This past August, another team sponsored by Long Island University (School of Nursing) went back to Haiti. We were a team of 15 that included: Nurse Practitioners, Nurses, Pharmacists a Physicians Assistant and a Nursing student. For 6 of us this was our second trip and some of us went mainly to provide training and education to the providers and staff of the 3 clinics. I myself did not work in the clinic at all this time – just went to teach. Although this second trip back was not as exciting because I did not have an opportunity to provide patient care – it was so very necessary! The type of training we provided was never done with this group before. It gave us an opportunity to actually sit down and talk about the issues in the 3 clinics as well as provided very important information and training to the permanent staff. As a pharmacist I was able to talk about the many issues related to pharmacy services such as medication inventory, maximizing pharmacy resources, patient education, etc. As volunteers it feels good to go to a place like Haiti and provide “good care” as best as we can for a week or two. However, 3 days training those that see patients on an every day basis has much more of an impact and as a result helps so many more people!
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Experience by Sweta Chawla, PharmD
Written by Monica Mehta, PharmD
An elderly gentleman presented to clinic with an elevated blood pressure of 160/90 mmHg. The nurse shouted across the clinic to me inquiring about hypertension medications. Sifting through my shelves, I pulled out a bottle with a foreign brand name. By chemical name, I recognized it to be a combination of amlodipine and telmisartan. We figured out a dosage regimen and by way of an English to Creole interpreter, I counseled the patient. Two days later, he returns with no change in blood pressure whatsoever. The flustered nurse asked what else I had. Before digging out the next bottle from my makeshift pharmacy, I decided to talk to the patient about how he took the medication. After some time, the translator, nurse practioner and I discovered the problem. Since I recommended that he take his pills with food, he never took the medication. He has no food.
Sometimes it’s not about the drug.
The opportunity to go to Haiti presented itself. If you were in my shoes, would you go? Why not? I’m a professor of pharmacy practice in at Long Island University in Brooklyn, New York with a specialization in community pharmacy. Patients in my clinic have hepatitis C, hypertension, and diabetes, among other things. More than just medication management of these diseases, I teach my students to provide care. In whatever form they can. During his rotation at my pharmacy in Brooklyn, a recent student measured a patient’s blood pressure with perfect technique and reported a normal reading. However, he failed to acknowledge and comfort the patient, who was in tears because of a recent death in the family. Sometimes caring for patients requires acknowledging their real problems – not just their objective parameters of disease. With this attitude, I said yes to the trip to Haiti.
Our team consisted of other Long Island University folks, led by the Dean of Nursing and included nurse practitioner faculty and students, some of whom had trauma experience. The six of us were to see patients in a family clinic in Haiti’s capital of just over 700,000 people, Port-au-Prince. Within the clinic, I set up my little pharmacy with the few medications that I brought. I organized them by indication, with antibiotics in one corner, cardiovascular meds in another, and so on. There was no pharmacist preceding me, as they are few and far between in this country. A local Haitian nurse dispensed medications before I arrived and I learned that she often turned patients away if she didn’t have the exact medication that the doctor wrote down. This is exactly why in this setting, organizing drugs by indication makes more sense. If I didn’t happen to have one antibiotic, I could recommend another. The bottom line for me is that we used what we had to help the situations. And resources were scarce.
An eight-year old boy, Franklin, who was much too thin for his age, arrived with fever and weakness. After a physical examination, the nurse practioners suspected meningitis. With out access to diagnostic tests, our team came up with a plane to give a dose of IV and ceftriaxone. He also, desperately needed hydration, but we only had a single bag of fluids remaining, which went fast so we came up with the idea that, while the nursing student held the IV line, I drew up saline from 10 ml saline flush vials. I withdrew fluid into a syringe and she injected it. Twenty minutes and twenty vials later, Franklin seemed appreciably better and was able to eat. Teamwork became our remedy for the extreme lack of resources.
Despite our rift in language, communication became key to providing health. Taking a thorough patient history led to critical differences in patient management. And this was a tremendous challenge in a naturally introverted population who were too respectful to ask questions. Local physicians were giving Bactrim® and chloroquine to every patient for empiric management of gastrointestinal infection and malaria. A young and thin woman in her mid-20’s arrived with severe suprapubic pain. She had prescriptions for Bactrim® and chloroquine, wishing to have them filled. After the nurse conducted a physical exam and found hepatosplenomegaly, we suspected that she needed more attention. After vigorous questioning, we discovered that she recently had an abortion by taking misoprostol. Could the misoprostol have contributed to the now enlarged liver? I recommend to switch the Bactrim® to ciprofloxacin to treat her suspected urinary tract infection in order to avoid further hepatotoxicity.
The patient counseling skills that I teach my students back home meant more in Haiti than anywhere else. These patients were so poor, that they came to us for management of every illness, not just those caused by trauma. There were many pediatric respiratory infections for which I had to use urine cups to administer oral antibiotic suspension when I ran out of the vials that I brought. Luckily, I had a squeeze bottle with volume gradients so that I could measure water for reconstitution. We simply couldn’t take for granted that they had a refrigerator to store the medication, so I taught them how to store medication bottles in chilled water. One cannot assume that they are able to open the bottles and must be taught. Even simple actions required physical strength beyond their means, as they were often malnourished and emaciated. I will never forget spending over thirty minutes to teach a young and frail 12-year old girl how to use her albuterol inhaler. The simple breath and hand coordination was a daunting task for her until we practiced together repeatedly.
The country was hot and humid with rainfall at night. We slept soundly in tents behind a damaged building. People lived in dire poverty with a goal of survival by the day. But they also danced and sang. Cooked wonderful meals for us. I held children so tightly, trying to give them strength. And with their laughter, despite conditions in which they lived, I became inspired by human resilience. On a trip downtown to gather more medications, I saw crumbled buildings. There was a street vendor selling crutches, which were most likely donations from the states. And next to him, a man was selling his family’s personal clothes. Nearby, a man who was clearly more affluent was eating a meal while leaning on his motorcycle. In spite of the resource gap between these people, there was no stealing. No fighting. Haitian people are not violent by culture. Back home, we hear about stories of explosive violence in the context of starvation in this country. But I wasn’t scared for one single day in Haiti. Not one moment. The connectedness with the people obliterated any fear of them.
There are two main things I’d like to express to pharmacists. First, if you want to help, there are opportunities if you seek them out. Don’t allow your perceptions of limitations prevent you. The first and last step of doing developmental work is the desire to. Your skills and knowledge are ample. And second, when working with a team, you can do anything. We compensated for our deficiencies with each other. I withdrew the saline and the nursing student pushed it.
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I cannot believe my month is coming to an end and I’m heading home in a day. I apologize to all my friends and family for not e-mailing more often, if at all, but it’s been very hard to put thoughts into words — I found myself mostly unable to do much more than take it all in. I am quite certain that I will be processing all that I have seen, heard, experienced, and felt for a long, long time to come.
It is really, really nice to think of being home again but I have to admit that I am a bit nervous about it. Dan did remind me that I would never be the same after this month. What we didn’t talk about was the fact that I wouldn’t know what to do with it all. The poverty; the sadness; the destruction; the respect, care and love for each other; the suffering; the trust; the deep and genuine trust in God; the deep felt pain that is only expressed through the crying that comes with the physical pain of PT….
I have never seen children cry such a deep felt painful cry from anything – certainly not from a PT stretch. We have 2 kids whose cry is clearly so much more than the physical pain… it comes from a place children (noone for that matter) should know.
Throughout the month I tried hard not to think of the details of our patients stories, but a month was long enough time for them to want to talk. It is heartbreaking to look at them now and have a vision of their hours or days in the destruction of the earthquake — there is the little 4 year old girl who lost her 2 sisters, her mom, an unborn sibling and a leg; the 11 year old girl who was found 2 days later and has lost both her legs; the mom and dad who had severe injuries and lost a daughter that was lying in bed between them; and the 23 year old young man that was trapped head down for 4 days without food or water and has lost a leg. The stories go on…….
In the midst of all of that they are all moving forward and grateful to be alive. In spite of all the suffering and the incredible poverty of Haiti, most I have met talk about how grateful they are to God for all that they have been given! There is nothing more humbling than to hear that from another human being who lives in a square room without electricity or water and who cannot pay for school and medicine and cannot eat everyday. They thank us, with such heart felt gratefulness, for leaving our loved ones and our lives behind to come take care of their ‘family’. And they have given me so much more than I could ever give them!
So, in a mixture of emotions from much sadness to laughter, here are some of things we have learned while working here in Haiti:
- yes, it is possible to have an open fracture (huge one), gait training, and a tarantula in the same room at the same time
- you have not known heat until you have been in Haiti…. more specifically, until you have done physical therapy while wearing heavy cotton scrubs (the kind that glues to your body) while working in Haiti
- a medical history can (and should) include – ‘when was the last time you ate?’ and ‘how frequently do you eat’?
- custom made braces can, and do, fit many people
- a trickling shower CAN be the ‘best shower you have ever had’
- yes, it is possible to have 4 children and an adult on a motorcycle
- waiting… for hours…. can be a daily and natural occurrence in one’s life
- open wounds can (sometimes) heal well despite the most unsanitary of conditions
- a cold soda can be the most amazing thing in the world
- it is quire possible, and very probable, that in your sweatiest and dirtiest day you were still in a better place than Mary and I at the end of each of our days this last week
- ice cubes can be the most amazing gift to a hungry child…..yes, just plain ice cubes
- scabies ARE contagious
- being inside a building with a cement ceiling can be very scary
- it is possible to see Mary Jean speechless
- it is possible to have absolutely nothing and yet have everything
- when you put it all together, it is impossible to spend time in Haiti and not want to come back….. my next trip is already scheduled for July!
Here are a few more pictures to help share our experience while in Les Cayes, Haiti…
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It was HOT today – I mean really really HOT. Our house mate said over 100′. I used to always use the expression Africa Hot. But now when we hit those 90′ days in Erie PA with humidity at 100% and no breeze to be found from the lake – I’m gonna say it’s Haiti Hot.
I’ve come to realize that a little goes a long way here. Thanks to the many generous people back home in Erie – I brought a lot of shoes to Haiti – almost 50 pairs. I was working with a young woman today named Gemima who was injured in the earthquake. Gemima had several injuries one of which included damage to a nerve in her leg which innervates the muscles in her foot. She can walk but she needs a brace on her ankle so she does not trip on her toes. Gemima told me that she needed new shoes because the ones we gave her last week to use with the brace were too big. Now I had to agree that they were a little big but mostly they were kind of ugly looking because truth be told they were probably men’s walking shoes. So I took her into the back room where we keep all the sneakers that I had carted here and we started going through the box. I told her she could pick out her favorite pair and we would see if they fit, if not we would keep looking until she was satisfied. I told her that after all – beautiful girls should have beautiful shoes. So she found a pair she really liked and like cinderella – they fit perfectly. Boy did she smile!
I also saw a young man named Moses. Moses is about 14 and fairly impaired cognitively functioning at about the level of a 2-3 year old. Moses lived on the street in a small community near the hospital. Everyone in the village knew him and looked out after him. It came to the attention of one of the missionaries that Moses had no guardian so he and his wife took Moses in to live with them. They came to the hospital to see us because the dad wondered if we could help Moses stand a little better. When Cris tapped me on the shoulder and told me she had someone she thought I should see, I turned and looked. My mouth opened and all that came out was “OH MY!!!!” Well like they say - you should never judge a book by its cover because although Moses looked fairly twisted, turned and bent in standing when he sat down and I started to take a closer look, he actually had very good flexibility. We decided he might do well with a brace for his back and a brace for his knee. Thirty minutes later, he stood before us and the transformation was astounding.
For some it’s a new pair of shoes or a brace for their back. For others it’s a lollipop, a smile, a kind word, bubbles floating through the air, or hand full of ice…. Maybe what I am most touched by – is that is takes so little to make my new Haitian friends so happy. They are so grateful for the smallest acts of kindness. For me- maybe it’s a call to recognize all the little things that people in my life do for me each and every day. When I return, I plan to be more thankful.
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Can you believe I am speechless? I have been here for three days and I don’t know how to begin to describe where I have been and what I have seen. The poverty in Haiti is beyond comprehension. People routinely go 2-3 days without food. I think many of them are hungry all the time. When we walked to the clinic today carrying ice for some of the patients, the children along the way were so excited when Cris stopped and gave them a handful of ice cubes. They live in houses with windows but they are not covered with glass or screens. Some of the houses have roofs but some do not. A 6×6 square house would be big enough for a family of 5-6. They only use the house to sleep and keep their possessions safe – the rest of the time they live outside. They cook and they eat outside. They bathe and wash clothes in the local streams. They walk back and forth to the local “spring” for water which most often is contaminated by sewage runoff. They seem to spend a lot of time waiting: waiting for job, waiting for the electricity to turn back on, waiting for church to start, waiting for the rain. After the earthquake came, they waited to be found, and to see doctors and to get medicine, and to have surgery, and to hear from family and friends they may never hear from again……. And still despite all this, they are people filled with great joy and hope! I feel so lucky to be here and witness their resilient spirit!
This morning I went into the hospital to see a little girl. She looks to be about 18 months. She has hydrocephalus (a very large head). In the US, this little girl would have had surgery shortly after she was born. But this is Haiti. It turns out this little girl is around 4 years old. Her mother brought her to the hospital about three years ago and has never returned. The hospital is her home. She spends all her days lying on her back. She is covered in flies because she can’t really move her arms and legs well enough to shoo them away. She has a beautiful smile and a giggle that is contagious. And she’s smart! She can repeat sounds that I make and looks to see whose passing by. No one ever holds this little girl not because they are unkind but because they never knew that they could. So I held her and I rocked her. I sang to her and I kissed her hands. We rubbed noses and we both smiled – a lot! Then I did a little therapy. Mostly I just wanted her to know that she is loveable. At nine o’clock I had to compose myself. It was, afterall, just the beginning of what turned out to be an adventurous day!
There’s this phrase from one of my girls’ favorite books. Never judge a man until you have walked two moons in his moccasins. I can not begin to imagine how hard it would be to walk in the shoes of the people who live here. Being here I am continually reminded of how blessed I am.
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So it’s now the beginning of week 4 — Clara and Jen have returned home and Mary Jean has arrived safely to share this last week with me. I have noticed that I am starting to break down a little so I decided to take the day off (my first since April 3rd) for my own mental and physical health. While taking the ride to Port au Prince to see Clara and Jen off and to pick up Mary was great, it certainly was not a very effective way to help my mental state — driving through Port au Prince the second time around was worse than the first time — the destruction and the poverty are so immense there are no words to describe what I have seen and what I feel.
I do know, however, that we cannot loose sight of the extent of the needs that are still very much present in Haiti. While the media may have stopped showing it, we cannot forget it or ignore it. It was great to see that a large number of individuals arriving at the PAP airport this afternoon were relief and medical workers. But much more is still desperately needed! Below are a few photos that should explain what I’m trying to say….
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