The General

Last night my patient slipped away, into the unknown, peacefully, with a smile on his face. He was surrounded every day- right up to his last moment- by the love and laughter of his wonderful family.

Caring for him during his last two nights in this world was one of the greatest honours I have had. Watching his family accept and grow with all decisions surrounding his care was beautiful, inspirational even. Hours before his passing his room was filled with the sound of laughter and delight for such a special individual. There is always a sense of peace and stillness that arrives with death, and this time there was a sense of beauty too. I cried with his family and loved him dearly, and we all smiled through our tears at the end, happy that the end had come in such a silent, peaceful way.

It was a far cry from my experience at the General Hospital in Port-Au-Prince. Robin and I worked four hours on our first day and saw three deaths during that time. The IMC staff worked around the clock in that godforsaken space to alleviate what little pain and suffering they were able to, with limited resources and very few staff. They did an amazing job, but it was an immense task to take on.

One of the physicians explained to me the shock he experienced on his first day: one guy with gunshot wounds to his abdomen on one of the resuscitation beds. The entire team had been working on him for twenty minutes when another guy with a gunshot wound came in- onto the only remaining resuscitation bed. No doubt from the same fight. So then the team was split up, and a few minutes later an entire tap-tap (think large pick-up truck with benches on it, used for public transport) unloaded the victims of a massive MVA into the ER. Chaos. “I thought every day was going to be like that,” he told me, laughing. “Some are better than others.”

We worked for three days in the ER, ICU, and triage. We worked alongside some of the most dedicated individuals, who were striving to create an environment that approximated the centers of care we take for granted at home. It was, it is safe to say, a lost cause. A losing battle. The first time I went to get a patient something for pain, the physician instructed me to find out what the “narcotic du jour” was, as it depended on stocks for that day. Wonderful. Half the time you went to get a med, they had run out, and in an already busy setting you end up scrambling to find abother med- which is available- that approximates the effects of the one you actually want to give. A seven year old codes, and no one knows if there is a suction available, and if there is, where it would be. And why he is coding. Patients lie wasting on cots with their buckets used as bedpans directly under their cots. The stench when you walk in is overwhelming. There are no sinks to wash your hands in- hand sanitizer is all that is available. Active TB predominates, and the staff advises you to wear a mask the entire day....and not throw it away, but reuse it the next day, as there are limited supplies. The TB area is “down that way”, but you also pass the holding area of TB patients waiting to be admitted every time you walk between triage and the ER or ICU. Which you do a hundred times a day. Prisoners come in with the shit beaten out of them, accompanied by police, to see if they need medical attention. It falls on us to decide whether they can stay or have to return to prison. They return; we have no room. One 17 year old prisoner lies handcuffed to his bed, he stole a goat. He stole a goat because he was hungry. A GOAT. And he has served out three months of his two month sentence (thats not a typo). And in the third month, he was beaten so badly that he arrived with a brain injury. He gets haldol every hour. And he lies in bed, handcuffed and tied down, agonizing.

This hospital is no shining star. It does however provide free care. And people arrive, sick, injured, dying, every day. And every day we would send many people home or elsewhere, and admit very few, restricted by beds and waiting for people to die. None of which will die the peaceful, loving way that my patient did last night.

The medicine unit, also jokingly but aptly referred to as the “catacombs” by one medical transporter houses row upon row of wasted, emaciated patients, waiting only for the release that death will bring. When you walk down through that dark space you are overwhelmed by the need. Robin and I walked down a dark and dingy hallway, and a weakened, emaciated shell of a man, wasting towards his end on a cot in a hall, reached his arm out, asked for “dlo” (water). We gave him some of our gatorade. He downed it. We gave him more. He downed that too. All that was left of him was protruding bones and a sweet smile, and it killed us to walk away, back to the intensity of the ICU and ER. Where were the nurses in this unit? Who was caring for these palliative patients? No medical staff to be seen...only tired, worn out, hungry and broke family members acting as caregivers in Haiti’s busiest medical establishment.

So I will no longer not take for granted our health care system; no matter how tired or crumbling or stretched in resources it appears to be. I will advocate for the resources we require to improve patient care, certainly- but never again will I take it all for granted. Not the extensive, complete pharmacy that caters to each unit. Not the labwork and tests- and results- that you can get immediately. Not the sink by every room and bathroom in every room. Not the multidisciplinary teams that descend upon the unit and whisk your charts away when you seem to need them most. Not the dirty utility room- never the dirty utility room- after seeing where the waste goes at the General (into the open gutters directly outside the hospital). Not the excellent resources we have right here, right now. Not the isolation rooms and the isolation precautions we take daily. And, finally, not the compassionate care we are able to provide in the most sterile of environments- a hospital- for a patient in his last hours. None of it will I take for granted. Because after working only a few short days in Port-au-Prince's main health care facility, I realized how lucky we are at home to be able to provide the care that we know.

And its not that when transported to Haiti you suddenly lose or give up your standard of care. Its that you aren't supported to provide that standard. You don't have the resources, not even close. You lose yourself in the frustration, but you keep going, because it is all you can do.

More photos on picasa:

General Hospital June 2010

Canada Day celebration: lessons from an orphanage

Happy Canada Day, everyone! On this day I am proud of this country where I put down my roots. This vast, wild, beautiful, open country. The Coast mountains, the Pacific ocean, the rainforest that I call home. I am grateful for this space, this place, this nation.

This home.

Robin and I spent our first two days in Haiti at an orphanage. We were immersed in the life of two women- a mother and her daughter- who had dedicated their lives to caring for the timoun- children- who came to them for warmth, love, and education.

Mami Kikine opened the orphanage in 1996, with the help of her energetic daughter, Madame Annie. At first they housed ten children in the village, and eventually made their way to Port-au-Prince and rented the ground floor of a home. They serve as an orphanage as well as a school of sorts; children both live in the home and come for their daily school program.

Prior to the earthquake, they had over 100 children. After the earthquake, many families sent their children to the countryside, to the promise of something better. Port-au-Prince has the highest density of any city in Haiti, which meant that post-earthquake, everything was compromised. Is compromised. Remains compromised.

So many children- timoun- were sent out to various families. Insert here a little cultural tidbit: In many- but not all- situations where a Haitian child is sent to live elsewhere, it is done so with the assumption that the child will be provided with food, clothing, shelter, medical care, and education, in return for domestic services. A live-in maid, if you will. However, in many cases, the domestic services are the only part of the bargain that is fulfilled, and the child is abused physically, psychologically, and sexually. When treated as slaves, the term for the child is “restavec”, and they are usually young females. In a country of 8 million people and climbing, 300,000 are restavecs. Food for thought.

NPR on restavecs: http://www.npr.org/templates/story/story.php?storyId=1779562

But I digress. The orphanage that we stayed at now had about 50 children during the day, and 20 at night. We spent two days with these children, and watched Mami Kikine and Madame Annie teach them their lessons through song and dance, through call and response, through dedicated sweat and love. The children crowded around the three tables- actually delaminating doors set onto table frames- and listened and learned. Shortage of chairs meant that in many situations, two chairs became seating for four with the addition of a wooden plank between the chairs. The children learned and rehearsed, sang and danced, and carefully copied their assignments into their notebooks. It was thrilling to be a part of this, to see them learning and listening, and to see them reflect our own encouraging emphasis on education with such motivation. The sweat poured off Madame Annie while she provided an entire hour of call-and-response French lessons.

The children get one MRE (military ration) per day. The MREs were previously donated, and they are running low. So when we were there, all the children got one. The next day, they confessed that they did not have enough to provide food for all the children, so they saved them for the live-in orphans, and hoped that the others were provided with enough food at home.

They sleep on the floor, girls on one side, boys on another. No mattresses, only a thin blanket between the hard concrete and their thin bodies.

The water cistern was near-empty the entire time, and yet they generously offered us daily bucket showers. Filling up one bucket took five minutes of work, and was promptly emptied again for drinking,cooking, and washing.

They are three months behind on their rent, and they have had to send other children away because they cannot afford to keep them. They have also let go of four other teachers due to a lack of funding.

But these incredible women push on, smiling the entire time, loving these children with such fierce compassion.

Robin and I brought donations from Canada. We did a tie-dye project with them and they laughed and smiled and concentrated and delighted in the results. The t-shirts were nothing like what we had expected, but they came out beautifully. We provided them with notebooks and pencils and art supplies and watched as they focused their energy into creating. We filled their water cistern and bought them new tables and chairs and clothing and food and toothbrushes and worm pills.

We gave them so much from all your donations. And yet- they gave us so much more. I wish that all of you who donated time, money, or even words to me could receive a piece of the gift that Robin and I received from the orphanage. We learned so much from the children. We learned that love is hope, and hope is our future. And children need hope to grow. We learned that life is harder there than anywhere our own children will grow up, and that the beauty comes in the children. We learned that children of all ages have something to teach you, and each other. We learned that children without parents can make you cry, but that if they are in a space of love and acceptance and learning and hope, it will be alright.

We learned so much more than we both even understand yet. I hope these photos show it, and share some of it with you. Thank you, everyone, for all your love, support, and encouragement.

Happy Canada Day, everyone. Love this place, this home, this space. We are all so lucky.

More photos from our orphanage work:

Haiti June 2010