Small Miracles

May 25th, 2010 by MSF Field Blog

This week Joseph was finally discharged completely from MSF’s program. It was a long journey to get here with Joseph, and there were days when I wasn’t sure that we would make it.

Joseph’s mother was witness to his worst days in hospital, and after a few weeks she had given up and returned home leaving him in the care of his teenage brother. This desperate little boy at our ITFC was no longer her son, she refused to acknowledge him or believe that Joseph could find his way back to her again, in short, she had already begun grieving. After his meeting with the psychiatrist Joseph began to improve, on medication he started to sleep, eat and gain weight, however with these improvements he became distraught over the absence of his mother. Most days Joseph would quickly descend into hysterics, crying for his mother, asking why she didn’t love him. In these moments there could be no reasoning; it became instead my daily routine to work with Joseph’s arms wrapped around me while he sobbed into my shoulder. He would become so inconsolable that the only option was to hold him until he quieted or fell asleep.

Slowly though these episodes became shorter, less frequent, Joseph still asked for his mother every day, always disappointed when she refused to come. He never stopped missing her, instead he began to better understand and manage the emotions he was feeling, without having them completely overwhelm him. It was several weeks after the visit with the psychiatrist that we finally began to learn who this boy Joseph was. He loved hip hop and dancing, was generous, wanted to be a football (soccer) star, was an incredible drawer of airplanes, helicopters, and houses, he wanted to go to school and mostly Joseph loved his family and wanted to go home. It was the day that Joseph asked if he could borrow my phone to call his family and find out why no one was coming for him that we knew he was ready to return home. When he reached his parents, instead of crying into the phone he demanded answers, he proceeded to get angry with his parents and was able to articulate these emotions in a way that most adults are unable to. The time had come to discharge Joseph home. It was his father who came to get him, explaining that his wife had almost left him over arguments about bringing Joseph home. Joseph’s mother refused to believe the reports of his improvements at the ITFC, instead believing that he would be a danger to the rest of the family. Joseph had been with us at the ITFC for over a month during which we had built him up as much as we could, but could he succeed in winning back the heart of his mother; was he strong enough to fight for his place in his family?

This week Joseph returned for his follow up visit with the medical and mental health teams. He talked about home, what he was doing, who he was playing with, all of the normal things a boy would share. When I asked him about his mother, he told me that she hugged and kissed him every day now. Joseph’s sister informed us that for the first week at home Joseph refused to talk to his mother out of anger, he had wanted to punish her before forgiving her. Joseph’s biggest concern now is school, it has restarted again In Haiti, but his family can’t afford to send him, instead he stays home…

Only now can I admit that I wasn’t sure if we were going to be able to save Joseph, who had been so determined to fade away into death. He will forever be counted among my short list of miracles witnessed.

Sherri – Blog 4 – It’s all about who you know!

April 15th, 2010 by sherrig

In Haiti’s Port-au-Prince/Carrefour region I am supervising MSF’s only ITFC (Inpatient Therapeutic Feeding Centre).  My program is small, fluctuating between 15 to 30 children admitted on any given day.  Unstable malnourished patients come to my program from all over Haiti for stabilization before they can be transferred into an ambulatory program.  The sooner a child can be transferred into an ambulatory program, the more likely he will thrive, as the disruption to a family’s daily routine is far less thus allowing a parent to balance the many priorities they have in a day.

MSF has an enormous capacity here in Haiti and I work closely with all of the sections.  With so many other NGO’s running medical activities however, a very important part of my time here has been spent building connections among local hospitals and clinics, making sure other organizations are equipped to both identify malnutrition and know how to properly refer them for the treatment they need.  There are many ambulatory feeding programs located throughout the Port-au-Prince area, some run by other organizations, which I have had to evaluate to ensure that they use the same protocols as MSF, that their programs are indeed free and well run before we could encourage any organizations to refer any stable malnourished children they encounter there.  In doing these evaluations with other organizations who encounter malnutrition, I have built up quite a network of contacts in the region.

Every organization has its specialty, it is inevitable however to encounter patients who are beyond your capacity and, at that moment, you try your hardest to find someone else who can help the patient.   Every person has that special case and every time they meet someone from another organization they inquire…. do you?  Could you?  Do you know where?  In building these connections around malnutrition I have become somewhat of a fixer for people, whether it be helping one organization find out who to call to successfully refer a burn patient for plastic surgery, or where someone else can get free echocardiograms, who runs pediatric TB/HIV, or the best way to get a patient into a neonatology unit, all of which are often full in the area.

Being able to help in these situations has become a small highlight for me.  We have all had those patients we have wanted to help and couldn’t.  With MSF in Africa, I have been in that helpless situation more times that I care to remember, where you are forced to tell a family that there is nothing more that can be done, and it still haunts me.  Here in Haiti, I am able to help people better access/utilize this huge NGO health care network  so that no patient should ever have to be turned away because a volunteer in a small health centre doesn’t know where to turn for help.

Sherri – Blog 3 – An Introduction to Mental Health

March 23rd, 2010 by sherrig

On one of my first days in my feeding centre I met Joseph. At 11 years old Joseph looked 7 at most. Joseph’s family includes 11 children; they have been living in one of the tent cities of Carrefour after the earthquake. Joseph and his 2 younger siblings were referred to the MSF Inpatient feeding centre (ITFC) for severe malnutrition complicated by illness. At the feeding centre we have successfully treated the 2 youngest children’s illnesses and they have gained enough weight on the therapeutic food MSF uses to be discharged home to their family. Unlike his brothers, Joseph has not thrived under the combination of therapeutic food and medical treatment. Instead, he became delusional and violent post earthquake, so traumatized by what he witnessed he now hears and sees things that aren’t there and lashes out at times towards others and himself. What broke my heart was his explanation as to why; Joseph believes he is already deceased, that he died in the earthquake. To me it seems as though he believes his spirit is already dead and he is simply letting his body catch up by refusing all treatment and food.

At an ITFC we are well equipped to handle the medical complications that come with malnutrition, Joseph’s case has presented us with special challenges. A very large part of the MSF response to the disaster in Haiti has been mental health, in my project we have psychologists who we work with. They however, have not been able to make progress with Joseph and our next step was to refer Joseph to a psychiatrist for an evaluation. Not as easy as it sounds, the psychiatrist is based 1.5 hours by car from us and with tightened security regulations in an already difficult context, it took 1 week to finally be able to arrange safe transportation. The day we went traffic was terrible and by the time we made it there was only 30 minutes left before we had to turn around and head home, so as to arrive before curfew. When we arrived I was so nervous, here we were with a child who rarely interacted with anyone and we had such a small window for the MSF psychiatrist to get a sense of him and put a plan in action. Imagine my relief when Joseph began talking and kept on going for the next half an hour. I left that day feeling hopeful, we had a plan, it had taken almost 2 weeks to put together but we had done it. Now we wait and see…

When Maslow was developing his hierarchy of human needs he made physiological needs the base of his pyramid. My experience thus far in Haiti has shown that safety and love can supersede physiological needs in the life of a child in crisis.

Wendy – Blog 13 – Last one

March 23rd, 2010 by wendyl

At least they are no longer made of bedsheets in the wind. That’s the upside.

I walked through a refugee camp yesterday. (Technically, not refugees, but internally-displaced people, or IDP’s.) This one is of modest size: estimates of its population vary from 8,000 to 15,000 people. MSF has been working on the water and sanitation situation there. There is also a busy outpatient clinic. And soon, we will start a children’s hospital on the premises, too.

This is the only camp I have had the opportunity to visit. We have flown past others by the side of the road, with no way to know how conditions are for those who live there.

In this one, at least, it seems that most people have acquired some plastic sheeting, and so made their homes a bit more waterproof. They are no less cramped, though. Nor do the residents show any signs of being about to move elsewhere. Where would they go?

The tents, then, are crammed in, side-by-side. Some are like pup-tents, many are now plastic-covered cubes. It is crowded.

But life does not stop. The camp is a community, bursting with everyday living. There are alleyways and boulevards. Children pull juice-bottle trucks on a string. Girls sit patiently for their braids to be woven in complicated patterns. Young men listen to music and cruise at a corner. There are street vendors for biscuits and candies and chips. People fry street food. I see a couple of restaurants, and a movie “theatre” advertising the next Champions League soccer game on TV. Little boys harass visitors with repeated, repetitive calls of “Hey, you!” as they follow one around the camp.

“Hey, you!”

“Hey, YOU!”

(It’s only cute the first time.)

There are women doing mounds of laundry by hand, the clothes drying on the ledges of the wall that surround the camp. A church service is taking place inside the semi-ruined hall. Some children chase a ball, squealing.

The camp is enclosed on private land, with gates at either end. Apparently, the community has organized themselves so that the gates close in the evening at a given hour, a self-imposed curfew. Security has been alright. I don’t feel at all uncomfortable to be walking around.

I buy some cookies — can’t find the local peanuts that I like, but can, I realize, ask for them in Creole. “Ou pas gen pistaches?” Wave at some kids. Groove to Haitian rap. Apparently I’m the only one in my group who thinks it’s cool.

Life has always been difficult for most Haitians, I think. But they are not sitting morosely in camps, waiting for help. They are living, exuberantly.

Wendy – Blog 12 – Miscommunication

March 13th, 2010 by wendyl

I can’t believe it’s taken me this long to figure it out.

I’ve now spent a total of nearly nine months in Haiti: just over seven months last year, and now another six weeks. My Creole isn’t very good, but I understand a lot.

French and Creole are similar and related. In fact, on more than one occasion, Haitians have complimented me for my Creole. Except that the words I had just uttered were in French.

But it only just dawned on me, why it is that with so many of our staff we have this maddening pattern of communication.

I ask what I think is a simple question, like, “Where is Sara?” or “Where is the patient’s chart?”

And I get a blank stare, and the answer, “Yes.”

No, where is it? “Where” is not answered with “Yes”! Argh!

Eureka. In French, où est (“where is”) sounds exactly like Creole ou wé (“you see”). So asking “where is Sara?” in French is indistinguishable phonetically from “Did you see Sara?” in Creole. It’s a bilingual homonym.

Of course the answer is yes. Argh!

Sherri – Blog 2 – A Haitian welcome

March 11th, 2010 by sherrig

My first day in the project and I know already that I am going to love it here!  On arriving at the ITFC (inpatient therapeutic feeding centre) I took a moment to speak with all the staff and mothers present, explaining to them who I was, why I had come and also about the blog I would be writing and why it was important.  I finished by saying that over the next 3 months I hoped that they would welcome me as a member of their families here in Haiti.  The most incredible thing happened; one after another the mothers and staff kissed my cheeks and wrapped me into these big hugs, the kind you almost never get from strangers back home.  I feel as though they have already given me their love and respect and now it is mine to protect, and hopefully grow.

Wendy – Blog 11 – Hospital in the Middle of the Road

March 9th, 2010 by wendyl

I’m getting ready to leave. I’m trying to explain everything I know about how the hospital functions, and where the hiccups usually occur, to my successor. It includes the progress from where we’ve evolved since I arrived, to the nascent plans of what we?re trying to accomplish next. And I’m trying to verbalize all the details, orthopedic and psychosocial and otherwise, of our almost-100 inpatients.

When I arrived, there were about thirty. Truthfully, most of those are still with us: the nature of serious orthopedic problems is that they take a long time to heal. These are the patients for whom I know not only their names and pathologies, but also their families and moods. I can say I’ve personally witnessed clinical improvement in some, like “Bobby” who is strong on his crutches (but still recalcitrant in extending his knee), and nine year-old “Rebecca” whom I discharged today, walking firmly on her healed femur fracture. I think her limp will soon hardly be noticeable.

“Dearie” finally had her skin graft today after many days of waiting: hers was particularly large. I found her crying this morning about it. She is sweet but always sad, at 19 years old, she lost an infant in the earthquake and has no family to help her. I think she despairs for her future: as her wounds improve and she walks more easily (no longer needing crutches), she fears being well enough for us to discharge her. She has nowhere to go and, I think, no way to support herself. Could healing be more bittersweet?

Since my arrival, we’ve added tents and beds, and more tents, and more beds. Most wounds are no longer infected. Some have had skin grafts. We’re starting to talk about taking people out of traction, or taking off external fixation sets. We’re discussing weight-bearing and walking. But also: non-union, mal-union, infection. The phase of the emergency has changed. Tomorrow will be the first set of fitting sessions for amputees who need prosthetic limbs, through another NGO.

From thirty patients to just-under a hundred. We opened a Rehabilitation service, where patients need less intensive medical care, and more intensive physiotherapy. There are more patients than will fit in the beds available there. We did grand rounds there this afternoon: it is rather a marathon.

I joke that I am kind of like the Orthopedics resident: trying to keep things moving on the wards, understanding diagnoses, filling out paperwork, running around chasing things that need to be chased, without being much in the operating room, or deciding on the course of therapy. I have learned a lot. Orthopedics wasn?t my forte before this.

I have to admit that for the more recently-arrived patients, I am less able to keep their stories separate and straight. There are several young men with fractured femurs – now was that from a fall? Or a car accident? Or since the earthquake? I cannot see their X-rays in my mind’s eye when the patient is in front of me. It’s hard to do a good job telling the story to my colleague when I can?t keep the details straight.

But for others I can recount their medical history without checking my notes: one young woman who is a model patient, has a perfect external fixator, no pain, good technique on her physio exercises, and a perpetually sunny disposition.

Today I also failed to contain my frustration because somehow, a little girl with rosebud mouth and alphabet barrettes had been inadvertently discharged not once, but twice, when the intention was to hospitalize her for IV antibiotics for her potentially infected plate-and-screws that hold together her femur fracture. Her treatment has been delayed for four days as a result. It’s time for me to go. My patience is too thin.

Much is left to be done. We need a proper emergency room with emergency physicians, if we want to call ourselves a trauma hospital. We want to expand to have a general paediatrics department. We should develop to have abdominal surgery capability.

Not long ago, this was a hospital in the middle of the road.

Sherri – Blog 1 – Touchdown

March 8th, 2010 by sherrig

After 4 previous missions I still find myself in the Toronto airport with butterflies in my stomach. In the air flying over Haiti for my first time, my first thought is how calm thing look down below, untouched, I took a moment to admire the colours of the Caribbean city which will be my home for the next 3 months. As the plane descended I was horrified to see that the colours I had been admiring were instead the plastic sheeting people had used to construct these tent cities so numerous and huge that they were visible from thousands of feet in the air. It is estiimated that 2.1 million people are living in the streets of Haiti, either because their homes were damaged or destroyed or because they are too afraid to return indoors. Life’s difficulties are nothing new for the people of Haiti, but I am struck by the fact that prior to the earthquake most Haitians rented, meaning that even if they had the tools necessary, these homes are not theirs to rebuild. The land where their previous homes stood is not theirs to use for the rebuilding of their lives. There is a lot of discussion about the coming months and the weather they bring, the small rains we are having now are wreaking havoc on the tent communities, how will they survive the true rainy season? Or worse hurricane season?

I have finally learned that I will be working in the city of Carrefour, which melds into the southern border of Port-au-Prince along the coast. Only a few kilometers from the epicenter and with a population of almost 1 million, Carrefour was in many ways devastated by the earthquake. I will be responsible for MSF’s nutritional program in the region. As a population who has always been at risk for malnutrition, the force of the earthquake seems to have tipped the scale. MSF is taking a proactive approach to malnutrition, as my colleague put it, treating the indirect consequences of the earthquake. My role here finally clear, briefing finished, I begin tomorrow in Carrefour, what will I find there?

Read my bio here!

Wendy – Blog 10 – Reverie on the Radial Nerve

March 7th, 2010 by wendyl

In our first week of medical school (more than 10 years ago), one of the earliest anatomy lessons was for us to memorize the roots and branches of the brachial plexus. (The nerves exit the spinal cord at the neck, coalesce into a web and gather into new configurations that become the nerves that travel down the arm to supply muscles, for movement, and skin, for sensation.) It’s complex. I, with my classmates, learned it by rote, passed the exam, and honestly, haven’t thought about it much since then. My colleagues who chose hand and upper-limb surgery are intimately involved with the radial nerve. The neurologists, I’m sure can trace out the branches. For me, as a generalist, I usually only need a passing knowledge. Is this injured patient neurologically intact? Almost always, the answer is yes (but I always check).

Wow, now I have a new appreciation for the radial nerve and its vulnerability. We have quite a few patients with radial nerve palsies (ie. injuries), so now I am quite used to identifying the syndrome: drop-hand, with difficulty extending the fingers and wrist, and difficulty with supination (turning palm up).

What’s interesting is the various levels of injury that have occurred. The most common is a radial nerve injury where it passes through the spiral groove of the humerus: often with a midshaft humeral fracture. One of our patients doesn’t have a humerus fracture, but you can see the scar on the medial aspect of her left upper arm where she had a laceration, exactly in the crucial spot. Sadly, her right hand is also badly crushed; I hope she will again use her right thumb and index finger, perhaps the middle finger, also.

Another patient was a man who, during the earthquake, was trapped in an awkward position trying to protect the baby cradled in his arms. Tragically, the baby perished, as did his wife and older child. He had a right drop-foot (peroneal nerve palsy from compression at the fibular head) and a left drop-hand, with a scar on the back of his wrist. He told us it had been a deep laceration that had since healed over. So, thinking that it had also cut his extensor tendons (of wrist and fingers), they did some exploratory surgery to look for the ends, in order to sew them back together. So many weeks after the accident, the ends risked being difficult to find since they can retract considerably. I joked to the surgeons that the tendons might be in Miami by now.

The extensor tendons, though, were still firmly in Haiti, intact. His problem was neurologic: a radial nerve palsy, possibly compressed in the forearm or elbow when he was trapped. “Maxine” is a little girl, nine years old, with round cheeks and a toothy grin. She had a compartment syndrome of the right forearm (as “Bobby” did of the leg). Her fingers are curled up in full flexion. We put her in a volar (palm-side) splint to prevent contracture at the wrist. There is no movement there at all. She is very tight in the elbow, too. I assume that her radial nerve injury occurred because of the increased pressure in the forearm; the elbow stiffness might just be from prolonged immobilization. The other possibility is that she has a concurrent injury more proximally, before the nerve branches to the triceps. The principle of neurology is always: where is the lesion, what is the lesion, which sounds easy but is (I think) difficult.

And there are others. One patient reportedly had some concrete fall on her shoulder, with axillary nerve dysfunction: my theory is that it pulled at the nerve roots coming from the vertebrae in the neck. Another of our patients, who is very depressed, had a shoulder dislocation for six weeks, which is now in the right position but with a very loose joint capsule. She also has an associated radial nerve palsy, probably at the level of the brachial plexus.

The good news is that the prognosis is fairly good. Peripheral nerves (as opposed to spinal cord) can repair themselves as long as the nerve sheath is intact to guide the way. Already, you can see the beginning of some wrist extension where before the hand flopped uselessly. Physiotherapy will help. And time is a great panacea. Nerve grows slowly – something like a millimetre a day – but it does grow.

Wendy – Blog 9 – Women

February 28th, 2010 by wendyl

Most of our patients are women. I’d say they make up 80% of our most serious fractures. The earthquake struck at 16h50 (4:50 PM) on a Tuesday afternoon  and apparently the most vulnerable were adult women at home, preparing the evening meal.

Among our patients who have been with us the longest are a group of young women in their early twenties. The core group is four: two with femur fractures in traction, one with a tibia fracture just below the knee, and one in an external fixation set for her tibia-fibula fracture. Then there are a few others, of the same age, with similar traction sets or external fixations, who round out the group. But the four are inseparable: when we started moving patients from the orthopedic hospital to the rehab (physiotherapy) service, we had to move them as a unit.

I call them M’s girlfriends. Their eyes light up at the attention paid to them by M, the attractive trauma surgeon who was one of the first team members to arrive after the earthquake. He has been involved in their treatment from the start. He teases them about when they will be well enough to dance with him. And when they moved to Rehab and they saw him less often, they insisted to me, tell him to come visit us.

The ringleader is N, who has a tibia fracture just below (but not involving) the joint line, undisplaced. She gets dressing changes under anaesthesia about every 5 days for the wound behind the knee. She is overflowing with life: talkative, mischievous, shining eyes and luminous smile, who wears her emotions like banners. Last week M told me she refused to talk to him on his most recent round: I said, she’s playing hard-to-get so next time you come begging, and with flowers.

I think they spend their time chatting and gossiping. A few can get around on crutches (as opposed to those confined to bed because of their traction sets), so they sit under a tree outside and gossip. One has a baby of 6 months, who is passed around the room and fawned over. Last Sunday, a hairdresser stopped by and must have done a booming business, because when I saw M’s girlfriends on Monday morning, they all had new matching coiffures.

Last week I asked them if they would consider moving indoors from the tent. The rains are starting. The Haitian doctor said, sure, they won’t mind: the roof of our Rehab building is aluminum sheeting, not concrete. No! M’s girlfriends cried in a unified, horrified voice: there are still walls. The walls are concrete and they will fall on us.

Well, yesterday M said his goodbyes to the girlfriends. He is exhausted and heading home. I think it was emotional on both sides: from the hospital on the street and operating under a tree to, soon, being able to remove their traction and learn again to walk. But he couldn’t play favourites. One burst into tears: why must everyone leave? she asked. Wendy, are you leaving? (Yes, chérie, I’ll leave in two weeks, but new people are arriving with new energy to continue with you.) There was an individual photo with each of them; none of the core four were left out. And when he left, he said, Wendy, please look after my girlfriends.