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.

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.

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!