Wednesday, May 5, 2010

Haiti Team #2: Summary of Week 1 and Week 2

As a team, we focused our first sessions with each year (Years 1-4) on a basic needs assessment for training, the normal stress response and exercises for managing stress. The students specifically requested information on stress including etiology, presentation, signs/ symptoms and treatment for both themselves and their patients. They also requested information on clinical diagnoses such as PTSD. We split the students into small groups. The students shared experiences of their patients and themselves. Many of the students were first responders to the earthquake at the school providing emergency care to anyone who showed up at the school. As both an individual and as a first responder, the students were affected by the trauma of the earthquake.


We established a clinic in two rooms of the school’s dormitory which also housed the hospital’s pharmacy. We provided individual consultations to nursing students and clinic patients. We also offered opportunities for nursing students to interview and assess clinic patients while a provider was also present. The clinic patients spoke both French and Creole. In the case of Creole only speaking patients, Alexa Tarter translated for Drs. Muhr and Smyth. We saw some patients more than once. Most patients had one clinic visit.
Patients often presented with somatic complaints that had been ruled out medically by the hospital medical staff. Our consultations often included supportive therapy, CBT, psychoeducation and, on rare occasions, medication. We offered follow-up visits to all of our patients.

Logistically, it was difficult to get a significant volume of hospital patients. The clinic providers did refer us patients. The location of our clinic was not on hospital grounds which meant we lost a lot of patients in the process of referral. Therefore, we set up our clinic across the field and through a closed gate in the nursing school’s dormitory.

All of the dormitory students are currently living in Dean Hilda Alcindor’s front yard in tents. Despite no damage to the dormitory from the earthquake, many of them are afraid of returning to the dormitory due to their fear of being under concrete or near concrete during another earthquake. They are also audibly and visibly fearful of sitting in the classroom. Some of the students preferred to be living in a tent. Many of the students preferred to have class outside in the courtyard.

Some of the students have specifically requested to return to the dorm rooms. We offered to work more closely with the students regarding their fears. Since Dean Alcindor requested that all students return together, we did not have the opportunity to provide therapeutic support for their anticipated return to the dorm. In sum, there were logistical obstacles to assisting the students in their return to the dorms.

On Friday of the first week, a memorial service had been planned for the three nursing students who lost their lives in the earthquake. We made ourselves available to students before and after the memorial service/ mass. We also helped prepare some of the nursing students for the memorial service. Additionally, we made ourselves available to nursing students, if individually requested, outside of clinic hours.

Week 2: In the second week, we continued to offer clinics and small group teaching to the first through fourth year students. Our teaching priorities the second week included mental health history taking, exam, and differential diagnosis specifically of anxiety disorders including phobia and PTSD. We focused on clinical presentation, signs/ symptoms, co-morbidities and treatment of depression. We also reviewed the stages of grief and responses to grief. We included a discussion of the use of cognitive behavioral exercises. In all groups, we included role plays specific to their clinical encounters.

As the week progressed, the students started to implement their interviewing, assessment and supportive therapeutic techniques in role plays and in the clinic. Additionally, there was a shift in interest, comfort and rapport with the team. In fact, there were more nursing students willing to participate in clinic and to seek private consultation.
During the second week we experienced at least two aftershocks which exarcerbated students level of stress temporarily. We made ourselves available for support with visits to their temporarily living quarters in Dean Alcindor's yard.

Our last day of teaching was a full day. We had a morning of teaching with the first year students. Similar to the first week, the students rotated through three stations with topics including grief, depression, PTSD, mental health history taking and assessment, patient/ nurse role plays, building self-esteem and cognitive behavioral techniques.

It was on our final clinic day that many nursing students decided they wanted to be seen. Thus our final day was a busiest clinic day, particularly for Dr. Rachelle Rene.

In sum, we saw patients with anxiety, PTSD, depression, grief, insomnia, conversion disorder, pseudocyesis and normal reactions to trauma and stress. We provided supportive therapy, cognitive behavioral techniques, relaxation and breathing techniques. The nursing student patients were very interested in any hands-on, concrete approaches to addressing their mental health. Two students were open to using medications. Most students stated that they were not interested in medications. In fact, some students requested Dr. Rachelle for at least one reason. “ I don’t want any medication.” Only one patient acknowledged having seen a psychiatrist in Port au Prince.

The nursing students were open, spontaneous, flexible, eager and curious. FSIL, Leogane and the surrounding communities would greatly benefit from at least one mental health provider. We spoke with a Haitian pediatrician who has a private practice (on hold) and currently works for Save the Children (a NGO) as an administrator. The pediatrician stated that if a child has any mental health needs the only option is to offer a mental health referral to Port au Prince (private pay psychiatrists) which is not feasible or accessible to almost all patients. There is a definite need for the mental health training of nurses committed to working as mental health providers in Leogane.



Thursday, April 29, 2010

Haiti Mission#2: Days 4 & 5

There is creativity, spontaneity, flexibility, enthusiasm and inspiration on Haiti Team #2. We are an educator/ translator, a psychologist and two psychiatrists. We are a Haitian, a Brit, and two Americans (one resides in Port at Prince). We are four women.

We see patients and sweat. We teach students and sweat. We learn from students and sweat. We provide healing exercises for students and sweat. We collaborate and collectively create a teaching curriculum and sweat. We sleep and sweat. We walk/ run with the Haitian children and sweat. We eat one meal a day (dinner) while sitting on the roof that has a mild (repeat mild) breeze and sweat.

We are a team contributing in unique ways to the teaching, learning and healing of nursing students at FSIL, and to the provision of mental health care at Hospital Saint Croix in Leogane. Leogane has no mental health care providers. A Haitian mental health literature review dated February 2010 states there are 10 psychiatrists and 4 psychiatric nurses (all of whom are in Port au Prince) for the approximately 9.7 million people living in Haiti.

Creativity and flexibility are essential in every moment and in every encounter. We collectively share our thoughts and ideas while we create a teaching plan (and alternative plans). The sparse Haitian mental health literature offers little insight. We are dealing with language and cultural barriers. We have on our team a Haitian psychologist whose perspective, insight and intuition are invaluable. Even so, we all make a lot of guesses.

Collaborative consultation with teaching and seeing patients incites:

What do you think of…..?

What about this…?

How about if we…..?

Or how about…..?

This might work….. or maybe this might work….


As a team, how are we contributing?

Assessing needs: The nursing students are grieving multiple losses including the loss of their peers, their children, their siblings, their parents, their best friends and their homes. They are especially eager to learn to live with stress. They are curious about PTSD. They want to understand how to care for patients with mental health problems. They want to know what mental health disorders “look like”. Some of them want to know how to overcome phobia, in this case the phobia of concrete and being inside a building made of concrete.

Healing loss: The nursing students draw pictures, tell stories, cry and share their physical, emotional and behavioral experiences of stress at different phases post-disaster.


Our collaborative, creative teaching includes:

Learning to live with stress and fear… The nursing students learn about and practice relaxation exercises, guided visualizations, grounding exercises and expressive art therapy. They practice changing negative thoughts into positive thoughts.

Self-care and living with stress….The students participate with curiosity in exercises for self-care. They identify (with smiles and laughter) what ‘fun’ activities offer them pleasure, freedom and lightness. They sing, dance, listen to music, talk to their friends and tell jokes.

Empathic listening, mental health history taking, assessment and education: The nursing students participate with enthusiasm in role plays that focus on enhancing their capacity to identify/ assess and offer support to patients with mental health concerns. They have opportunities to practice empathic interviewing, make assessments and provide psycho-education with each role play

This is just a sliver of the journey…a sliver.

Tomorrow afternoon there is a memorial service for three nursing students who lives were lost in the January 12 earthquake. Many students also lost family members and loved ones in the earthquake. We plan on attending, and will be available for support.

Tuesday, April 27, 2010

Team #2 Haiti Post-Earthquake

Team #2 Haiti Post-Earthquake: Day 2 and 3
Rachelle Rene, PhD, BCB, Heather Muhr DO, MPH, Angela Smyth MD

Monday and Tuesday, April 26 and 27

Heather Muhr blogs: On Monday morning, we met 16 fourth year nursing students from FSIL. On Tuesday morning, we met 14 third year nursing students. In our Creole and French introductions, we emphasized, as a psychologist and two psychiatrists, that we were clinicians for both the students and the Hospital Saint Croix clinic patients. We also focused on our roles as teachers and discussed the psychosocial effects and impact of stress after a disaster such as the January 12 earthquake.

After the students separated into three groups (each group with one clinician), they shared with us their personal experiences of what patients have been telling them since the earthquake. This organically led into an interactive, dynamic sharing of their emotional, physical and spiritual experiences post-earthquake. Descriptions included: “vide(emptiness)”, “le denil(denial)”, “tristesse(sadness)” ,“le deuil(grief)” and not wanting to make connections with their friends. The feelings connected to loss, stress and grief are tangible. There was a deep sense of community and shared humanity amidst all of our connections with the students.

The students made specific requests for skills or tools ( i.e. psychoeducation) that could help them with their stress and the stress of their community, including patients. We began with a discussion of the normal response to stress. We did an interactive exercise on self-care and a guided visualization and grounding exercise. As teachers and clinicians, we are focused on offering the nursing students a set of hands-on therapeutic techniques and self-care approaches to address their stress and that of their patients.

Angela Smyth blogs: Clinic started Tuesday morning. Although our space is a long way from the primary care clinic, we have networked with the other hospital providers and made them aware of our location and availability. We saw the first six patients today. All of the patients have their medical problems ruled out before they come to see us in our clinic.

Today most of the patients presented with somatic signs and symptoms related to the trauma of the earthquake. One young woman was convinced that she had a cancerous growth in her abdomen and was unable to eat/swallow. There was another older woman with pain all down the left side. Most of the patients have trouble sleeping. Angie also had a therapy session with a patient, first seen by Kobie, who is grieving the loss her 2 year old daughter.

At moments, it can seem overwhelming to provide education to Haitians about mental health. Even the educated people have very fixed ideas about psychiatry. If we can pass on the value of mental health to a few nurses, we can make a difference for patients, their families and the community. We hope to include some outreach to key stakeholders who are interested in providing counseling and support in the community. As an example, we plan to meet with pastors who provide pastoral counseling to their parishioners. In Leogane, the church and their pastors provide significant support for the local community.

Rachelle Rene blogs: Despite the daunting task of educating people here about basic psychiatry and psychology, the nursing students have been extremely eager and receptive to learning from us. They asked a lot of questions and are grateful for any and all information we provide. The nervous laughter they exhibit when we begin to teach them some simple relaxation techniques quickly gives way to enthusiasm and openness.

Everything here has to be customized within the context of the Haitian culture. Simple visualization techniques have to incorporate Haitian idioms and imagery. The response is greatest if the students are able to come up with the examples themselves. In helping them to recall what they have done to cope with stress prior to the earthquake helps to set a foundation for what tools they can engage in again and hopefully teach their patients. We emphasize that self-care cannot be understated.

There is a lot of need here in Leogane, on all levels. We want to make the best out of our time here and hopefully leave a lasting impact; one that can be sustained by the people who will remain here to continue the work. That being said our presence among the locals here, the children especially seem to have an impact already. They are a resilient bunch these children; always smiling and happy to see us when we walk by. You would never know that they have no home, no bed to sleep in or that the sandals on their feet are torn. It really drives home how much we can sometimes take for granted.

Heather Muhr blogs: Moments of gratitude are abundant. A few examples follow.
1-When sharing with her classmates about stress, a nursing student with a distant, flat affect states that she does not wish to connect with the world or talk to anybody about feelings related to her stress. After the self-care exercise in which the same nursing student identified dance as a place of celebration, I see her dancing alone in the back of the classroom with a big smile on her face.
2- Another nursing student recognizes that ‘denial’ is how she is coping, she admits to the group and to me that she wants to talk about “it” (“it” is the denial and/ or her stress response to the earthquake).

3-Ah-ha moments: A young woman I saw in the clinic lost her sister in the earthquake. We talk about grief, and discuss ways to seek support for her grief. She smiles brightly(”ah-ha”), and pulls out a book from her purse in French. The title of the book is loosely translated as, “Working with the problems of young adults in marriage and the Christian family”. She carries this book with her in her purse wherever she goes. She admits to finding a lot of support for her grief from this self-help book. This book also reminds her of the support available to her in her church community.

4- Resilience. Every day a group of young Haitian boys and girls from the tent city outside our front door join us in a run to the beach. As they run, fast, with their almost bare feet for five miles, they recount in Creole or French their loss and losses from the ‘evenement’ (earthquake). There is loss of their parents, the loss of their siblings, the loss of their family members, the loss of their home, and the loss of their limbs. The resilience of the Haitian children is not lost.

Monday, April 26, 2010

Haiti Mission 2: Day 1


A Return to Haiti
Written by Dr. Rachelle Rene

Wow, what an adventure this has been thus far! We (Angie, Heather and myself) spent the night in Miami...it is really nice in Miami...at least what I could see for a night on the drive to the hotel. This morning we headed back to the airport...Haiti bound. Checking in luggage went without much fanfare. Despite my worries about having too many bags, it turned out I wasn't alone. I even had some room in mine to accommodate my colleague so we could be just under the 50lbs per bag limit. We each had at least two bags of supplies (mostly toys and art supplies, etc) for the children we hope to see at the hospital.

There was something refreshing hearing Creole spoken at the Miami airport. Something about it gave me a sense of comfort. We boarded a small plane with strict instructions not too carry-on too big a bag. Well, my duffle bag had become a carry-on a la military style, if you can picture it. In order words, it went on with me. But I worked it out so that it became two small bags. Hey, you gotta be resourceful, and you gotta protect at least the laptop from which I write you tonight.

So, sitting on the plane I met a lady Nicole, her and her husband are directors of a forestation program here in Leogane. She speaks fluent Creole. We talked about the earthquake. Why she and her family moved here (since Sept 2009) and how her work is helping to provide some education and support to the Haitian peasants. It was a wonderful conversation. And to prove how small the world really is, just two weeks ago this same woman met the previous two psychiatrists on our team...no coincidence! So, as Nicole and I talked, we hit a bit of turbulence on the plane going through clouds...why is that? The gentlemen to the right of Nicole, a Haitian man, just let out a yelp, yep, a yelp. Was he scared? Hmmm, you tell me. But instantly I knew he had experienced the January 12th earthquake. Something in his reaction. Sure enough, he confirmed it when we talked a little later...we both had done our best to calm his nerves. He wondered why we hadn't landed yet since the pilot said we were 20 minutes from the airport. I wondered too, but just thanked God and went with the flow. I mean what do you do when the plane you're flying on takes a dip, not just any dip, but a very quick gravity insides all turned upside down dip? Well, I guess by now, I've sort of learned to just say, aight God, thank you, whatever happens here goes. Seriously, I say that in my head.

Anyway, safe landings in Port-au-Prince...everyone clapped. Nicole tells me, most Haitians usually do clap with each landing, turbulence or not. It dawned on me that perhaps it's because we are keenly aware we don't control the skies. You know it's funny, when you realize that there's very little you have control over, you tend to be a little less stressed about major events. You kinda shrug your shoulders and go about your business...the life you have now. And I think that's perhaps what many of the people here have done...but this is only my cursory view from an airplane window.

We land in Port-au-Prince. We wait on a long line to clear customs I imagine, except, it's a line to go out of the airport and onto a shuttle bus to the Cargo station to pick up our luggage. We get there and oh, it's swelteringly hot! We go through customs, give our declaration forms and meet with chaos on the other end. Luggage is everywhere. People are everywhere. It is a colorful sea of people, Haitians, Americans and of course those who kindly offer their assistance to get your luggage, for a small fee. Except they don't tell you this up front. But tell you how beautiful you look and they are very serious about helping. I almost fell for it. This of course after I reminded my colleagues of our instructions to clearly say, "non merci." I had to chuckle at myself. So, a small airport, people everywhere, and it's hot. But we manage to get our luggage onto a cart and head outside to meet our driver. The scene is surreal. People behind a fence looking in. Security trying to have people with luggage move out from the cargo station and yelling at the would be drivers to clear the way. THAT was a gripping scene. My more than 25 years adopted western mentality and blend of many cultures wondered, "hmm, why does he have to be so mean, can't he just be nice." Hey, what can I say, I'm a sucker for niceness. Guess, security was never my calling, at least not that type anyway.

So, you're probably wondering how am I feeling about all this? I have not been in this country in 25 years! To be honest with you I think I am holding myself together. I don't know how to explain it. It is both familiar and foreign. Does that make sense? That's the only way I can describe it for now. I was really young when I left Haiti, but there is something familiar about it. Yet, as an adult now, it's a bit foreign, yet curious. I have this inquisitiveness about me that pushes me to observe, to wonder, even silently and to simply take it all in. What is most familiar is the language! I hear it and I smile, because I understand it. And there is something about one Haitian that recognizes another. I don't know how that is, but some recognized instantly that I was Haitian, even with braided extensions. Others, didn't know, and that's mainly the ones who were trying to hit on me. Needless to say I learned not to respond either in Creole or in English, smile, I am learning.

Our team is all together including a group of 12 or more from another Medical team, also part of the Notre Dame University Haiti Project. Our drivers take our luggage and we walk on gravel/dirt road to get to the bus (and that's clearly not a great description of what it really was) to load them and drive to Leogane. The street is filled with people, young people, lots of young man asking to help, for money. Our bags are safely loaded and we squeeze in a small jeep like car, 7 of us not including the driver and the one guy who sat in the passenger seat up front. I am in the back with Paul and Alexa, barely any room to fit. It is a tight fit for sure. But off we go. As we drive through the city, I take pictures as best as I could in my squeezed space. None of us are comfortably seated, but no one complains, we shift our behinds periodically, pull down the window, take pictures and shake our heads at the devastation. When people talk about tent cities, you really have to see it for yourself!
The city is mostly covered in tents, rubbles, trash is pretty much everywhere, little storefronts along the road. People carrying stuff on their heads; others on bike. It's definitely a sight not to behold. Some place we drive by, I wonder how people endure the stench!!?? And then I think that while my Haitian people are a resilient one and have endured so much, I still don't know, how you endure something like this. How do you rebuild a place that from all objective observation seems so broken. We drive pass the palace. I get a good look at the toppled over roof top of the Presidential Palace. I think that moment for me made my being in Haiti real. Wow, it is really destyroyed. I snap a picture as quickly and as best I can...I attached it. Wow, it is something else.

The drive is bumpy, sometimes dirt-filled, but safe. At no point did I feel unsafe. But you couldn't help to see toppled over homes, rubbles, yet people everywhere doing the best they can...selling, cooking, kids running around; women sitting talking; men on bicycles or motorcycles; young men walking around; some looking at us as we drive by; other cars on the road...nothing like cars here in the U.S. Another reminder of what we take for granted!
Well, we make it safely to our residence. Driving to get to it are more tent cities all along the sides of the residence. We see where the nursing director lives. It looks like a nice place. All in her front yard however are tents were her nursing students stay. The makeshift hospital, also tents. As we get off the "bus" curious kids run to come see who these new poeple are. They seem so happy. That's the amazing things about kids sometimes...no matter what horrific thing is going on in their lives, they are an enthusiastic curious demeanor about them. I greet them hello.

Later "Ali" takes us on a tour/jog around town. It's really our first outreach I think. As we walk, a bunch of kids literally come running up to us and ask curious questions about who Heather and I. They know Ally and call her "L." She introduces us and tells them that I am Haitian. Oh, boy, the questions start to roll. Were you born here or "over there [U.S.]" Here I tell them in Creole. They seem excited that I speak Creole. As we continue our walk more kids join us. You know, there is no certainty on how you will outreach or minister or help someone. You can have a set plan. This is how I will do this and that... and sometimes that doesn't pan out. On this walk, at least two of this kids who are with us begin to talk about their experience of the earthquake. Le tremblement terre rive tout bagay sekwe, mwen santi-m tap tombe nan yon tou. Nou kouri soti. Yon nan se-m te blese." "When the eartquake occurred, everything shook. I felt like I was falling in a deep hole. We ran outside. One of my sisters was injured," one of the little girls told me in Creole. As we continued on the walk towards the water, another tells me that both her parents died, but a month before the quake. And she goes on to say that her mother was coming after her to take her with her. I simply had to listen, otherwise I'd have to put on my clinical hat and go through the list of diagnosis. But in this culture where such beliefs are a norm, you simply listen. So it turns out that it was this little girls God-mother who saw in a vision the mother wishing to take her daughter with her to the grave. According to the little girl, the Godmother cursed the mom away. This little girl says this with confidence and a smile. She seems well adjusted and very, very smart. They cling to the three of us, these curious children. I don't know all their stories of lost or otherwise. But for this moment, this walk that we went on provided maybe an escape, perhaps company for them, and for us, an introduction/re-introduction to the culture. We see many tents along our walk; many huts too. That's the best way I can describe it. People look at us, at me with curiosity. Some say "Bonsoir" "Good evening or hello. I smile and respond. As I walk I hear some of them call me "Blanc," and this is not a literal translation for "white" either. Here, I think it simply means foreigner. And in many ways, perhaps I am a foreigner in my own land. I don't remember coming to Leogane as a child. The sugar canes look familiar. The mango trees make me smile. The banana trees bring a sense of awe. The gravel roads take me back to the roads I walked on as a small girl. All of it familiar, but today I am a "blanc." I don't know if that label will stick once we begin our work with the nursing students and the patients. But for now, I am content to be in a place where I completely understand the language spoken here.

I would write more...it's late...and time for bed. Actually, I don't even know what time it is. I don't have a sense of that. I am not wearing a watch. But mostly everyone here at the residence is asleep. We are safe. We have been well fed...beans and rice and ban-nan peze (fried plantains avec pic-clise), yum! Day one over and out. Good night.

Sunday, April 18, 2010

Haiti: Team 1 Conclusion

Disaster Psychiatry

Typing this final blog post, I am already back stateside, at my favorite neighborhood restaurant, about to enjoy a good, hot meal and a cold beer. It's a luxury that I will try to never again take for granted. As I look back at our experience in Haiti, at the goals we hoped to accomplish, I am both proud that we were able to do some significant good, and frustrated that so much more is needed and left undone. The healthcare needs of the Haitian people have been and are being grossly undermet. Now, after a devastating catastophe which has claimed over 200,000 lives, the world's moral focus has been directed upon Haiti, and there has been a tremendous amount of humanitarian and financial support. But the question I struggle with is, "What does the disaster psychiatrist do when, prior to the designated event, the mental health care system was disastrous? In Haiti, the healthcare system as a whole was in such gross disarray before the earthquake, that disaster-specific responses fall woefully short of addressing the needs of the people. After a few months, after a few years even, what then?

Of course, those really are questions for governments to answer. But even a perfunctory review of Haitian history will suggest that such answers are unlikely to obtained. Prior to the January 12th earthquake, physician presence in the Leogane region was nearly non-existent. After the January 12th earthquake, and after the Disaster Psychiatry Outreach response, psychiatry presence in the region will be...nonexistent. There will be absolutely no psychiatrists in a region serving greater than 300,000 people.

This is why it is so critical to train the FSIL nursing students the basic tenets of psychiatry...in my opinion, expanding beyond even trauma-related issues. As of right now, the main physician presence in the region is volunteer-based. And though all of the doctors have some psychiatric training, certain issues amplified in importance with psychiatry...language, culture, rapport...are poorly met by a foreign volunteer staff. It is critical that we train the nurses who, as they were before the earthquake, may soon be the lone providers of both mental and physical health care to the people of Leogane.

So the questions arise again. What constitutes a disaster? What if the disaster spans two centuries? What strategies, systems, responses need to be employed? Certainly, an attempt to respond to such needs is well beyond the scope of what we can hope to achieve as disaster psychiatrists...(as I cut into my perfectly prepared, medium-rare steak) Right?

Thursday, April 15, 2010

Haiti: Day 13

Resources

Well, today was the last day of clinic. Again, we saw many patients, ranging from a follow-up of my first psychotic patient (bumped her risperidone up to 2mg po qhs) to a consult on a patient who felt his lips were swollen (his lip was swollen...we never did quite nail down that appropriate consult thing.) The provision of care here, for all the medical teams including ours, has obviously been limited by the confines of our resources. Many resources we take for granted in the States, such as proper waste disposal units, a functioning lab, and adequate imaging equipment. Medication is probably the most valuable and obvious limited resource. Three other resources, though, have had a particularly significant impact on the way care is delivered, and may not be so immediately obvious.

SHELTER
You know, I really can't emphasize it enough...it's very hot here. The heat and the sun affect almost everything that is done, especially in the clinic. Being outdoors, the clinic is exposed to the elements...and so are the patients. Remember, there is a long line of patients formed outside the clinic daily at six AM, and patients often come steadily until five PM. The location of the line shifts throughout the day, following of course, the shade. Clinicians must make sure they avoid excessive sun as well, as they are exposed day after day. It should be no surprise that by the time patients are seen by their providers, many exhibit signs of dehydration. Though the pharmacy is located indoors, it still gets very hot and humid inside. Those conditions directly degrade the viability of the medications inside... a factor whose importance should not be underestimated in a pharmacy stocked almost entirely by donated meds.
And I've yet to mention the effect of rainwater. Three days ago, the entire clinic moved from outside the nursing school to just outside the hospital. There were three recently built wooden structures there, but they had not yet been completed. After the rains last week, conditions in the clinic became very wet, muddy and quite frankly, grossly unhygienic. In no small part due to Dean Alcindor's outrage, a drainage ditch was dug, tarps were placed over the structures, and the clinic was moved to higher and drier ground.

TRANSLATORS
There is almost nothing that can be done here without the help of a translator. Most of the patients here speak only Creole, maybe a little bit of French, and rarely a tiny bit of English. Most of the humanitarian providers don't even speak a word of French, let alone Creole. Several providers, especially those who have made several trips here, have taken it upon themselves to learn quite a bit of Creole. But for the large part, nothing happens without the help of a translator. There are about 20 translators on staff (all young males, for some reason). Most of these guys are self-taught locals, who continue to learn as they work more and more with the hospital and providers. They are informally led by Peterson "Much respect...I'm a businessman, you understand?" and formally by Jack, whom I've never seen without his big, Kanye West-style shades on. Love them or hate them (I love them), nothing happens in the hospital without them. That was never more painfully obvious than this past week, after Ali was gone. Unless a patient spoke very good French, we just could do absolutely nothing until a translator became available.

TIME
The world's eyes will not be turned toward Haiti forever. The temporary hospital and steady influx of doctors are not permanent. From our standpoint, there's just only so much you can do in two weeks. It's extremely difficult to provide good care, provide good follow-up care or have something approaching a legitimate impact on the mental health of even a small region of Haitians in two to four weeks. Treatment takes longer. Proper education takes even longer. And establishment of adequate systems and structures...in this country...I hate to think of how long it might take. If anything is going to happen of significance, its going to take more time. But we all know what they say time is...

Wednesday, April 14, 2010

Haiti: Day 12

Back in Business

Today was a very good day on many levels. Firstly, our referrals picked up again. I'm sure the reason they slowed down was due to having a brand new set of medical professionals work with us. These practitioners come from many different settings, and I think often are not used to making psychiatric referrals. Also, as in so many instances, once we've both strengthened the interpersonal aspect of our relationships, the professional often follows.

More importantly, I had a number of good converstions with some key individuals today. I think I'm close to having a good overall feel for the dynamics of the hospital/nursing school/region, and may soon be able to synthesize a good plan of action to impart some significant change in the way that mental health care is delivered here. But I'm close...not there yet. More on that soon.

Today, I'd rather update you on the mother and baby we admitted to the hospital yesterday. In my opinion, their case highlights some of the clear weaknesses and potential strengths of mental health care in the region. This morning before clinic(after rounding on a woman in the ER with reported pseudoseizures) I checked in on mother and baby. All went well with them last night; the hospital staff of course had no need to use the tabs of haldol 2mg and lorazepam 1mg I set aside for them in case of agitation. From their neighbor's report, and from my assessment, we had no reason to suspect she would become agitated, but I like to be safe.
We planned to do a home visit this morning, but as was the problem with the mobile clinic yesterday, there is still a gasoline shortage in the area (someone working on a completely separate project was able to find some many miles away for almost $12/gallon). This afternoon, though, Cara from the nutrition program let me know they had found a truck (using diesel) to take us on the visit. So she, the neighbor and I hopped in the truck, and made our way to the home.

She lives not too far away from the compound, which is very encouraging...it increases the likelihood that someone can come and regularly pick up formula. It was far enough away for me, however, to get a feel for a more rural area. As we traveled, I began to see much fewer people on the side of the roads. We became more surrounded by trees and brush than by homes and rubble. We arrived at our destination, hopped out of the truck, and made our way down a winding narrow path, which opened into a hidden community of people off the roadway.

As we walked, as always, everyone was very friendly... the neighbor said hello to everyone, and we responded with "Bon Soir!" That's pretty much all I said, as the only non-Creole speaker in the group. (I gotta work on that) She introduced us to another lady, harvesting fruit in the middle of the clearing, who was "fou", or psychotic. When we got to the family's home, we found the patient's blind mother and her aunt sitting at the front of their very humble light wooden (heavy straw), tin roofed abode. They explained that yesterday, the daughter had gone to the hospital to get some help for the baby, but was supposed to be accompanied by her brother. Instead, she had wandered off alone, as she is prone to do, without an escort. They were very glad to hear that she and the baby were doing well. The aunt assured us that she would be responsible for coming to the hospital weekly to get help for the baby. And with that, we were off with a plan.

Many things strike me regarding this case. It speaks both to the abundance of resources available to individuals in this country (if they can find it) since the earthquake, and to the question of what happened before the earthquake when there weren't such great nutrition programs available? It speaks of course also to issues of competence, culture, paternalism and protection. But mostly I was struck by the fact that, although the community would kind of smile and say "Oh, she's 'fou'", their mentally ill were very much still a part of their community. I'm no longer even so sure that the patient needs an antipsychotic. I will continue to recommend it with the hope she will have some improvement in her thought organization, and maybe some associated improvement in mood with a decrease in her hallucinations. But as we know, our meds are much better with perceptual disturbances than they are with thought disorganization and mood. And the hallucinations themselves don't really bother me, or her community. They might bother her, though...so we'll keep it. But if she were adequately breast-feeding, I probably would not.