Reader Comment: A Child’s Chest Pain

A reader recently commented on the SW101 post Will My Child Have A Heart Attack with a disturbing letter about her child.  It has now been granted its own blog.  I have written my own comments in throughout the letter in red italics to make me appear extra important and potentially infallible.

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Thank you for that article. My typically healthy 6 year old daughter has been complaining of chest pain, burning on the left side of the neck and feeling her heart “in her throat” as she says. This is not a big deal.  Kids say this stuff all the time.  It goes along with the ubiquitous ”Tummy ache”, “I’m full”, “My eyes hurt”, “I need a drink of water”, and “Where’s my bear you can’t expect me to sleep in such harsh conditions so until you find my bear I’m going to sit here and attempt to poop my pants in protest so start lookin’ quick, POPS.”

She says it goes too fast and she gets dizzy and has actually passed out several times while doing minimal activity. This IS a big deal.  Kids don’t do this…ever.  True loss of consciousness in a 6 year old kid has a genuine cause.  In the elderly, things like autonomic instability lead to syncopal episodes (pass out when they stand up).  Add 90 years to your kid’s life, and your letter wouldn’t have won itself a full blog post.

I have taken her to several Dr’s, only to be told “kids don’t have heart attacks”.  I agree.  Kids don’t.  Adolescents do, however.  And young adults in their early 20′s do too. I’m at my wit’s end with this and worry over it constantly.  You’re right to be.  The hair is starting to stand up on the back of my neck over this one.

She had bloodwork to check her cholesterol about 14 months ago and it was high. Genetics..ding!  ding!  ding!  That, or you’ve set her up with a continuous Big Mac infusion pump through her sleeping hours.

She recently had it checked again and it was 259. That’s worse than mine…and I’m 37 spending most of my time with my butt glued to a chair while I hover like an anxious hen over my blog. Her sister (age 10) had a cholesterol level of 126. Luck of the draw, kid.  I’d see the bet and raise it if I were her. They eat virtually the same thing and my 6 year old is only 40 lbs, so she isn’t overweight. Another sign of a genetic component…which makes this just fantastically unfair.

This is now starting to affect her normal playing routine because she says running/playing make it hurt worse. REALLY bad sign.  Kids run.  Especially skinny kids.  They RUN.

I’ve been told it’s constipation ?, seriously?, reflux probable in ADULTS, heartburn same thing…grown ups, not kids, pulled sternum maybe the strangest musculoskeletal diagnosis I’ve ever heard….but so far no Doctor feels it is anything to worry about.  Are you seeing actual doctors…in actual America?  I hear the medical system on the plains of Balinor is a bit iffy.

She had a EKG and it showed she was tachycardic based on her age?  EVERY kid is tachycardic compared to an adult and a few arrythmias this is like saying “oh, we had some red wine”.  Some arrythmias KILL YOU, others are meaningless…and everything in between.  What kind of arrythmia?, however her pediatrician feels that could be normal for her age. ‘Could be?‘

Her teacher at school tells me she complains 5-10 times a day and says ‘my heart hearts’.  My 3 year old boy is obsessed with candy, but I’d guess he rarely actually asks for it 10 times in one 24 hour period (considering he sleeps for about 14 of them).

We live in a very small town population 4?, and have to travel 120 miles to a ped. cardiologist worth it…however they won’t see her without a referral and her pediatrician doesn’t feel it is necessary I suspect an insurance issue.  How hard is it to make a referral, even if only to help reassure mom?

If you have any suggestions for me I would love to hear them. I’m worried
that even though diet has been modified and the rest of the family has no cholesterol issues (grandparents do) that this high level is affecting her.  Do you know of any other tests that I could suggest her Doctor perform? Short of a cardiac catheterization, I’m not aware of any other helpful tests in this situation. He has also shrugged off any suggestions of a heart echo.

Final Thoughts – (I’ll dispense with the red italics, even though it makes me feel Extremely Important):

I can’t be certain that your story is completely true, because I don’t know you and haven’t seen your daughter’s medical file.  It also rings a bit fantastical since I’ve spent lots of time around pediatricians and have never seen one as cavalier as what you describe based on the small amount of information you’ve provided me.  As a rule, I do not believe that many doctors are lazy, incompetent, negligent…or drunk.  If you’re going to a licensed child specialist physician, they probably know what they’re talking about.

That said, IF your story is completely true, my advice is to knock on doors – pound on them if you have to.  Walk up to any door with an M.D. on it (be wary of any other initials except perhaps D.O.) – until you get a referral to a pediatric cardiologist for an echo.  Women walked for 5 solid hours under the Haitian sun to have their child seen in our clinics when I did relief work there, so you can cross vast distances for your child too.

The echo, in my opinion, is the first place to start.  Your child also probably needs medication for the cholesterol issue – or will in the very near future – and if your pediatrician seems to be cavalier about this, you may need to look for one that is more aggressive.  But diet changes won’t help this situation much, and exercise could be dangerous until you rule out structural heart disease.  It’s almost impossible to find cardiomyopathy without imaging, and totally impossible to find early atherosclerosis without a significant work up by a cardiologist.

Rest assured, there is a doctor out there who will find in in their writing hand to put in 10 minutes and refer you to a specialist if your story is as legit as it appears on this blog.  If it takes spending a week in a larger city, fine.  If it takes getting on an airplane, DO IT!  If what you said is true, and there are no additional conveniently omitted facts, your child needs to see a specialist.  Do NOT stop pestering doctors until she does.

Finally, let me say that while my heart goes out to you, remember that I am a doctor…but not YOUR doctor.  And this is a blog, not my clinic.  As you can see by my responses, I’m giving my honest opinion, but also being silly.  I write this blog for fun, not to extend my day at the office.  Therefore, these responses qualify only as  suggestions and musings, not medical advice.  A licensed physician, who has actually seen your daughter and evaluated her entire history, is the one who needs to make a real recommendation in this situation.  It completely annoys me that I find it necessary to say that….the world these days is run by lawyers.

All joking and useless lawyer pandering aside, my responses in this blog really boil down to one thing:  Keep knocking….

Who Dies from Typhoid?

Hardly anybody.  In America, anyway.

This is why it was so shocking to hear that one of our translators in Haiti – a healthy father with children – died of typhoid fever recently.

I didn’t work much with this particular translator, Daniel, mostly because he spent so much time interlocuting between our group and the local community leaders, especially in Noyo.

I spent my second week in the very rural village of Noyo, and my experience there was vastly different than the one I had during my first week in Thomaseau.  The physical village looks like a bunch of twig huts that all unrolled themselves from one giant ball as it bounced down a mountainside.  

Despite this scattered layout, the people there were a tight-knit bunch; working with them required constant communication.  Work of the kind we did in Haiti brings with it nearly endless opportunities for misunderstanding.  Daniel was a big part of that because he was well-connected with the local leaders.  

A few times, I wondered what besides common humanity kept the locals from simply overrunning our tiny isolated clinic, taking all the medicine and holding us hostage.  We’re not just talking about picking up some bling bling, either.  They could demand HUGE ransoms for each of us, and never be in poverty again.  

I thought about this frequently in Noyo because the village clings to lost and forgotten hillsides so far from roads that you can’t find it on most maps.  We hiked for over an hour to get there.  And the road that brought us to the beginning of our hike arguably ended miles back from where we actually stopped our battered 4-wheel drive monster trucks.

I think the moral fabric of Haitian culture gets most of the credit for keeping us protected during our time in the mountains.  But some also should be given to people like Daniel, who moved easily between native, locally-powerful villagers and obtuse, big-hearted, mildly-guilt motivated Americans.

 More than once I saw disappoinment in the faces of patients as I sent them out the door with not much more than a toothbrush and some TUMS.

I’m sure I projected a bit, but often I felt their dismay at my ineffectiveness in the midst of so many very real problems.  I could almost hear some of them say, “This is all you have for me?  Look at all that medicine in the back of the church!  Look at those nice tents you live in!  Look at that nice watch and thousand-dollar camera you have.  All you have for me is some antacids?  Do you know that I could feed this child for weeks with just the money I could get for your sparkly watch?  How is it worth that much to you?  How can you still cling to your expensive camera when it could feed a family for months?  Is that moral?

If you claim to be a Christian…how is this not a sin?” 

Often I reflect on how much I care about my children – the lengths I would go to protect and provide for them.  In that light, I do not think I would be nearly so gracious if it were my child wasting away in my arms and some rich foreign king gave me only calcium tablets and a toothbrush (until we ran out of them and just gave the calcium).

Although the Haitians displayed celestial graciousness because I believe they are by nature a gracious people, translators like Daniel helped undergird that goodwill.

Being Haitian, he could agree that yes, these people come from a rich country and enjoy many things that people can’t even dream of in Noyo.  

But he could also point but these particular people don’t have as much as it seems.  He could explain that these kings used a very large amount of their own money just to be there, in the suffering, trying to help however they could.  He could explain that even with the best medicine, their children might still be very sick.  He could point out that ALL the medicine we have left over will be given to the village, to the most in need.

 

It takes over 100,000 of these (Salmonella) to cause typhoid fever in an average human. A closely-related organism - Shigella - only needs about 100 to cause disease.

Typhoid fever shouldn’t kill anyone.  It causes some fevers, some abdominal pain, some gnarly diarrhea and maybe some delerium.  Throw any of a number of antibiotics at the problem, and the odds of dying from it drop to about 1%.  If I gave you a 99% chance of winning big in Vegas, I bet you would put a good part of your inheritance on those odds.

 

Even untreated, typhoid fever is fatal in only about 30% of cases.

So Daniel’s story is a tragedy simply because death is a tragedy.  His death is a tragedy because there is a wife somewhere who loves him and is now alone.  It is a tragedy because there are children huddling around their mother wondering in pain and incomplete understanding what happened to Daddy.  It is a tragedy because his role was so valuable to our work and efforts in Haiti.

But most agonizing…Daniel’s death is a tragedy because it didn’t need to happen.

I Want It Thaaat Way

“Just…look under your seat.  I’m sure it’s there.”  Said Bobby, my driver.  We were rushing my ailing patient from Thomaseau to the general hospital in Port Au Prince when Bobby suddenly stopped our car to find a CD.

He made me get completely out of the car so he could check all around my seat, under it, inside the faux fur cover.  Nothing.

“Daang, MAN!  I borrowed that from a friend.  Now I lost it.”  He sighed, “Ok, get in.  We’re in a hurry here.”

Thus began my first experience with the most famous man in Thomaseau.  Bobby grew up here.  His parents owned a general store that apparently did extremely well.  But with the rise of an anti-aristocracy movement when he was young, Bobby’s family found themselves in the grim cross hairs of a violent revolution.  So, his father pulled some strings (one very convenient perk of wealth in Haiti) and immigrated to the United States.

“I’ve never been to a public school,”  Bobby said as we bounced over a stretch of land that might be described as smooth for a Siberian rock quarry.  With Jedi-like reflexes, he swerved around some of the the bigger pot-holes and cranium-sized stones.  “Always private.  Even college.”

Bobby has a smile like a sun-flare and fashion sense straight from New York.  He knows English well enough to drop innuendo and colloquialism into his jokes.

“S-s-s-s-oh you went to c-c-c-c-c-ollege-ege?”  I chattered out as we pounded the Haitian “road” into submission.

“Yep.  Boston University.  Was getting a degree in…beer.”  He laughed.  “It was such a waste.  I dropped out and started my own contracting business.  Made a fortune.  I had money everywhere.”

But now he runs an orphanage in one of the poorest villages in Haiti.

Bobby's Mom

When his parents decided to return to Haiti, Bobby followed.  Soon after returning, his Dad died and Bobby stayed to take care of his mom. Just like that.  Shut down his business, sold off the valuable parts and stayed.  It’s a family thing, I guess.

Bobby and his wife have been unsuccessful at having children, so they closed the family store and opened an orphanage in that building.  Mom lives in what was their house.  Lemons from lemonade.

“So, can you even make a living as an orphanage director?”

“A living?  HA!  Tell me another joke.  I don’t even know where I’m gonna get the money to pay my friend back for his CD.”

“Then,” I pressed, baffled, “clear this up for me: you left a few hundred-thousand dollar a year job to come back to Haiti and live on donations?”

Something like that, he responded.  “You do what you gotta do.”

I once heard a missionary talk about why they lived on pork and beans in a hut in Gambia.  “Love constrains us,”  he asserted.  Sometimes the call to service overwhelms the call for comfort and the pursuit of happiness.  Bobby seems to think the same way.

That said, I myself do not believe in true altruism, with perhaps the exception of one perfectly selfless act somewhere around A.D. none.  Even the great works of Mother Teresa and Father Damien, most probably, have some selfish motive tied up in them.  The great Christian missionaries like Hudson Taylor and Jim Eliot were as much promoting their own worldview as providing service.  They probably would agree with me in this assessment on some level, too.  Great Christians are constantly in touch with their need for salvation.

And I wasn’t about to let some Haitian guy restore my belief in completely sacrificial love, but he certainly got me thinking about it, especially as we entered the inner city of Port Au Prince…

I wasn’t prepared for the hopeless destitution I saw there.  The place is a singular universe, filled with the dank and putrid entrails of human suffering.  The streets teem with staring hungry, lifeless eyes.  Hollow, gaunt faces watch expressionlessly as our car blisters by.  Breathe too deeply and you will retch, but you won’t know if it’s because of the stench or the scene.  Maybe both.  These slums fester like an abscess, limitless human pestilence stewing within the wound.  And instead of drinking with his buddies at Boston U, Bobby drives through this nearly every day.

Some of the orhpans

As we bounced along, Bobby described some of the problems that led to such squalor.  I noticed his voice drop a pitch in the effort, and I could feel the sorrow in his countenance.  He described the floods, the fires, the rebellions and litany of misguided UN and WHO initiatives.  He outlined some of the self-serving and catastrophic policy choices by the French, and lately by – you guessed it – the United States.

We stopped at a stoplight and a child came to the window, asking for money, food, anything.

“Say something in English.”  Bobby told the child in Creole.  “If you want something from me you have to earn it.”

“Gim me dullah.”  Said the boy.

“Allright!”  Bobby exclaimed, “You’re on your way!”  He flashed his fantastic smile, the display of mirth some sort of anachronistic throwback to better times, handing the boy a US dollar bill.

Then my escort looked at me, reading my thoughts.  “I know about the handout thing,” he said.  “It just perpetuates poverty and dependency.  I know.  But you gotta remember…this is Haiti.  That kid isn’t going to go buy drugs or something stupid with that money.  He and a good portion of his family will eat with it.”

He paused as we asserted ourselves – alpha-wolf style – through a melee obliquely described as a roundabout.  “And anyway,”  He said swerving around a donkey and accelerating into oncoming traffic, “It’ll get that kid off the street for at least one night.”

Just as he said this, the expansive grill of an impressively huge white truck bore down upon us; clearly with no intention of stopping.  Deftly, Bobby yanked the steering wheel to the right at (what felt like) the very last moment, the blare of the truck’s horn bending into lower tones as we passed by.

But in avoiding certain death with the truck, even the Bruce Lee reflexes of Bobby couldn’t avoid two giant potholes now in our path.  I gasped slightly and dug my fingers into the IV bag I was holding for our patient.

Blam!  Followed quickly by BAMBAM!!

“No problem,”  he started to say, “we-…”  Bobby stopped, looking at me as he drove.  “Do you hear a crowd cheering?”

Extracting my fingers from the ceiling, I listened.  “Actually, yes!  I hear it too.  Like, a real crowd.”

Just then the band kicked in, “Tell me WHYii!”  And then the crowd REALLY roared (screams, actually…it was mostly girls).  “III want it, thaat way!”

Bobby laughs.  The sound reverberates through the car, energetic and infectious.  “THERE’S my CD!  I knew I didn’t lose it.”  Apparently the shock of foot-deep potholes jarred the CD player loose from some track fixation and it just spontaneously started playing again.

I never, in the imagined space of 10,000 lifetimes, thought I would find such joy in a Backstreet Boys song.  But I did.  There we were, driving through a sorrow I will never forget, singing one of the cheesiest pop songs in American music history…together.

This child would not survive the Spring.

Later I would tour Bobby’s orphanage, a jewel of glimmering hope for forgotten children.  I would see the 40 foot well he dug through the hard dirt and rocks in his back yard.  I would listen to him describe his days that start at 5am so he and his wife can care for nearly a dozen kids with no home, no family and no safe keeping.  I would meet one of his orphan boys with cerebral palsy that would be dead within a month.

Through it all – with so much emotion and despair pressing me into ineffective stillness – Bobby is belting out American pop tunes, driving like Andretti with a midichlorian infusion and trying to save lives.

Sure, some part of what this guy does is self-serving.  He’d laugh if anyone called him a saint.  He’d probably ask that you dispense with the titles and donate t0 his orphanage instead.  But his life reflects a near-image of genuine altruism in ways that might inspire even the most jaded.

And he’s a perfect fit here.  This place is destitute and tragic to me.  But this is Bobby’s home.  He can see the hope that I can’t.  He waves to friends he knows as he barrels down the street; he looks with affection on the same things I see as symbols of misery and suffering.  With just a little help from people like me – so ill-fitting here – guys like Bobby will change the world.  They will change Haiti.

Even in a place like this, he still sings.

Half A Delivery

I wouldn’t say we’re competitive, me and ChinaDoc.  If you don’t recall, she was the other FP resident on our trip to Haiti.  Although I’ve mentioned her actual name before, in true blogging fashion I will heretofore call her by a nickname.  Being Chinese, and very small and elegant, I’ve settled on ChinaDoc.

True, she plays Hearts to the death.  And we’re constantly harassing each other about who has more deliveries.  But that’s not real competition…is it?  Just friendly banter.  Or so I thought…

Just as we’re closing up shop on the 4th night of our adventure in Haiti, a woman arrived in labor, but dilated to only 3cm.  Since she needed to get to 10 to be “complete”, we knew she had some work to do.  We thus set up a makeshift labor room out of the flight-line of the bats that inhabited our clinic at night.

Our stellar OB nurse – with something like 30 years experience on a labor ward; one of the best I’ve ever worked with - stayed with the patient to watch her, while the rest of the team walked across the courtyard for dinner.  ChinaDoc and I each had one delivery since arriving in Haiti.  It was thus my turn for this one.

Stretching nonchalantly as we headed up the stairs, I just mentioned to my illustrious colleague, “Hmmm.  Looks like this will be TWO for me.  How many do you have again?  Sorry, I forgot.  Something like…uhhh, ONE, isn’t it?  Don’t feel lame, dear ChinaDoc.  Some doctors are just, you know, more successful than others.”

I can’t recall what mean, snide thing she said then – MUCH to my surprise since I was just trying to make personable conversation (and gently help her feel better for losing the delivery race).  It was something along the lines of, “At least I’ll sleep, loser.”

She made a good point, actually.  I was probably in for a long night.

Since I was “on”, I found a perch along the edge of the balcony where we ate our meals.  From that vantage point, I could see through the door of our OB room and observe things as they unfolded.

About an hour later, my nurse stuck her head of the room and yelled up to me, “She’s 7.  Won’t be long!”

Good, I thought.  7cm.  Our patient had delivered numerous other children, which we medical folk term “multiparous” (multip, for short).  Multips don’t usually hang around at 7cm for very long.

To my surprise, a short time later I saw our patient wander away from her hastily constructed labor room.  Accompanying her were the two friendy/family types who arrived with her.  No nurse.

Here’s the thing about walking while in labor:  It almost always helps things progress.  We encourage it most of the time.  How it works is something of a mystery, but it has to do with gravity, and mental distraction and pain control.  However, I can NOT envision a time when an experienced labor nurse would encourage – nay, allow – a multiparous mom at 7 cm to walk around.

Welcome To Your Delivery Suite, Ma'am

Babies have been known to drop right out of multiparous women.  Into toilets, showers, cab seats, soccer fields, gondolas, dog bowls, ferris wheel benches, classrooms, ski slopes, two-seater airplanes, office cubicles, hot air balloons, the space shuttle, those suction chutes at banks that kids love…

…OK, so I made some of those up, but you get the point.

But for some reason, this woman wandered away from our clinic room – ambling slowly with one hand in the small of her back – into the front courtyard of the building we use daily for the clinic.  From my roost on the ledge, I watched our patient virtually evaporate into the pitch-dense maw of the rural Haitian night.

To describe just how dark it was in the front courtyard, I’ll refer you to the ’80′s classic movie “This Is Spinal Tap”, where at one point the question was, “How much more black could it be?”  And the self-evident answer: “None.  It’s none more black.” (stated by a band-member describing the cover of their new “black” album).

Thomaseau has no street lights.  Or, maybe a few odd ones here and there, but realistically there aren’t any.  Furthermore, the power for this village comes from Port Au Prince, which shunts electrons out there based on some whimsical benevolent prescription that befuddles even the least logical among us.  On this night, there was no power.  So the courtyard was…black.

None more black.

Nervous by this point, I figured my OB nurse had been taken captive and thrown to the yapping Haitian dogs.  She would never walk a multip at 7cm.

Just then, the two women who walked out with our patient came running back into the halo of generator-powered light from our clinic, frantically yelling in Creole.  I knew exactly what they were saying, “YOU LET OUR MULTIPAROUS SISTER WALK AT 7cm AND NOW WE’RE HAVING A BABY IN THE PITCH-DARK!  WHAT KIND OF TWISTED FREAK-SHOW OF AN EXCUSE FOR OB DO THEY TEACH YOU IDIOTS IN AMERICA?”

Already I was bolting down the stairs and running for the courtyard.  I was armed with only 1 tool, perhaps the most valuable physical item a doctor can have in Haiti:  A headlamp.

I rounded the corner, flipping on the light and arriving at a scene that would make the prop crew of CSI envious.  The mother was sitting on the top step of our clinic porch, with a wide pool of blood mixed with clear fluid and thick meconium shimmering from between her legs.  Lying right in the middle of this stark lake of glistening life was a motionless baby, still connected to the umbilical cord, which still curled it’s way into the mother’s body.  The picture of that initial visual moment still glistens realistically in my mind’s eye – the image etched and harsh under the chill glow of my headlamp.

My first concern was the baby.  Motionless, caked in blood meconium and mud from the dirty courtyard, I worried about hypothermia (a real risk for a wet newborn even at Haitian temperatures), and I knew that tactile stimulation would be the best way to try to get “it” (I never even noticed the gender) breathing.

Since I had nothing but the headlamp and clothes on my back, I pulled my shirt off and wrapped up the baby in it.  “It’s dark, I reasoned, nobody will see my rotund beer-gut anyway”.  In the process, I scooped a good amount of the birth-goo onto my bare hands.  I’ve done nearly 100 deliveries, and never touched a newborn with my bare hands.

For the record: it feels exactly like it does in gloves, so there’s no sense in trying it at home, boys and girls.

Dropped Out of my Mom Onto Concrete. All Good.

Eventually, we got the baby and mom back into their rightful places.  Turns out our OB nurse had been unable to talk the patient out of a walk, and so asked her to wait while she ran up to her room to get her shoes.  The patient didn’t wait, and off she went before our nurse could return to walk with her.  So, no fault of ours, ma’am.

The baby did great.  No head wound from a drop onto concrete.  Breathing fine.  The mom had no vaginal lacerations, and did great too.  We sent them home that night.

ChinaDoc arrived as we were settling the mother back into her cot with the baby, now wrapped in a blanket.  She seemed completely uninterested in the fact that I was shirtless and covered in blood.

“So, I heard the baby was on the ground when you got there.”

“Uh, yeah.  Blood and stuff everywhere.  All I had was my headlamp.  I’m incredibly awesome.”

“So, you didn’t actually deliver the baby, then.”

My eyes grew wide.  “WHAT?”

“Yeah.  It doesn’t count.  All you did was pick it up.  We’ve both delivered one baby in Haiti.  We’re still tied.”

“Here I am, shirtless, covered in blood – look, LOOK AT THAT POOPY, MUDDY, SOAKING FORMER-SHIRT I JUST THREW AWAY – I don’t get credit for a delivery?  I could have AIDS!  I could have an alphabet of hepatitis!  I didn’t even use gloves for God sake, woman!”

ChineDoc sniffed, unmoved.  “You wrapped up a wet baby.  Brilliant work.  But anyone could have done it.  Don’t need a doctor for that.”

Quickly I determined the best way to bend my itinerant classmate to my will was to smear my contaminated hands all over her face.  She backed away quickly at my advance, “OK!” She relented, ”Maybe you can have a half a delivery.  Nice job…I guess or whatever.”

Partially gratified, I made my way to the showers to clean off the painting of real, human blood from my body.  Turns out Port Au Prince didn’t deign to allow running water that night, either, along with electricity.

Faced with laying around for the next 8 hours in that blood, purified only with a Wet Ones shower, I realized the bald injustice of my colleague’s proclamation.  “Forget it, ChinaDoc!”  I yelled to the parched shower.  “That’s one WHOLE delivery!”

Left To Die On A Tile Floor

“Dr. SW101,”  said Father Larry, “There’s a woman lying unconscious in the church courtyard.  Can you go see her?”

With little more than a quick nod, I grabbed my interpreter and headed out the door. How, I wondered as harsh sunlight spilled into my eyes, is a doctor supposed to help an unconscious patient?  In Haiti.

I tried to think of all the reasons a woman might collapse, and what sort of assistance I might be able to offer.  Again…in Haiti.

Quickly, I reviewed ACLS in my head.  I tried to revise the arcane algorithms based on the fact that we probably did not have ONE SINGLE med used in a typical code.  I thought through hypoglycemic coma, and stroke signs and symptoms.  I tried to recall how I might distinguish between ischemic and hemorrhagic types (and would it help to know the difference?).

Our team working on the patient

Also on my list of worries were seizures, pulmonary emboli, electrolyte disorders, dehydration and the difference between heat exhaustion and heat stroke.  Distantly, I pondered the probability of this being a simple “waiting delirium” where people fake a collapse to get to the front of a line.

I approach what must be the patient but of course I can’t see her.  All I see is a giant throng of people hovering in a circle; a shark frenzy of curiosity.

My interpreter helps me push through the crowd to a thin elderly woman lying with eyes half closed on a tattered blanket.  She was placed in the half-shade of a skinny, leafless tree on dusty cobblestones just outside the church offices.  People are yelling and pointing in all directions.  They give me space grudgingly.

I learn that the woman had a seizure sometime in the night, passed out, and has been seizing regularly ever since.  She is completely unresponsive.  Someone tells me she’s around 70 years old.  Someone mentions that she’s a grandma.  Someone says it’s hot out.

After a brief exam, I have her brought into our clinic and placed her on a army-issue stretcher.  I rummage around our supplies with the help of a spectacular nursing student named Kim.  Together we come up with an angiocath (for IV’s), a bag of normal saline…even some gauze.

We place the IV and get some fluids running to treat possible dehydration.  Kim and an OB nurse place a foley urine catheter we happen to have too.  Clear urine runs into the bag, ruling out dehydration.  We find urine test kits and note that there is no blood or glucose in the urine, thus arguing against diabetic problems or UTI.

The immediate problem was the seizures.  And we had no medicines we could give a patient who, every 15 minutes or so, had a full seizure on the entire left side of her body.  Kim and I riffled through the meds again and found some dilantin (good for seizures)…but in pill form, which made them totally useless.

Knowing the patient would die in her current state, I wrestled with the problem of how to get some sort of sedative – ANY sedative – into her tortured body.  At one point a group of us seriously considered IV Haitian Rum.  I thought about crushing up the dilantin and trying to trip a slurry down her throat, or pushing it rectally.

We eventually found liquid dilantin; made for oral administration.  The discovery felt like a ray of sunshine in a mausoleum.  Now all we needed was a naso-gastric (NG) tube.  Gotta be lots of those lying around, right?

None.  The patient is seizing again, Dr. SW101.  The family is getting frantic.  People are looking in at the patient through every window.  What do we do?

Kim and I did find a feeding bag. Looking at it, I envisioned how we could fashion some version of an NG tube out of the tubing from the bag.  I talked up my plan to Kim.  Seeming like this kind of thing was a daily occurrence for her, she retrofitted the tubing, reversed the adapter connections…lubed the thing up and slid it right down into the patient’s stomach.  Perfect.  I had my tube.

I dose out my best guess for the patient’s weight, not knowing her renal function, her hepatic status, her chronic diseases or her current metabolic state.  I gave it my best guess – shooting for safety and efficacy – and we started a regimen of dilantin.

Along with trying to treat this patient urgently, we knew this woman needed to be in a hospital, and Father Larry had been working on the weirdly complicated logistics of transporting a critical patient to General Hospital in Port Au Prince.  Father Larry also supported my desire to stay with my patient to make sure that someone on the receiving end knew the story and could adaquately take over for us.

Our best effort at an ambulance

Not ungently, we put the woman in the back of a tough Isuzu jeep and then blasted out of Thomaseau over rocks and roots and dusty country roads, headed for the thriving city of Port Au Prince.  Nearly 2 hours later, sweaty and dusty, we pulled in through the hospital gates.

My driver and translator is something of a celebrity in the village and knows many people in Port Au Prince also.  He did some quick talking at a back entrance to the ER, and ran back to our car and told me to, “help me pick her up…quick!  They’re letting us in the back.  Otherwise we have to go through the front and it will be at least 8 hours until she is seen.”

We carry the woman through wards teeming with people.  I sense many stares as I pass as quickly as possible through hordes of sick patients, family members, hospital staff and equipment.  We enter an austere room made of tile and bricks, with windows high above us grudgingly tossing some light to the floor.  A kid of about 15 is walking back and forth, tears streaming down his face as he intermittantly screams and jams his hands down his pants (psych?  testicular tortion maybe?).

“Lay her here.”  Instructs Bobby, my interpreter, the celebrity-guy.

“Right here?  On the tile?”  I reply, looking around anxiously.  “Where’s the bed?”

“No beds.  There won’t be one for hours.  Maybe days.  It’s leave her here or we take her back.”

We lay her on the floor.  Two of her family members that came with us huddle on the cold linoleum next to her.  I tell her story to a bored and tired looking orderly.

“Ok.  They’ve got it from here.”  Says Bobby, already heading for the exit.  “Stay any longer and they’re going to demand more money to keep her.  We need to get out now while we can.”

Fighting a sense of revulsion at the place where I’m leaving my patient, and vicerally wrestling with nearly-overwhelming waves of guilt for abandoning her, I snap a quick photo and leave.

As we walked away, I knew she would die on that cold, lonely floor.  Her family trusted her to me, and I left her lying in a tile grave.

Her Final Moments

Not long after we returned to Thomaseau, after a harrowing drive through some of the worst slums in Port Au Prince – and in the entire Western Hemisphere – after hours and hours of efforts to save a life…she died.  Probably from a stroke that occurred before we found her in the courtyard.  Within 2 hours of our return to the village we were notified that the patient was gone.  Please come collect the body.  We wouldn’t have given her a bed in the hospital anyway because you didn’t pay for food and supplies.

We did calm down the seizures, by the way.  By the second dose of dilantin, the repeated convulsions faded away and our patient clearly became more peaceful. 

A small consolation.

The news of this woman’s death was somehow devastating to me, even though I knew she had no chance.  I couldn’t help but get emotionally involved in something that required so much effort and focus. 

And for all that work, I ended up with a dead patient; her last moments spent in squalor, destitution and abandon. 

I have now spent hours trying to frame this experience in some sort of meaningful context; actively resisting raw emotions of fury and hopelessness and sheer nhilism.  So far, I know only this:  all I can really do for Haiti, is care about the suffering there. 

And never, ever forget…

Haiti Musings

I recently returned from a 2-week medical relief trip to the country of Haiti.  You will notice that my blogs mostly describe this topic these days.  Later, I’ll collect all of the posts and give them their very own Tab at the top of the page.

The independent country of Haiti shares a caribbean island with the Dominican Republic.  Unlike its relatively wealthy and stable neighbor, Haiti is poor.  Destitute.  The poorest country in the Western Hemisphere and one of 15 poorest in the world.  Haiti suffers from high infant mortality, devastating chronic diseases, illiteracy, poor education, over population, deforestation, soil erosion, rapid urbanization, high unemployment and a weak government that grapples with violent uprisings on a regular basis.  The country has been manipulated and abused over the years by the French, the U.S., the U.N., the W.H.O. and many others.  1% of the population possesses 97% of the country’s wealth.

The group we went with is called Friends of Haiti.  If you ever wonder where you can give money that will truly help humanity, check these guys out.  Led by a catholic priest named Father Larry Canavera – but ecumenical and non-evangelical in mission – this organization provides medical care and support to numerous villages in Haiti.  The volunteer teams return to Haiti every 6 months and stay for 2 weeks.  They work principally in Thomaseau, a town about an hour NE of Port Au Prince.  During the 2 weeks, smaller teams also move out into the Haitian countryside and work in rural villages with names like Grand Boulage and Noyo.

Friends of Haiti is based in Green Bay, WI.  Our WA contingent consisted of another 3rd year family med resident like myself, one of our full-time faculty members and two part-time faculty.  The costs of my trip were largely supplanted by a $1000 grant from two different foundations associated with my hospital and clinic.

I can’t describe this experience in singular words; can’t distill it into one major theme or valuable impression.  The time I spent there wove itself around me like a dense, intricate and finely-detailed tapistry.  Dozens of times a day I found myself thinking, in the midst of a nearly-overwhelming experience, “Somehow, you need to figure out a way to describe this in words.  Somehow you have to capture all this fury and sadness, this joy and passion and fear and loss and desire and music and…this incomprehensible hope.”

These stories are my best attempt at such an impossible task.

Yap!Yap!Yap!…..Yap!

YAP!!!

YAPYAPYAP!!

BARK!!

Sniff, sniff….whine.  Whimper.

Haitian dogs.  I didn’t even notice them when I first arrived.  They’re the color of street dirt.  Diminutive, scruffy; a 7th grade English teacher’s iconic example of the word mangy.

I'm pretty sure EVERY dog in Haiti looks exactly like this one.

All day, they’re easy to miss.  You can mistake them for chunks of street that move occasionally.  But at night, things change.  The creature’s inner-dog hits center stage.

Weirdly, the dogs don’t start barking until approximately 10:30 pm.  Until then, the falling night settles gently, still and quiet; filled with color and culture and maybe even possibility.  Around that time I start thinking ahead to tomorrow’s impending 6:30 wake-up, and so prepare to slip peacefully into my Kelty sleeping bag liner.

Before I settle in, I brush my teeth carefully with bottled water.  Even more carefully I hover over the “toilet” and perform an intricate dance I fondly refer to as urifecation.  I then crawl into my hut and proceed to wipe myself down with WetOnes, donated unknowingly by my 3-year old son to remove the constant grimy feeling of DEET all over my body.

Refreshed, I settle into my little sleeping hide-away, exhausted from a day of genuinely hard, hot work.  With a final ZZZZZIITT, I close my bug hut, and congratulate myself.  I think I helped people today.  I did good work.  I deserve some relaxation, right?  Clinic from 8 ’till headlamps with only a break for lunch entitles a guy to some well-earned rest–

BARK!  BARK!

BARK!

No problem.  He probably saw a cat, or rat, or rooster or goat or sheep or donkey or cow in the street.  Now he’ll shu–

BARK! BARK! BARK!B ARK!BA RK….inhale…BAR K!B ARK! BA RKB ARKB ARKBA RK!

After a few hours of this, strange things happened to my mind.  I started examining the dark and variegated contours of the bark itself.  I sorted out the staccato syllables, found the edges, sounded them out…repeated them backwards, tried them on upside-down.  I imagined the sound coming out of the mouth of a cat, my mother, President Obama, the butt-end of an oversized hippo.

The barking seemed to be led by a leader-dog.  A kingpin.  The Don of our village – Thomaseau.  And by 2am I was certain the thing lived in my tent. Squashed into my 1-man nylon dome, somewhere between my navel and ankles; seemingly quite happy to communicate with the island at large in an endless stream of dog-talk.

I think my mind truly warped after hours of this auditory battering-ram, especially because it would stop just long enough to make me think  it was over…and then begin again.  My rather deep love of dogs dissolved into highly sophisticated methods of unapologetic canninicide.  Here’s a few:

Rum darts.

Ativan hot dogs.

A giant STOMP from my foot that seemed to grow to a size 38 in my mind.

Nooses.

Spears.

A kind pat followed by a yank of the muzzle in a 200 degree arc.

Gratefully, I learned that the dog – even the Grand Poobah of Thomaseau – usually cuts it off around 0300.  By then of course, he’s hoarse and worn out, but at least he has some sense of propriety.

Nearly delirious, I instantly slip into sleep.

Until I realize that the dog has awakened the roosters.

An hour later they wake up the goats.  If you can’t sleep with barking dogs, forget sleeping through opinionated goats (think the Gorgon Sisters dismembering rabbits).

Around 5:30 or so, a group of some type of religion appears on the street corner right outside our sleeping area.  Megaphone in hand, they preach directly at us, often with accompanying gaudy singing.  Their message, most likely, had to do with my current pitiful spiritual state.  Clearly they do not understand that they were preaching to the converted.

No question, I am damned.

Somewhere in the course of my day, I think I mentioned the word ‘entitled’.  If I didn’t say it, I believed it.  I worked hard, I was now entitled to something.  Sleep, maybe.  Or money.  Or success.  Or happiness.  That’s the American way, right?  Work hard (or steal intelligently), and get happiness.

Not in Haiti.  You aren’t even entitled to sleep.  Nothing is earned there…only gotten – if you’re lucky.  I didn’t get that kind of luck until Thursday…assisted by more-than-responsible doses of Haitian rum.  People say the dogs barked and preachers megaphoned that night, too, but this time I slept right through all of it.  Just like a Haitian.

Lucky me.

Le Flip-Flop Be`be`

Journal entry after the 1st day of clinic work:

A garrulous, ebullient, colorful people.  Haiti teems with energy and noise.  The creole language sounds like a brook hurriedly scrabbling across smooth stones.  At first, you think you hear French; those soft contoured and drawn-out vowels.  And you are.  But more, too.  It’s French plus native.  Plus pride.  Plus individualism and cultural distinction.

Creole is French drenched in the personality and attitude of a people.

**********

I achieved the pinnacle of my profession on my first day in Haiti.  I practiced clinical medicine while wearing my Reef flip-flops.  Every day, including for the delivery of a baby.

Long have I pondered where in the world I might have the chance to be a doctor and still wear the greatest shoes ever invented on planet earth, and I think I finally found it.  Haiti.

I think the prohibition against open-toed shoes in medical practice is probably much more about Victorian anti-sexual, social dictatorial fashion strictures than any true sterile or safety issue.  I wore my flippers every day in med school…I even wore them under my gown at graduation, flapping happily across the stage to get my powerful and awe-inspiring diploma.

My singular goal in life – if you press me – is to find a job where I can wear flip-flops with impunity.

As you can see, I found my professional soul in Haiti…through my flip-flops.  My very first case was a baby delivery, in fact, and nobody said anything about the irreverent shoes (sandals, really, footwear of Jesus, clogs of the Gods).

The case began while everyone was still sitting around the breakfast table.  We planned on getting an introduction to the mores of our makeshift clinic, led by a highly capable nurse who oversaw things each time she made the trip to Haiti.

Before I could even see my clinic area however, a voice blared over a hand-held loudspeaker from outside the church walls, crying “Le bebe!  Le bebe!”

Even I knew what that meant.

Quickly we settled the woman onto a rather uncomfortable wooden table with stirrups drilled into the sides.  Shortly thereafter, the woman’s, amnion ruptured with thick meconium staining.  Missed my exposed toes by inches.

Mec, especially when thick and gooey like this, suggests a very stressed baby. In the “real world” we call pediatric hospitalists to be present for deliveries like this because a resuscitation will likely be needed.

Just next to my exam “room”, we just happened to have a pediatric ER doc down from Miami.  While she provided a welcome level of expertise, supplies were in short supply.  We had no resuscitation equipment.  No baby warmer.  MAYBE a pediatric IV, but we would have to give adult saline.

One of the things we didn’t have was a welcome omission, however.  Adding to my joy about the flip-flops, we also were without a fetal heart tone monitor to watch obsessively.  I hate those things.  I blame them for thousands of needless C-sections a year.  It’s only because of the prolific lawsuits of John Edwards that we worship at the altar of FHT strips anyway.  No science even supports their use.

I could have done without the mosquitoes and flies buzzing around, the open window behind me (and directly in line with the woman’s exposed perineum as numerous couplets of eyes looked on), and the flimsy shower curtains that separated us from other exam “rooms”.  But overall, I could not have been happier, hovering around my new patient, waiting for new life in Haiti.

The baby came out small, stained and floppy.  One unintended benefit of malnourishment is that babies don’t get too big, and don’t often get stuck in the birth canal.  The delivery itself went rather smoothly.  Minimal tearing.  Things started off slowly for the baby, but our noble pediatrician performed some equipment-less magic, and the baby came around after a few minutes.  Eventually, he looked good enough to go home by the end of the morning.

That’s right.  3 hours later, the lady slowly tottered out the front door, heading home.  As I sent her out – consternation swirling in my chest at sending a stressed baby home on the day of delivery – I asked her to bring the baby back tomorrow so we could check on him.  The mother agreed, and appeared as promised almost exactly 24 hours later with a clearly healthy baby boy.

Only on her return did I learn that she lived 3 hours away…on foot.  The day before, the woman walked 3 hours to our clinic in labor, and then returned home the very same day, carrying her new baby.  Without complaint, she returned to the clinic again.  Another 3 hours.  Just routine for people like this, I guess.  Never a complaint.  Only dignified, quiet gratitude.

And nary a word about my flip-flops.

Pizza Hut? Starbucks? Haiti’s Not So Bad!

I play a mental game on airplanes.  I try to determine as accurately as possible when I cross the line from “likely to live” to “likely to die”.

As the plan taxis to the runway, I often think, “No problem.  Wheels could fall off and we’d be fine.”  Then the plane accelerates dramatically, the landscape begins to slide by with increasing rapidity.  “Not yet,” I think.  “Still wouldn’t die if we skidded off the runway”  Or, say, fell into a huge sink-hole nobody noticed.

“NOW!” I exclaim to myself at some arbitrary point just before lift off.  “We’re dead!”  I have no science for this, it just feels like human life probably was never really meant to achieve speeds like that.

I do the opposite on the way down, too.  I usually choose that point when the wheels have touched the ground, the wings have exploded into fins and panels to catch the wind and help the brakes slow us down.  Sometime around the point when the entire cabin roars and rattles in wind-shear friction I proclaim as objectively as possible, “Ok.  We’ll live.”

You can imagine my instant consternation when our plane lost power for a split-second after lift off from Miami as we headed toward Port Au Prince.  Some may not have noticed, but I sure did. 

We couldn’t have been more than 300 feet in the air.  Cars and buildings were still BIG.  I’d just proclaimed us “likely to die”, when suddenly the plane just seemed to sag.  The nose dipped slightly, and my heart caught in my throat.  But in an instant then the engines roared back to their previous RPM’s, and we kept climbing.

NOT comforting.

A few minutes later, the captain’s voice announced that yes we did in fact have a problem.  The landing gear did not retract into the belly of the plane.  Stuck.  The good news was that the wheels were stuck OUT, rather than IN.  “But”, the captian informed his white-knuckled crowd, “If we can’t get the landing gear into the plane, we can’t go to Haiti.”

So, we needed to turn around and land the plane.  Great.  No problem.  I don’t like this plane anymore anyway.  Unfortunately, landing the aircraft presented some uncomfortable dangers.  One problem was the huge amount of fuel we had in the tanks.  The extra weight made landing dangerous.  Unspoken, of course, was the grim prospect of just how big a flaming explosion all that fuel could make.

We also didn’t know if the landing gear actually worked.  Maybe it only partially extended from the plane.  Maybe it wouldn’t hold the aircraft under the stress of a real landing.  Maybe someone shoulda spent 15 bucks on a little internet cam down there so the captain could actually see what the gear looked like.

So, we circled Miami for close to an hour.  Burning fuel.  Losing weight with an efficiency any American could appreciate.

I spent this time pondering my choice to spend two weeks in Haiti.  I wondered if I could really provide any aid to anyone.  Was this really just tourism couched in the self-important guise of Western medicine?

How would my kids feel, 10 years after we saponified in a brilliant sun-ball of death on MIA’s runway #4?  Would they say, “My Dad died on a medical mission to Haiti.  It has been hard growing up without him, but I’m proud of what he was trying to do.”  Or, conversely, would they simply never understand why their Dad left them for what turned out to be  forever so he could go try to help a bunch of people he didn’t even know.

Around this time, the plane approached the runway, but we didn’t actually land.  Just before touching the runway, we took off again.  As we passed over, crews on the ground visually inspected the landing gear to determine if it was actually locked in place.  Things must have looked good because we then circled around, re-approached the runway and finally land the plane.

Waiting for us were emergency crews, lights flashing, posted at intervals along the runway;  each successive crew ready to pick through pieces of wreckage that flung away from the main one.  Nice image.  “Could you guys at Crew 1 look for my charred arm, please?”

Four news helicopters also hovered along the runway expectantly.  I’m not sure that a Bell-Howell chopper can lick its lips in salivating anticipation of afternoon of “news”, but I found the image easy to imagine.

Since I’m typing this, it should be clear to you that we landed without incident.  The choppers turned away forlornly, off to cover the boring Miami traffic; hoping for someone else to perish dramatically, preferably with flames involved.  We taxied to the quizzically-named “terminal” to board another plane while repair crews swarmed over our ailing one.

As we entered the airport, I felt a new lease on life although still haunted by the grim possibilities of what we “survived”.  Just then, I see Lisa, the only other resident doctor on the team.  Figuring she might be a little distraught about nearly losing her life, I walk over to check on her.  Be strong and manly, I think.  Supportive.  The rock.  Fearless, me.  The poor girl.

“Haiti’s not that bad.”  She says, looking around curiously.  “I saw a bunch of nice tiled roofs and high-rises as we flew in.  And-” She points to an airport Starbucks, “They even have coffee and pizza and stuff.”

Lisa then turns at me and beams.  “I think this trip’s going to be pretty cool!”

For a beat, I’m utterly speechless as I thickly connect the dots, “You’re serious?  What the heck have you been doing this past hour and a half?”

“Oh, I just had my ipod on and then I fell asleep.”

I think, your ELECTRONIC DEVICE?  ON?!  During TAKEOFF?

I realize that she has no clue what nearly happened to us.  No questions.  No worries.  Chilled out to music and then sleeping like a child.  No freaky captian, no fuel, no existential questions about loved ones, sacrifice and mission work.

She thinks we landed in HAITI!

“Good idea, Lisa.  Let’s get some freaking coffee.  Maybe they sell cigarettes valium too.”

Haiti – Part 1

I’m leaving for a medical mission trip to Haiti for 2 weeks in a matter of days.  Naturally, my life – aside from residency – has been largely focused on this big deal.

This is the season of Lent – a time of giving up and doing without, in Christian circles.  Well, let’s be specific: Lent is commonly practiced in more traditional branches of Christianity where guilt historically ran its totalitarian regime on the human soul.  Back then, the guilt-vibe generated extreme and wonderfully creative (in a Nazian sort of way) acts of suffering and penitence.  Think dull iron hooks and exposed collar bones.  Anyway, these days, many Lenten observers give up something rather level-headed, like T.V., to remind them of the suffering of Christ.

My family – slouching ever closer toward the Episcopal church, thanks largely to this wishy, squishy, lukewarm, doubtful Christian in the loosest sense of the word (as charged by my hyper-conservative heritage) – is observing Lent this year.

Wife is giving up chocolate.  Eldest daughter is giving up goldfish (the crackers, not the creatures).  Next daughter threw out the same.  Things get hazy in the lower echelons.  I’m trying to give up desert, but…lukewarm, you see.  We’re all giving up restaurants.

But what we’re really giving up is 2 weeks when I’m in Haiti, doing work I had once hoped to do full-time.  Truth is, I sold my soul to medicine in a mist of Christian charity back when I was debt-free, young, rather dumb and convinced I could do anything.  Something about, “if God is for us, who can be against us?”

Then I ended up $300,000 in debt and unlikely to be free of it until after retirement.  Couple that with the recent incident where guys uttering something similar to the above scripture – but in Arabic – blew up the World Trade Center and Pentagon in firey madness.  Suddenly, relativism and reality colluded to hamper as many elements of my personal life force as existentially possible.

So, I’m soon off to do for 2 weeks – jaded, hopeless about the lofty ideals I once had for my career – what I once had hoped to do with my professional life.  Not the last 5 years of it, but the first 40.  And to do these 2 weeks, my kids will give up their Dad.  For some of the younger and more empirical kids, there will be a lingering question about whether or not Dad is gone forever.  The older ones will have to deal with a MUCH quieter and decidedly feminine-heavy abode, with all the accompanying sorrows drama and virtues.

My wife will give up my daily witty commentary on  politics and my clothes flung to every corner of the house (actually, her Lent may get under way not long after I return).  She will also take care of everyone by herself for 2 weeks.  I flatter myself to suggest that this is much different that usual…but I suppose I have put a diaper on someone in the past month or so.

Me?  I can’t say I’m giving up much at all.  My passion for travel and curiosity about the rest of the world trumps the negatives of dusty, sweaty days in a medical clinic.

Long ago, I figured I needed to just be honest and admit that the reason I wanted to be a missionary had much more to do with the love of knowledge and travel that it did the lost souls of Ximbiaha.  Sure, Jesus loved me enough to die for my purity and for our relationship – yeah, I really do actually believe that, lukewarmness notwithstanding – and if you push me you’ll find that I do have a reasonable amount of energy for passing some semblance of that kind of altruism on to someone else.  So, Haiti won’t be much of a sacrifice for me.  There are lots of upsides in my world.  It’s a brier patch sort of thing.

Except that malaria is endemic there.  So’s dengue and typhus.  I gotta say, if I end up crapping my innards out for 3 weeks…consider my debt to Lent paid in FULL!