Today’s blog was written by one of our recent volunteers, Dr. Ravi Chokshi, just beginning a residency in Obstetrics and Gynecology. These are his thoughts and impressions of our 4-day mobile clinic up in the mountains to a remote village called La Sabana, or ‘The Grasslands.” Over 200 patients were seen, including pediatric and trauma emergencies. Thanks Ravi! best of luck in your residency, and I look forward to working with you again.
He was different at first glance. Quieter. Saw more, spoke little and took his time to smile.
“It hurts here” he exclaimed pointing at his 12 year old heart.
I had examined 20 chests that day, listened to 20 hearts. But only his jumped at me as I lifted his shirt.
A heart that had decided the only way to get noticed was to become outgoing. I place my stethoscope and still the squall fighting within. My ears record and my fingers feel for the familiar radial pulse. There is a flaw here. A Woosh-woosh where a lub-dub should be. I bring over some counsel and we use the portable ultrasound to perform a tropical echocardiogram. What I had heard, we now see. A hole connecting the two atrial chambers of his heart, and a chance to be normal forever taken away.
By the second morning, we had hit our stride. Awake at 7am with the hum of the village around us. I wish that I could say that I
slept wonderfully on the hammock. Tied across the wooden beams of the village Rancho, covered in a mosquito net donated by the Lake County Sheriff Cliff Matthews.
I almost did, but the cold from the two rivers that flow around La Sabana got to me.
To build your own bed where the clinic just was. Settle into it with the laughter of new friends around and your mind alive with the memories of the day before you. Of the cold stream water you had bathed in, or the hojaldras and coffee that had started your day. Sleep comes easy and you drift imperceptibly towards it as the days’ labor catches up to you and the hungry river swims around you.
The cold shudders in, and you wake up surrounded by the chatter of excited Ngobe children. A quick breakfast and swim later you are ready for work. Walking back from the river you can already see a mass of patients organizing themselves around the rancho. In 10 minutes a fully functional clinic sits where we had just dismantled our bedroom. A pharmacy lies ready and capable. Our amazing interpreters have already lined up patients, sequestered the roving bands of excited children and started patient intake. I sit with my stethoscope around my neck, a clipboard on my school desk of a chair and try to look ready.
This is impossible.
And we begin! In groups of 4 to 6 the mothers and fathers patiently answer my questions posed in broken Spanish while the kids run around, openly gawking at me and my strange tools. As I address them, smiles break out. They are terribly shy and hide their little faces in their mother’s dresses. But I bring them out and I let them listen to their heart beat through my stethoscope and I see their eyes widen and them calling out their amigos to do the same. ‘Ahh this crazy gringo is funny’.
I hear about coughs and colds, about chronic pain, about diarrhea that just won’t go away. I examine distended bellies and the scars from years of no-see-um bites and battery acid burns from cured cutaneous leishmaniasis. Most of all I see the relief as I dispense Albendazole like candy telling them, “Este Medicamento va a quitar las lombrices de su estomago y su piel”. And I urge them to eat it in front of me. I work in a chain with 4 other doctors, most with many more years of experience than me and I confer with them constantly. I learn to recognize scabies and lice and infected wounds and what treatments we can offer for such. I get called occasionally for my input on obstetric patients, being that it is my area of interest.
Using the Sonosite I am able to show a woman 7 months pregnant her unborn child’s face and lips and nose. The kick she feels – she now sees and she can’t stop smiling. In a place where most of the people have never seen an outsider, a white person, or even a TV an ultrasound is magic and we are a mystery they are too polite to solve.
We are observed constantly. And for good reason. In a place as isolated as this from the rest of the world, we are as alien to them as
imaginable. Taking a picture of the children and showing it fascinates them. Then I realize why. There are no mirrors here, no still water. Their first good look at themselves is thru the lens of my camera.
These are the Ngöbe-Buglé Indians, Panama’s largest indigenous group. After years of historical fighting they were allowed to retain their ancestral lands largely confined to the western rainforests of Panama. Here in their Comarca, they implement their own system of governance and economy. In terms of healthcare they have a raw deal. A long history of poor interactions with outside groups (pretty much everyone since the first explorers) has left the Ngöbe understandably skeptical of ‘Meriginees’ (non-Ngabe people). As the mother of a very sick Ngöbe child put it to us, “the hospital is where we go to die.” Language is another barrier. While the Ngöbe men have reason to conduct business with communities in close contact with the mainland and thus have some Spanish speaking skills, the women and children are different matters. Not being able to speak Spanish in Panama is as isolating as it gets.
La Sabaña, the remote Ngobe village that we have made our way too, is one of the more isolated communities dotting the Chiriqui
province of Panama.
Our journey there begins at 5am from Bocas marina, where the Southern Wind currently rests.
A group of 9 odd, we sleepily catch a water taxi to our first destination – the port town of Almirante. Blazing through the Caribbean on a 200 horsepower boat is enough to get everyone up and awake.
?Costa Rica!, usted? is the banner cry as we disembark.
Ahh Almirante. A hastily thatched together port town created entirely by the Chiquita Banana Company, it is best described as a jump off point to better places.
Brushing off the taxi drivers, we find ourselves in a car on a 90-minute ride to the sleepy little village of Pueblo-Nuevo. A tasty Panamian breakfast of fried bread and coffee awaits us and now we are ready for our hike. Ben has hired horses to carry the supplies up the slope, while we carry only water and essentials on ourselves. A 3-hour hike when dry, 5 plus when wet and we approach La Sabaña by late afternoon.
La Sabaña – literally translating to ‘The Grasslands’ is a mesmerizing place. Found at the crossing of two rivers, its thatched huts and raised wooden floors are as living artifacts to the age before Panama won the geographical lottery and started collecting revenue from the canal. The Ngobe here live simple lives, the men work in agriculture and raise animals. The women take care of the children and keep the house, all while dressed in the colorful patterns unique to their culture.
It is here we are most in need.
Along with the storm, comes the call from up the mountain. A child has been hurt severely, on his foot by a self-inflicted machete cut. Ben quickly
dispenses half our group with the general surgeon on a race up the slope. I am part of the group that stays behind, together seeing the last few families waiting to be seen. The number of patients has been growing larger every day. Word has gotten around about us and families have traveled on foot for many hours to see a doctor, possibly for the first time in their lives. I have to remind myself of this, as I quietly ache to learn what is transpiring with our other half.
Hours we wait, the rain pouring down, the darkness absolute. The conversation feels forced, every one’s mind on our missing party and what has transpired with them.
Moments before a search party must be raised, their lights are spotted, little moonbeams making their way down the muddy path. They have returned, soaked to the bone but with stories to tell.
It had been necessary to amputate the 10 year old child’s little toe. Amputate it. In the darkness, working on a wooden floor guided by headlamps.
They had quelled the bleeding, stitched it together and addressed his pain as best as they could. We would return the next day with antibiotics and supplies to redress the wound. To leave supplies and to teach the family to keep the site clean. And a phone number to call, just in case.
By our last night the hammocks come up like clockwork. Clinic today had been a sold out success. Patients came from all around the mountain, with many families walking a day’s journey to reach us. We had worked like a well-oiled machine.
As we pack our boxes for the long journey back, the stories come through.
And its not the number of patients seen that we count, but the tooth brushes we had run out of. The soap we had no more off. The medicine for scabies we had to deny.
If there were patients to count, they were the ones we now had the responsibility of following up on. The 12 year old that needed to see a pediatric cardiologist. The women with suspicious breast lumps that needed mammograms, and the ones we couldn’t quite put a diagnosis on out in the field.
Ben and his crew will arrange transport, appointments with the necessary consultants and provide a voice of advocacy to accompany these patients.
What I have seen here erased all presumptions I had before the trip. We were there to see patients and dispense medicine yes, but much more importantly we were there to build trust. To raise the community up bit by bit. To give out toothbrushes and teach kids how to clean their teeth. To teach mothers to recognize dehydration in their children and how to make ORS. Most of all, to provide the village with an avenue of communication they could rely on when posed with a serious problem.
I had been promised an experience of a lifetime when I signed up to volunteer. I say they undersold it.
Four days I lived alongside the Ngöbe Indians. Absolute cutout from the world I knew and an absolute outsider to this hidden world that time had forgotten. I almost died. I very nearly lived. I fell in love again. I yearned to go on, to live this fantasy of waking up in a hammock with lines of patients to see and a fast flowing river to bathe in. Four days is much too short but somehow felt like a lifetime in terms of lessons learned.
In a few short weeks I will return to the US to train in one of the most developed and technologically advanced healthcare systems in the world. I will learns volumes everyday and gain skill sets I ache to possess. But it will always be in a remote Ngöbe village in the protected area of western Panama where I first really learned the gravity of the promise we make everyday on saying these words, “Me llamo Ravi. Soy su Doctor”.
Added by Ben La Brot:
“It is from the numberless diverse acts of courage and belief that human history is shaped. Each time a man stands up for an ideal or acts to improve the lot of others or strikes out against injustice, he sends forth a tiny ripple of hope, and crossing each other from a million different centers of energy and daring, those ripples build a current that can sweep down the mightiest walls of oppression and resistance.”
–Robert F. Kennedy speech in South Africa, carved in stone on his grave.
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Nec Aspera Terrent: “Difficulties be Damned”–the Family Motto of Perry Fawcett, Amazonian Explorer
Labadie, Camp Louise, Caracol; Haiti
It has been a very, very busy few weeks…a lot accomplished; we recently treated our 750th patient for this month. That’s an average of 30 patients a day, including minor surgeries, ultrasounds and acting as 24/7 floating urgent care center. In that time, we have also done mobile clinics in Shadda, Coco, Camp Louise and pre-natal vitamin distribution in Caracol and have visited Milot Hospital, Justinian Hospital, and the HHH physiotherapy center and have helped many patients connect with needed specialist care (I got the schedule of all the visiting American specialist teams for the next few months at Milot so I know when and to whom to refer patients).
Pietre, Dave and everyone at Royal Caribbean have been awesome—we are wrapping up
our time here and getting ready to make our way to Panama to work south of the hurricane zone as the season advances, but I am very grateful to RCCL for making us welcome in Labadie and we will miss everyone when we go.
There’s a saying in medicine: “Common things are common,” and at a certain level of poverty some things become VERY common. Scabies, parasites, respiratory infections and fungal infections are common among my patients, but I hate when several such conditions are found simultaneously in all the members of only one family. A mother, daughter and young son came in with terrible scabies, secondary skin infections from scratching, bad worm infestations, anemia, and chest infections…we medically treated all the ailments, but I spent most of the consult working to make the mom understand the importance of washing, cutting the dirty fingernails of itchy children, washing, not drinking coffee at age 5, washing…and washing. Properly used, a single bar of soap can prevent an awful lot of disease, but poor home conditions and poor health awareness are two regular factors in the illnesses of my patients.
We did a mobile clinic by small boat in Camp Louise, a diffuse farming community of a few thousand people living a few miles west of Labadie. We visited the health center there but did our clinic in one of the local schools, treating the school kids and a lot of other children in the neighborhood. We were joined by a nurse from the Camp Louise Clinic, a Doctor, Physio and two teachers and Hannah from the Cap Haitian Health Network. This clinic was a tough one…a crowd of several hundred gathered within minutes; people were trying to literally pull themselves into the room we were working in (we all worked in one room, hot and crowded but impossible to maintain security otherwise). Hannah and the teachers had their hands full trying to keep us from being overrun, but we got through it—as usual in schools, lots and lots of scabies and parasites, and this location had lot of urinary tract infections and bacterial vaginosis in the young kids. Camp Louise is somewhere I would like to spend some time doing health education in the charitable schools there, as the high prevalence and poorer hygiene of the kids with UTIs suggests there might be a special need there.
Aside from the common stuff, the last couple of weeks have also brought us some very
unusual cases, and some unfortunate ones. The one that caught me the most off-guard was when I was consulting with a 96-year old woman (she’s in awesome shape, totally ambulatory) presenting with shoulder pain radiating to the arm. As I was writing “?mild strain?arthritis” on her notes, she told me that she had accidentally picked up some cursed money (people don’t like picking up money on the ground in Haiti, because JuJu men will curse the coins and scatter them around) and essentially been voodoo’d, so I gave her an anti-inflammatory and Noah showed her gentle stretches and exercises for improving shoulder stability. A few days later she came in and thanked us because she hadn’t had to go to a voodoo man to pay to remove the curse; our medicine had beaten the voodoo.
Let’s see…my shark bite victim is all healed up…the kid who came in with his stitched knee all torn open and infected is all healed up, but he’ll have a big scar on that knee for the rest of his life (but gets to keep his leg; it was pretty horrible looking when he came in and we first unwrapped the dirty bandage covering the torn-open, homemade stitches). The other night, just before dinner, we heard a familiar sound…a small wooden boat making its way towards Southern Wind, with a man, a woman, and a young kid with a dark-stained rag wrapped around his leg. He had been cut with broken glass, and a deep, 5-inch laceration on the back of his calf. It was pretty deep, with a lot of fat and connective tissue exposed and swollen with fluid; at first I wasn’t sure if the edges could actually be
closed, but skin is always a lot stretchier than you might think—I washed the wound and sutured it back up, and a few days later the edges had pretty well opposed. Incredibly, the sutures were ready to come out after about 4 days (really—they were already starting to be grown over); I love healthy kids—they heal so fast and bounce back.
While walking on the beach, we met a guy whose upper arm bone was completely fractured 2 years ago—I mean completely fractured, and it was never treated at all. It hurt badly for a year…and then the next year, without healing, it somehow stopped hurting and he retained use of the arm. It’s some kind of one in a million medical anomaly; absolutely incredible. His arm essentially has another hinge in it…if you bend the arm, the broken bone tents up under the skin and the arm bends right at the middle of the upper arm—Noah and I were absolutely shocked; this guy needs surgery to screw the 2 broken bones back together, so we are going to see if we can get the surgery arranged with someone before we leave.
And lastly…some bad news…a small baby came in about 5 days ago, age 1 month. It looked premature; it had been born weighing 6 pounds but had lost half its body weight, tipping the scales at a skeletal 3.3 pounds. It had no fever, no diarrhea, no vomiting, no cough, but hadn’t eaten much at all since birth.
The baby was listless and weak; it looked pretty thin at first glance but when Donna unwrapped it, we were shocked and dismayed at its emaciated body. I will always remember the apathy of the mother, the frustration of her sister…but especially the moment when we were examining the baby for its sucking reflex—young babies, if you stroke their cheeks with the tip of your finger, will reflexively turn toward the stimuli (as when the nipple brushes their face when they are being put to breast). This baby repeatedly turned its head away, almost as if it were deliberately giving up…unsettling to watch.
We contacted the Cap Haitian Health Network and got the mom and baby transported over the mountains to a hospital in Cap Haitian where they tried to feed the baby through a nasogastric tube, but last night, after 5 days of deteriorating steadily, the baby died (and it was only fed for 1 or 2 days through the NG because the mom couldn’t afford more…I found out too late or I would have found the funds somewhere!).
Things like this almost always penetrate my Zen, I’m afraid…it takes a lot of determination to let it go when things
that shouldn’t happen just keep happening, like that poor guy’s untreated broken arm, or the 10 kids with urinary tract infections I saw in Camp Louise, or that woman’s baby, or the hundreds of other things like that that drop in my lap every month. If you have a 1 month old premature baby that has lost half its body weight you damn well get it care right away, not after it has been deteriorating for a month…but that is easy to say, since to get checked or get prompt neonatal care, care has to actually be available and affordable, and this baby and mother didn’t have that luxury.
So when I sent that baby to the hospital, I knew that it was so fragile it could slip away at any moment, but I knew that its life or death was not mine to decide, only to do everything in my power right then to give it a chance, and the universe would decide. The universe chose to take it back. I’d be lying if I said this time I really, really, really am working hard to not be upset that the result I wanted wasn’t what happened. I wanted the baby to have a future, not just a chance, but I can’t give futures…only chances.
I need more doctors and clinicians out here. Come where your training is REALLY needed!
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Cap Haitian, Labadee, Shadda, Milot, Coco (east of Bayeux)
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
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.
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
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.
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,
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
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).
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
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
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
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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