Our Man In Haiti, Part V

By Kent Ravenscroft, M.D.

IPI Emeritus Faculty

I was in a narrow muddy rutted road between tents when I saw a green steamroller, or maybe one of those big, bug-like French street sweepers, coming straight at me.  Nowhere to hide.  So I quickly rolled over to the side in a panic.  Then I awoke.  It was 4 am and I had landed in my suitcase!  As my mind locked in, I realized I was feeling ill-prepared for my first clinic in Petite Guinee, a beautiful spot on the edge of the azure Caribbean in perhaps one of the most impoverished destroyed areas in the Petit Goave area. My mind started grinding out the supplies I must take: 5 folding chairs — one each for me, my Haitian general practitioner,  my trusty interpreter, Tessier, and the patient, his mother — a folding work table, my pharmaceuticals, chart materials, and lots of water.  It would be sweltering. Then I realized no little tent for my clinic had arrived.  Making mental notes, I fell back to sleep until 6.

My clinic was supposed to start at 10 am, two hours after the Guinee staff had picked up their meds to go set up and get started.  So I had arranged to meet Tessier and our driver at 9.  Only that morning things went hay wire because of transportation snafu’s, and I hastily had to pull up stakes at 7:30 am, loose ends trailing.  But I liked going out with the team, and chatting with the eager but anxious new volunteers, who were amazed at the extent of the damage this far down the peninsula.  One quoted the most recent CNN commentary, which said the rubble from the Haiti earthquake would fill the entire Washington Mall to the height of the Washington Monument.  My heart caught in my throat as a realized the fresh impact of what we were seeing.  We saw a house totally destroyed, with a slanting rough slab, now taken over by goats standing at the peak.  At least they wouldn’t be eaten at night, unlike the ‘free-range’ chickens with nowhere to hide.  I now had more sympathy for the roosters and realized why they were crowing at random hours.  Packs of hungry dogs roamed, seeking food, given the scarcity of left-overs.

I was privileged to see how they set up the clinic. Tables were put up, and blankets suspended and tied into make shift walls in a semblance of private rooms.  Chairs were at a premium, as were tables, so my nightmare and the list it led to was useful as the clinic began to roll. Waiting on fractured cinder blocks for stools or squatting Haitian style all around the periphery, huddled under a huge, slightly twisted corrugated roof with open sides, were perhaps 75 patients, some mothers breast feeding, others holding sleeping children, all eager but respectfully waiting for a turn. I was given a corner up on a cement dais and we saw our first patient.

Pierre, a shy, taciturn eleven old presented with insomnia.  He couldn’t sleep because he kept hearing the cries of a baby and the voices of dead neighbors.  He had been holding a neighbor’s baby when his house collapsed on him.  His mother could only see the boy’s head when she tried to rescue them.  Pierre tried to protect the baby in his arms, but it was gasping when his mother got them out, and died on the way to the hospital.  Pierre felt horrendously guilty, not helped by the baby’s angry grieving parents, whose house had also collapsed.  His mother explained that they weren’t really angry at him personally, but he felt guilty, even for surviving.  He had had a friend die three years earlier and had heard his voice for a long time, and kept thinking he saw him in groups of children.  I worked with the doctor to do the interview, using the interpreter to get feedback and give guidance, at times even speaking to her, the boy, and the mother in my rusty Creole.  Pierre had made it through the mourning of his previous friend, and we told him he now had more complicated grief work to do, but would do fine.  We reassured him that, as he told us, he really did all he could for the baby.  We emphasized he was a shy boy with a strong conscience, making him self-critical, and he needed to ease off.  We told him and his mother he was doing too much work at night in bad dreams and voices, and that they needed to bring the work into the daylight for more effective work.  We advised his mother to have a little session with him in the morning, gathering him and his thoughts and worries into her mind and arms, and another session before bed to help him clear his mind, reassuring him that she would hold the worries and work on them so he could sleep — like Guatemalan worry dolls.  We felt they would be a good team doing their healthy homework.  So we gave no meds, but scheduled a follow-up. They left encouraged and armed with self-help they could carry with them.

The next woman complained of severe palpitations.  On her way home after the earthquake, she passed many friends in front of their destroyed houses wailing for their dead or missing children, and she rushed to see how her five children had done.  She found four of them alive in front of their collapsed house, ‘Grace a Dieu.’  But her fifth child had not made it home from her school, which had partially collapsed. The woman wanted to rush out to find her, but her children reassured her she would come home, and she waited stoically.  Her daughter did eventually return, full of stories of other kids being hurt or trapped.  Three days later the woman had severe palpitations, in response to some random trigger that reminded her of her stoic vigil.  She was already on medication for high blood pressure, but she had never had this before, except when walking up steep hills. Now she was worried her heart was giving out, and that she was dying.  She let us know she was emotionally fit and able to help many of her grieving friends, and so she was sure that her heart symptom was physical.  We agreed she should see her doctor to get checked out, maybe even have that electrocardiogram, but after taking her blood pressure and taking her pulse rate, and listening to her heart, it did seem that she was physically okay.  She had the strength and intelligence to work this out in time, and in the meantime we gave her simple techniques to restore her trust in her body and in life.

I explained the endocrine fear response to her.  Her scary self-diagnosis was escalating her panic.  Her fast walking on the day of the earthquake would make anyone’s heart beat faster, and the new bursts of heart beats were normal fear responses triggered by thoughts, noises, or tremors.  She needed a couple of techniques to interrupt the beginning palpitations. So we taught her the partial Valsalva maneuver, in which she would hold her breath and bear down as if having a bowel movement. The Valsalva works to stop arrhythmia — and is a competence distraction.  We also showed her how to rebreathe from a paper bag sealed around the mouth.  We also suggested noting down each time she had such an attack, so she could outfox the triggers, and disconnect them with an “I told you so”.  She needed to be a kind doctor to herself, just as she was being a good friend to her friend, and not scare herself.  She got the hang of it, and understood the psychology and physiology of it.  She was a school teacher, and so I suggested she could help teach this to scared symptomatic friends, as she herself got good at it.

One other patient had serious insomnia.  Glassy-eyed and depressed, she showed us a certificate of scholastic accomplishment earned by her 21 year old son, his handsome photograph on the front.  Between sobs she told how he was teaching in Gressier, away from home for a while, and was crushed in his little room there by the earthquake.  We listened with near reverent attention, checked on her friendship and religious network, and noted her blood pressure was elevated.  She was consolable but in deep prolonged, but not arrested, mourning.  But it bordered on depression.  I suggested they give her atenolol, a relaxing, sleep-promoting, and anti-hypertensive agent to help her through this sad, sad passing.  She had other children to live for, but we would follow her up closely next week just to make sure she was doing all right.

We saw other patients today, and as time went on I relied on the Haitian doctor more.  We are hoping to give them increased front line competence, a good sense of basic psychotropic meds, and diagnostic acumen for triage and deciding when to refer for specialist care.  Referral should occur only when absolutely necessary.  There is not much psychiatric care to go around, and most people, even if deeply affected, are able to self-right with simple help and access to their own resilience, provided they have their basics met, that is, shelter, water, food, security, and social connectedness.

When I got back to the Residence office, I had to go with Stephanie, my director, and Peter, my colleague, to a meeting for all mental health leadership, which was boring, but necessary, a key brief encounter with the hospital administrator, from whom we must get approval as a hospital resource for medical and surgical inpatients requiring psychiatric intervention.  Though I love this kind of work, I’m feeling spread a little thin.  I also hear there is a movement to base me at the hospital instead of going out to the individual clinics –bad idea for the Haitian docs and nurses, and for the patients.  I am lobbying for staying clinic-based, and we shall see.  I noticed Stephanie was in a good mood, but had forgotten why.  Then I saw her screen saver again, and there he is, her friend and co-worker in Darfur, the man who was abducted for ransom, like her.  That was back in November.  After all this time, after losing hope, he had just been freed, and she was thanking her lucky stars.  It had been a long hard vigil.

Stephanie is a vegetarian, not really interested in food, and eats at sporadic times.  I cooked lunch Sunday, and I made dinner tonight, linguini with olives, onions, tomato and Prego mushroom spaghetti sauce.  Yum, after my fashion, and, Stephanie liked it.  I clued Crystal the cook in on the fact that we would be moving to consolidate all staff and volunteers, making 7 for dinner each night, with the volunteers used to hotel choices and lots of food.  Her eyes got wide, and she thanked me.  My Creole isn’t too bad in a pinch.

I must admit, though, that from a creature comfort point of view, I will be using Haiti, and this experience, as a litmus test of my materialism.  I may think what I am going through at times here is a near-death experience for me, but it is nothing to what the Haitians have gone through.  We had one other woman patient today who lost a child, an aunt, a house and a business, which was crushed and then robbed, and, a van that was trapped under a concrete wall.  So she is without even a tent and no means of livelihood.  She was depressed, and, I sensed, smoldering with rage.  She had been unable to reconnect with her Pentacostal Church, and she seemed close to needing meds.  We started her with a sleep med and not a heavy duty antidepressant, because antidepressants are costly and needed for a long time, and we sensed she might come around the corner. We will see her right away again next week, just to make sure.  Continuity and taking the mental pulse is the key.  We don’t want her remaining children to suffer a maternal suicide, given everything else.

Thank you all for bearing with me.  This blog is bibliotherapy for me, part of my self-care, something we emphasize around here.  It’s a great team down here.