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.

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.

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.

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?

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...

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.

Haiti: days 10 & 11

Slow Times at Leogane High

Things have slowed down way too far for my taste. The flow of psychiatric referrals has slowed down to a trickle. There's a new team of physicians this week, and though we continue to remind them to send us patients, they still come too far and few between. Worsening things, nursing participation with the team has been volunatary this week, but today and yesterday that translated into nonexistent. I have some clear suggestions for the next team, to make sure they are maximally effective. Today, I actually was scheduled to ride on the mobile clinic (which basically consists of Evans, some students and supplies on a truck) into some of the more remote parts of the area...I was really excited about it, too. Unfortunately, the truck was in need of repair today, so we couldn't go. So this morning, sitting around waiting for patients, I was on the verge of grabbing a hammer and some nails, and running off to find Sean Penn in an effort to be productive. (He'll make it all better...)

Patience though, not one of my stronger traits, proved to be most useful for me today. I got a referral from the pediatric nurse, who had just seen a severely malnourished baby, and wanted us to interview the mother. The mother, it turned out, was severely ill. She suffered from chronic auditory hallucinations, gross thought disorganization and inappropriate affect. Though she was only twenty-two years old, she said the baby was 18 years old. She initially said she lived three minutes away, but then said she lived eight days away. She was disoriented to time, saying it was "year two." She denied SI/HI, or thoughts of harming the child, however.

I, of course, felt uncomfortable sending this child home with she and her mother in their present conditions. I was able to find one of the doctors on call in the hospital, who agreed to consider the child for acceptance into the nutrition program. After some "liaison" with the nutrition team (they were initially leaning toward sending them home) they began an assessment of the child, and of the mother's ability to feed her. Very luckily, a local assistant on the team knew the patient from her neighborhood, and knew of her family. On further examination, the baby proved to be underneath their weight/height ratio requirements for hospitalization, and they agreed to keep the child overnight. Complicating factor--the patient has been breastfeeding (not adequately), but clearly needs an antipsychotic. We have a good solution, though. Tomorrow, we will all go on a home visit, assess her support system, and hopefully enroll her in the hospital's baby formula program, in which formula can be provided indefinitely. Once we have them enrolled, mommy begins her trial of risperidone. So, win/win. Mommy gets treatment, baby gets fed. Family gets ongoing social follow-up, with an option to involve the Save the Children program and their social services/ child protective services if needed. All and all, a good day's work, even with one family. Maybe I'll just be content doing my thing, and let Sean Penn do his.

Haiti: Days 8 & 9

The Community

Saturday was Ali’s last day with the team…she needed to return to Port-au-Prince and get back to her real job. So Friday night, a group of us decided to go out for drinks and ice cream. It was a group of about ten of us, and at about 7:30PM, we ventured out into the streets of Leogane. It was pretty dark out, but Steve, who had been here for some time, knew the way. We first went to a place called Massage, a restaurant/bar in the middle of town. They served ice cream, cheeseburgers, pizza, and of course, beer. I went in on a bottle of Haitian whiskey (called “Something Special”) with Michelle, a pharmacist. That maybe was not one of my better decisions this trip… Massage was apparently one of the more popular venues in town, as it was very crowded. The atmosphere was basically that of a block party, with everyone hanging out outside in the street. We didn’t stay there long, though, and made our way back to Joe’s. Joe’s is a bar not far from our residence, located adjacent to the Hands on Haiti camp, typically filled with Canadians. Joe’s was nice, but it closed at ten. By then, I was feeling very “special,” and some of us hopped in a Jeep and went to a local club. Well, that was a lot of fun, too. Only problem was, I didn’t get back to the residence until about 1:30AM, and I had clinic the next morning. So by Saturday morning, sitting at my desk, with no place to hide from the Haitian heat, I didn’t feel so “special”.

Patient-wise, things were pretty slow Saturday and Sunday. But that gave James and I a little more time for teaching, and a little more time to explore the town. There is a mini-tent city along the entrypath to the Residence Filiariasis. The entire compound, containing the residence, nursing school and current hospital is largely enclosed by brick walls, with manned gates in the front and back. How these few individuals came to live within the compound, I am not sure, but it is a significant number of people. Out the front gate is the main part of town, with Hands on Haiti and Joe’s being just to the right, and the bulk of town (city hall, Episcopal church, former hospital, police station, Massage) to the left. The back gate opens into a large, sprawling tent city, from which many of our patients come.

Though I had my concerns regarding travelling about town, at no time throughout the weekend did I feel unsafe. Even at night, everyone in Leogane has been very cordial and respectful. Last week at the Port-au-Prince airport, things got a little hectic…but that’s at the airport, where travelers are easy targets for people soliciting money. In town, everything has been smooth. Now, I’m not an idiot either, and so general street safety rules were of course in full effect. For my street-knowledge-challenged readers, those include in no particular order: 1. Stay on main streets. 2. Know where you’re going, and walk like you know where you’re going. 3. Try not to travel alone, unless you know the area. 4. Watch what’s happening around you. 5. Avoid too much eye contact. Those are the basics, some might add a couple more rules. Not too difficult…follow them, and there aren’t too many places you can’t travel. If you like to bop around shady streets at midnight with a camera around your neck, laughing, smiling and flashing Benjamins, I’m not going to be walking with you. Be it in Haiti, Manhattan, or on Butterfield Road.

Haiti: Day 7

On Patients

Most of the patients we’ve had have been pretty straightforward. The vast majority, even the ones we don’t see, have a poor appetite, poor sleep and frequent GI complaints. But a few have been somewhat more complicated.

Two days ago, I saw a 21 year old woman who most likely is a first break schizophrenic . As one might imagine, given the subtleties in translation and cultural nuance, on top of the usual difficulties in obtaining an accurate history from a patient, we must be very careful in giving such diagnoses. For one, the patients here tend to describe their symptoms very figuratively. One gentleman came to me saying he was hearing sounds, when actually he had ringing in his ears after a head trauma. The same patient told me he had a brick on top of his head (headache.) Others have described seeing visions, but careful dissection reveals that those visions are actually memories. This woman, however, reported hearing voices she didn’t recognize for several years prior to the earthquake, though they have worsened since. She exhibited classic symptoms of schizophrenia, including inappropriate affect, thought disorganization and bizarre behavior. Strengthening my faith in the diagnosis were the nursing student’s subjective observations, since as a foreigner I can’t confidently say what is or is not out of the cultural norm. This is why it is so critical to teach the students psychiatric diagnostic skills…because once they are taught, they can do a better job at it than any foreigner. Our patient received a week’s worth of risperidone 1mg po qhs and a follow-up visit with me next week.

Yesterday, we admitted our first patient to the hospital. She was a forty-one year old woman who was referred to us because reportedly she had not eaten or had anything to drink since the earthquake. At the time, they had found no medical reason why she wasn’t eating. James talked to her and her family, and found that she had a history of psychosis prior to the earthquake. She was extremely emaciated, and definitely malnourished. Upon the interview, James decided the patient needed to be hospitalized…I ran over to the hospital, grabbed a stretcher, and with the help of one of the clinic translators, transported her over to the hospital. The docs set her up with an IV, and soon she was feeling a little better. That afternoon, they wanted to send her home, but on our suggestion, agreed to keep her for a while. Today, just as we were headed over to the hospital with the students to round on our patient, Christina (a fourth year med student who does a great job managing the ER) told me they were sending her for a chest film, as they were suspecting TB. Sure enough, the film appeared to reveal TB and she was sent to the sanitarium. Maybe saved her life.

Also yesterday, we saw our first official child and adolescent cases. The adolescent was a bright, energetic thirteen year-old girl who came to the clinic for her nasal congestion. She was a typical thirteen year-old girl, who I imagine were she in the states, would spend most of her time talking a mile a minute on her cell phone. Ali had a hard time keeping up with her! Though she had lost several family members in the earthquake, she actually was doing pretty well, and just came to see us because she was upset by the aftershock I described yesterday.

Our child case was a little more complicated. He was a ten year old boy referred to us because his sister stated that since the earthquake, he hasn’t spoken. So…sheltered space being at a premium, our office became our Kid’s Corner. I found some toys at the residence, and started playing with him while James, Ali and the students interviewed the sister. She said he had been a normal little boy, got good grades in school, played with his friends, but all that changed after the earthquake. He had a leg injury, but she couldn’t give a clear history about when it happened. It seems he wasn’t injured at all in the earthquake. From his play, I immediately had serious doubts about the veracity of the given history. I gave him a notepad to write/draw on, and he happily began to draw repetitive circles all over the page. He drooled continuously, and flashed me a huge smile after he finished each line of circles. He couldn’t talk, but would give me a merry grunt when I’d say “Hi”. I asked him to draw a picture of his sister…he drew circles. I asked him to write his name…he drew circles. The sister soon admitted that he never could write his name. Suspecting MR, Ali explained to me there was a huge stigma in the country about MR/DD children. Parents will often say that some event caused the child to have his or her difficulties. They hope that the doctors can give them a medication that will make everything better. I wish that I could.

Haiti: Day 6

Apres la pluie…le deluge

So, I initially awoke at about midnight last night to the sound of James moving about the room. It had begun to rain pretty heavily, and after some discussion, we agreed to close the window. James was also kind enough to move my luggage away from the window for me, to prevent my things from getting wet. With that, I rolled over and went back to sleep. About forty-five minutes later, I awoke again, this time to James saying, “Uh…Kobie? We have some flooding?” (If you know my former attending, you know he likes to make statements in interrogative form.)

And boy, did we have some flooding. We were standing in about two and a half inches of water. I got out of bed, and rushed to save my belongings from any further assault by the water of unknown origin. After doing so, (my things really weren’t in too bad of shape) I walked out of the room, to find that the entire first floor had at least an inch of standing water, and the residential staff and residents had begun to frantically try to remove it. I grabbed the nearest mop I could find, and started to mop the water in the direction of the first door…and the handle promptly popped off the head of the mop. Not to be discouraged, I popped it back on, until it popped off the second time. I fought this battle with the mop and the water repeatedly, until we realized that buckets were probably more useful. All four rooms at the end of the hallway were covered in water, but with the help of most of the residence, we began to make progress in getting rid of the water.

Most of the residence, that is. I forgot how much I hate doctors. And yes, I am aware that I am a doctor. For the most part, everyone pitched in and helped each other out. But one doctor, whose own room was one of the most flooded, kind of sat back watching while everyone else mopped/swept/wiped his room. So I hand the guy a broom, while I go and dump some of his water outside. I just assume he’s chilling because he didn’t have any tools. Five minutes later, I look up again from sweating in his room, and I see him chilling again, sans broom. Thirty minutes later, he’s back sleeping in his bed. Frickin’ surgeons, I swear.

Finally, by 2:30 in the morning, I made my way back to sleep, with a very sore back, and blistered thumb. I awake the next morning still very fatigued of course, with the goal of just making it through the day. But though it started slow, it turned out to be a very interesting day. We formally saw our first child and first adolescent, and actually hospitalized one patient. But my blog is getting long, I’m still tired, and I have one more quick story to share. Tell you about the patients tomorrow.

So, at about noon, I was sitting at our desk in the clinic, talking to Ali, waiting for the next shift of students to arrive. Our office was in a new location today, owing to the heavy rain last night, and our usual area was pretty muddy. The fifty or so patients waiting to see the medical doctors were also sitting all around us. Right about that time, we got hit by a pretty strong aftershock. It was like a really loud thunder, only you didn’t first hear it and feel it resonate through your body…you felt it rumble under your feet and the sound felt like it came second. Every single waiting patient leapt from where they were sitting on the side of the outside of the building, and scurried towards the open area. It was over nearly as suddenly as it started, however, and the group let out resounding nervous laughter. All and all, the people took the aftershock pretty well… though in truth, it definitely rattled them. A couple of hours later, patience began to run thin. Patients quickly grew weary of waiting to see the doctors, whereas every other day patients have been grateful to wait hours upon hours to get medical care. People began to attempt to cut the line, causing a bit of a commotion. Also, we got a few extra consults after that, with patients specifically stating they were disturbed by the aftershock. Who can blame them?

Haiti: Day 5

Liaison

Today was our first full clinical day: scheduled to see patients from 8AM to 5PM. Bright and early, we arrived and set up shop...shooing away the goats and chickens to make room for the head shrinkers. We saw several patients today, with diagnoses ranging from likely PTSD to likely Schizophrenia. A word on diagnoses later... The students worked with us all day, and were very helpful in translation and appreciation of cultural nuances. I've started to be able to appreciate a few more subtleties in our work thus far, and I'd like to share them.

The nursing students' need for psychiatric consultation is even greater than I expected. After meeting with most of the students yesterday, I did feel that the discourse went well...but I've been somewhat surprised at their response to us thus far. What we've found already today and yesterday is that many students have been significantly traumatized by the earthquake. Either by rotating with us, or nonchalantly sliding up to us in an incognito fashion, many students are coming to us, and sharing their experiences. Some of their fellow students died. Many of them lost family members, even their own children. Many of them are not doing well and, as the only psychiatrists in Leogane, they need our help.

The tricky part is how to best help them. We are not here to pathologize our patients...let alone the students of the school of whom we are guests. On the other hand, though, we were asked to come and help. If you ask me to come and do what I do, what I come to do gets done, does it not? (Now say it three times, fast) But we have to respect the confidentiality of those who are coming to us for help. We also do not want to jeapordize in any way, subjectively or objectively, the students' educational pursuits. I'm not convinced that the school is prepared to handle the fact that a good portion of their student body is having significant difficulties. Maybe they are, since they called us, but sometimes organizations (especially board members of organizations) just want either a quick fix or a clean bill of health to make them feel better, and aren't really ready to deal with reality. When they ask for a report (or if they read this blog) all of this will be in it. Without patient specific information, or course. I just hope that moving forward, there may be some resources mobilized to provide some continued services.

Other tricky situations between medical staff...which humorously remind me that often, unfortunately, the more things change, the more they stay the same. I had one tense moment with the medical director of the Hospital Sainte Croix. It seems no one had told him that we would be working there, and he, understandably, was wondering who this guy with "Dr. Kobie" scribbled on a piece of medical tape stuck his chest was doing seeing patients in his clinic. He barged right in on one of my consultations, and demanded to speak with me at once. We quickly saw eye to eye, though, once I summoned my French and overcame our language difficulties (my French is still..how should I put it? Pauvre...and Dr. Frenchy was away at the time). I apologized for the miscommunication, he apologized for interrupting my session, and thanked me for my help. So..just like back home...turf wars.

The other all too common situation is that of getting..let me not call them bad, just questionable consults. The amount of consults that I'm getting for so-called anxiety that are truly medical issues is disturbingly high. But hey...what else is new? Another day in the life of the Consult-Liaison shrink.

Haiti: Day 4

Bonjour, etudiants!

The day began with a bang. We decided to meet with Hilda to get a better idea of how to proceed today, and how to proceed for the week. James, being the eager master of linguistics that he is, surprised me during the conversation. It went something like this. Me: “We’d like to have the students rotate with us in the clinic.” Hilda: “I was thinking they’d also have a more structured lecture.” James: “Great! How about today!” Hilda: “OK, the students will meet you in the classroom in an hour.” And thus, our first lecture was born.

Of course, we had been summoned early in the morning and, since there is always an AM battle for bathroom time, had not showered or gotten ready for the day. So we ran off to get ready…I also rushed to get a hard copy of some English/Kreyol teaching materials to pass around the classroom, highlighting some common trauma-related issues. James, relishing the opportunity to utilize his French, prepared to give the lecture. James, Ali and I made our way to the tent, and got ready.

We set up at a table that was set in the tent. As we set up, the students began to enter, carrying their chairs with them. I had them all sign in as they entered, so that I would have their names to set up their clinical rotation schedule. I was expecting 15-20 students. …but they just kept coming in! When it was all said and done, we had 44 students at the lecture. 18 freshmen, 7 sophmores, 6 juniors and 13 seniors. James was great giving the lecture, and he was most certainly enjoying being able to give a lecture entirely en Francais. He introduced some basic trauma-related concepts, and gave the students some ideas of what to look for, preparing them for their upcoming clinical rotations with us. Of course, our lectures and clinical preceptorship serve a dual purpose, as the students are not only clinicians, but survivors themselves of the January 12th tremblement de terre. If the students are open to it, we let them know that we are available for consultation.

During James’ lecture, I was creating a schedule for their psychiatry preceptorship. After the lecture, we took questions, and many of the students had questions, the most frequent one essentially being: Is it good to talk about the earthquake? We informed them that it can be helpful to talk about it if someone feels ready to do it, but that if a person is not ready, they should not be forced. Everyone has their own healing process, and it is generally not helpful if an individual is pushed. And in saying that, I am telling them that, they too are allowed to take things at their own pace. That point seemed well received.

We then dismissed the first and second year students, retaining the third and fourth year students to set up the schedule. Each of those students was to sign up for a four hour period to work with us in the clinic during the upcoming week. The shifts filled up pretty quickly, with our first students to begin that afternoon. We dismissed those students, apprised Hilda of the plan, and returned to the residence to prepare for clinic. Clinic went well…we got a chance to see several patients with our first two students, and teach them some psychopharmacology. Then, back to the residence for our one meal a day, all you can eat buffet…et une Prestige, bien sur.

Haiti: Day 3

Finally, Work!

Woke this morning, anticipating the Dean of the the nursing school, Hilda Alcindor, to arrive sometime midday, and that possibly we'd meet with her in the early afternoon. So I woke early, went for a morning jog around Leogane, and exercised in the makeshift gym in the residence. Of course, as soon as I returned, we found that Dean Alcindor had arrived, and that she was awaiting our presence in her home. So, we rushed off to meet Hilda in the morning. The meeting went very well, I thought. She is a very pleasant woman who cares a great deal for her school, and cares a great deal for her students. As to the "iron fistedness" the American workers warned me of, I believe it's misconstrued. I think it's a misinterpretation of her protectiveness of her students and their education. Rightful protectiveness, I believe, from Western paternalistic tendencies. And her students, it is clear, respect and adore her. I can't remember which movie that was which posed the question of whether it is better to be loved than feared...A Bronx Tale, maybe?...anyway, Hilda is most definitely both.

The outcome of the meeting was that we were to begin work immediately....immediately meaning that very moment! She provided us access to one of her prize former pupils, Evans, who upon graduation last year, was kept on staff for clinical and administrative purposes. Evans was to work with us for the day, interview patients with us, help translate, and get us oriented. But first, there was an independent American couple living in Haiti doing humanitarian work who heard we were in town, and had came to the clinic seeking our help. We interviewed them in Hilda's dining room...that went great, actually. Then, it was off to the clinic...

The clinic is another series of tents (not as nice as the hospital, of course) set up on the campus of the the nursing school. Every morning at 8AM, the clinic opens its doors (wooden plank covering a hole in the fence, that is) and sees patients until 5PM. The patients, though, have been in line since about 6AM outside along the gate. The clinic houses a triage area, several primary care clinicians, an OB/GYN dept, X-Ray area, pharmacy, and an area for a dentist. As there is currently no dentist on staff, we commandeered the dentist's office. The whole setup is very efficient, effective, and inventive considering the available resources. The clinic has both indoor and outdoor components. Our office is outdoors. Evans scouted out the area for us, cleared space, and got us set up to see our first patients. Right away, we were busy, and accumulated a quick line. We saw several patients and, with the help of Ali and Evans, it felt like business as usual! The day was long, and hot, of course, but the work was good, and we got a chance to help some people.

After clinic, dinner was at 6, with a staff meeting at 7, where we formally introduced ourselves to the rest of the clinical staff, and told them to send us patients. Then, time to relax and try to see if I can get the funky internet to allow us to watch a live stream of the NCAA basketball championship on cbssports.com! Come on, Butler!

Haiti: Day 2

Easter Sunday

Day 2 of our mission is Easter Sunday. The city of Leogane had a great feel about it today. A group of about 15 of us from the residence decided to attend Easter services at an Epicopalian church near the site of the old, damaged l'hospital St. Croix (the current one being the set of tents I mentioned yesterday). The walk through town was a really valuable experience; I'm not sure how many more similar opportunities I'll have, as I'm starting to expect we'll be very busy on the medical compound. Everyone was conducting their business as usual, going to church themselves, washing clothes, getting haircuts etc., as one might expect on any Sunday morning. Of course, the sight of 14 White women and one strange-looking Black dude was cause for pretty much everybody we passed to pause and watch us go by. Aside from the local kids yelling "Blanc! Blanc!" Everyone pretty much just waved or gave us a "Bonjour!" It was a beautiful morning, too. The walk also let me get a closer look at the extent of the destruction in the town.

Many homes/businesses are completely demolished, most are partially damaged but uninhabitable, some are OK. People have set up tents aligning the streets, right outside of their previous homes. Most streets are lined with a pile of rubble on both sides, pushed away from the tents, often making travel down the streets difficult. Motorcycle appears to be the current preferred mode of transportation, for several obvious reasons (e.g. space, gas mileage...immediately after the earthquake, gas prices rose to nearly $100 US/gallon...they're currently down to about $5/gallon.)

So, many times on the way to the church, I almost got hit by a motorcycle. Or a truck. Or an ox. The church service was great. Immediately, though, I felt very much like an outsider. And not because of the congregation, the service, or anything like that. It was because I realized I was embarrasingly underdressed. Everone had on their Sunday best...the men had on their slacks, shirts, ties, fly shoes(of course), some even suits, despite the 80-90 degree humid weather. The women had on their nice dresses, and the little girls wore their Easter whites, making me REALLY miss my sweethearts back home. But me...with my American, fairer-skinned, glasses-wearing, rollin with 14 white women ass, walks into church on Easter Sunday wearing shorts, a polo, and sandals, for Godssakes. I had to look like a complete idiot. The workers I went with I'm sure weren't aware that they, too, were underdressed...but no matter. Occasionally, people here in Haiti come up to me speaking Kreyol, thinking that I'm one of them. Not this morning at the church. It was pretty clear to all that I wasn't......

Again, the service was great. It was an Episcopal service, much less animated and shorter than I expected (given my Baptist/AME-ish background). I got a chance to meet the minister, and we made our way back. We were going to make a trip to the beach, and some did, but I decided to wait until later. The clinic was closed for the morning, but many of the group returned to work in the hospital. The rest of the day James and I spent brainstorming about Monday, when we will meet Hilda, the director of the Nursing School. "She rules with an iron fist.." they tell us. Once we meet her, we'll have a better idea of what resources we'll have available to us, and have a clearer view of our goals and objectives. I downloaded some great information from Oneresponse.org...just more tools and information that will help us be more useful while we're here.

Haiti: Day 1

First Impressions

It's been a great day. I'm on the balcony of the Residence Filiariasis, after a long day of travel and scouting. My colleague James and I have been very well received, as everyone here has been exceptionally warm and welcoming. It hasn't been the easiest road here...after some confusion at the airport, our ambassador Alexa (rather, Ali, who has been a Godsend) was able to obtain transportation from Toussaint Louverture International Airport into our final destination, Leogane, roughly 30 miles away. It turned out to be the best way to travel, as we got a tour of Port-au-Prince along the way, and I got to take some remarkable pictures. Photos to come soon... Along the way, several thoughts bounded through my head.

The poverty is palpable here. But it's not a Western/New York slum/G.I. type of poverty. It's a poverty which is more of a standard of existence, rather than a poverty that is easily juxtaposed with examples of decadence nearby. These aren't a people who live in the corners of urban sprawl, forgotten by those who walk/drive by, mere feet away. Here, they make do. There's something much more real, much more attuned to the human experience about it. But unfortunately, the lack of those very resources which spoil us in the U.S. makes it very hard to compete in our modern world, and things get left behind. Like sound construction and retrofitting. So when something so destructive as the quake happens, the effects are devastating.
But as I said, people get by. Tent communities are alive and well throughout the metropolitan area, marketplaces continue to function. Schools start up again on Monday. Today, families prepare to celebarate Easter tomorrow.

I look forward to the opportunity to engage the community...I'm eager to dive in and help. James and I took a little tour of the compound upon arrival, and it seems we will not be short on the opportunity to contribute. The residence is run by The University of Notre Dame, a pill that I am forced to swallow as a University of Michigan alum. The building is nestled between a hospital (made of quite elaborate tents) to the south, and the Nursing school to the west. We first walked over to the nursing school, which is at present being occupied by the Japanese Red Cross, and met a lovely nurse named Nami, who told us about their goings on, and suggested we visit the hospital. At the hospital, we were lucky enough to be allowed in, received a tour of the facilities, and met a couple of the doctors (Jennifer and Sharon.) The field hospital is coimplete with an ER, OR, L&D and a general medical unit. Sadly, no iinpatient psych unit;). In speaking to the staff at the hospital and here at the residence, it is certain that our services are desparately needed here. There have been no psychiatrists rotating through the hospital as of yet, but there is frequently need of one. Though our primary function is to train the nursing student here in Leogane, our direct services are very much needed in the hospital, at least in a consult/liaison capacity. We'll see how that works out.
For now, though, I'm off to bed. It's been a long day...