hand. We pulled him aboard and unwrapped the hand to find he had been bitten by an 8 foot hammerhead shark (HE says 8 feet…but I’m a fisherman too, so I say read ‘5-6 foot;’plus 5-6 feet is about right for the bite radius). We patched it up and he has come every day for dressing changes. I understand he was offshore, tried to pull the hammerhead into his small boat, and it got the best of him before it escaped. Two worlds collide…Shark one, fisherman zero (for a change).
Me and Jean Claude, one of Cousteau's original divers and one of my heroes
Speaking of worlds colliding, I am fortunate here to have met one of my childhood heroes, Jean-Claude (one of Jacques Cousteau’s original divers), who has built and run the Cormier Plage hotel near Labadie for the last 23 years. He is 79 years old, dives every single day, swims a couple of miles in the ocean every couple of days, and showed me the artifacts he has collected off wrecks he has discovered over 23 years of diving this dangerous lee shore (I nearly keeled over in shock at the collection of priceless artifacts he has recovered for a museum display when it is complete).
I think that so far one of my favorite days here in the North so far has been setting off
The only way to pass a physically uncomfortable journey
from our ship on an 11 mile trip in a leaky handmade wooden boat with no floor or seats, run by one of our new friends here, through a treacherous series of shallow reefs (on a lee shore, too…bet there’s lots of ships’ bones down there), landing not far from columbus’s landing in the new world. I’ll always have a memory of Sky sitting on the bow trying to keep her back from being destroyed, scanning the mile-long, desolate beach for our contact and a safe passage through the surf. We located our contact and another boat rowed out through the surf, we transferred our gear and under oars we backed through the surf.
Donna’s shorts were soaked in the landing and she abandoned them, so partially clothed
sky clerking in a kid 8 years old going on 47...
we put our gear on our backs and heads and followed our guide off the beach into the trees, stopping at a small school in a village supported by Dr. Anne, an HIV specialist who helped make this mission possible. We did health checks on all the kids in the school, treating a LOT of scabies and skin fungus, respiratory tract infections, some severe malnutrition from parasite infestation, anemia, and a pre-teen patient who told us they ‘had dirty blood’ from birth. This patient travels 2 days once a month to visit a doctor providing their meds. And, as per our SOP, we gave vitamins and albendazole (for worms) to every kid (and quite a few adults, too).
I love the mobile clinics…each one is its own adventure, at the end of it I have a wealth of valuable firsthand information about the location, and I’ve never done one that did not have at least one patient that I was very, very glad to have come to see.
And to be honest, it also felt good to ply the same waters as Columbus for a short time. I
landing our clinic through the surf a short distance from where columbus first made landfall in the new world...
hope the legacy we leave behind has a kinder footprint than his, but I loved rowing through the surf to land in a new place, with mystery and unknown patients waiting somewhere beyond the tree line in the Haiti’s own heart of darkness. Humans aren’t meant to look at cubicle walls…we are hardwired with the desire to stand on new worlds and look to the next. All of us have the explorer soul written into our DNA, and the expression of this most uniquely human characteristic is always a beautiful thing—I think it is when we are being the most true to who we are as human beings.
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