Thursday, May 17, 2012

Rosaline's Stairs Eimear 5/16/12

Rosaline lived close to the clinic at the bottom of the grand new stairs that President Martelly built to connect a densely populated area of housing and Petionville. She dropped into the clinic from time to time to check her blood pressure, always accompanied by her great big smile and friendly chatter. On Thursday, much to Andrew's dismay, Donna and I decided to go exploring the new stairs and their surrounds. We bumbed into Rosaline who escorted us on the stairs. She took my hand to guide me. She showed us her home and her children. The stairs was Rosaline's pride and joy. Back at the clinic Rosaline's blood pressure was sky high. We informed her of the dangers and inquired about her blood pressure medications. These were all gone so we informed her of a clinic that would provide free medications. Donna gave her a bracelet to remind her to get some hypertensives and to take them regularly. Rosaline sang with us before returning home.

Efforts continued to complete the stairs and to decorate the street for the Presidents official opening on Monday. All of the walls were painted in pink, the president's colour and a mural was painted in his honor.

On Monday, as we were waiting for the president to come and inaugurate the stairs, one of Rosaline's daughters came up to the clinic screaming. We ran down to find Rosaline collapsed in a dirty brick alley which connects her house to the stairs. On instinct, I promptly go about my ABCs, she was breathing, barely responsive, massively tachycardic and had a blood pressure of 220/180.

I momentarily took control of the situation and asked Andrew to find out who had called the ambulance or doctor and when would they be here. I got really frustrated because I couldn't get a straight answer from anyone. Apparantly they didn't want a doctor or ambulance, they didn't want to move her. They wanted to let her get up by herself, they shooed me away and started pouring water over her and placing leaves on her feet and around her body.

I was so confused. It appeared that nobody was making any effort to get her any help, or to bring her to hospital. At first I thought it was because they couldn't afford help. But soon I realised that they believed that if you touch someone when they are down that you'll make them paralysed on one side. I did my best to convince them that she is probably already paralysed on one side and is desperately in need of urgent medical attention.

I had both Caroline and Andrew translate my opinion to the family and what the best course of action was. My efforts to get her help were futile.

I had to respect the wishes of the family and walk away leaving a poor soul lying in a dirty puddle on the ground. I unknowingly had disrespecting their culture. I left with on old lady scorning me (I was a bit worried when I missed my flight in Miami!). If she survives, and is hemiplegic, they will think that I caused it. 

I knew that it was a big bad world down in Haiti, this just drilled it home. If only primary health care was more accessible. Perhaps it is better that she didn't get help.

It is unlikely that Rosaline will ever climb her stairs again. 

Monday, May 14, 2012

Eimear Working with Donna 5/13/12

Sunday, May 13, 2012
Donna and I have had a great week working at the clinic. It has been awesome working with Donna. Sometimes we are lucky enough to meet such amazingly positive and inspirational characters. People like Donna tend to bring out the best in us. It's been a pleasure Donna, thank you!

It was our mission this week to try and communicate with Michel Martelly, the Haitian President. He is a former musician known as "Sweet Micky". Martelly was sworn in as president on 14 May 2011 following the Haitian general election. The following day, the incumbent Prime Minister, Jean-Max Bellerive resigned to allow Martelly to choose his own Prime Minister. Martelly was quick to pledge reforms the post-earthquake reconstruction process.

In August 2011, Martelly announced a plan to reinstate the nation's military. This plan was met with controversy as many human rights activists were concerned about bringing back a military which had been responsible for many atrocities in the past.
In September 2011, Martelly formed an advisory board that included business executives, bankers, and politicians such as Bill Clinton, that he hopes will improve business and economy in Haiti.
Martelly underwent bilateral shoulder surgery in Miami last month. He developed a pulmonary embolus post surgery. This left disaster struck Haiti without a president or prime minister for some time. He is back now and we figured that he must need some good shoulder rehabilitation. Unfortunately, after some research through the small circles of elite Haitian society, we found that he already had a therapist, perhaps he had flown somebody in from the US. We had hoped to personally convince him to support our organisation by giving us some desperately needed funding or a new premises to open a more permanent clinic. It was a long shot, but worth a try!!

On Monday, Martelly will be officially opening a great big set of stairs that connects two levels of Petionville. It happens that it is right beside our clinic. I have an elevator speech prepared just incase! Here's hoping, fingers crossed! Although, I'm a bit skeptical that I'll get past the security gaurds...let's see how far Irish charm can actually get you....!

We met lots of patients at the clinic this week. I have really enjoyed working with the wide range of disability and injury that we see here. We tend to get up to 3 new patients a day with the remainder attending for ongoing rehab. We see about 10-12 patients per day. One of our new clients is 6 year old Dayens who presented with Cerebral Palsy. We sent him home with a sketch of a standing frame, in the hope that his family may be able to build him one. Haitians do seem to have particularly good ingenuity. The following are pictures of a young lady who suffered multiple orthopaedic injuries to her arm in the earthquake. She was fitted with an external fixator by palpation with no xray. She finally received an xray in April this year. We had her bring it to us. Unfortunately, there is very little callus formation around the distal radius and ulnar fractures. Her wrist range of movement is very impaired, with little hope of improvement. Despite her injuries she has returned to work and appears to be managing well.

I don't have long left in Haiti. I'm excited to escape the mosquitos, hectic roads and humidity. I really look forward to climbing a mountain, or having a surf, or ripping up a trail on a mountain bike. However, I will be sad to say goodbye to Andrew, Frantzo, the clinic and the Hudicourt family. I do regret leaving when there is so much work for me to do here.

Tuesday, May 8, 2012

Eimear May 7, 2012

Friday was another great day at the clinic. A lovely lady gifted me with two pretty paper-maché roosters, nice! How I will get them safely home on 3 different flights, I do not know!!

I had an awesome weekend with Donna Hutchinson (one of the founders of Global Therapy) and the fabulous Hudicourt family. We spent today on a beach, a couple of hours drive from Port-au-Prince. We swam in the most beautiful turquoise ocean, ate lobster and lambi straight from the sea and enjoyed the beautiful country scenery. It has so much scope for mountain biking, hiking and watersports here, I was in awe!
It appears that Haiti has some incredible resources but lacks the organization to benefit from them. Haiti produces amazing fruit, great coffee and lots of rum, however, not much of it reaches the global market.

On the drive out of the city, I was fascinated to see mile after mile of transitional shelters set up for the many thousands who's  homes were devastated in the earthquake. At its peak, one and a half million people were living in camps. Tremendous efforts have been made to re-home hundreds of thousands, however, there are still some 300-400 thousand people living in tent slums. 

At the clinic, I made the mistake of asking one gentleman patient to practice his hip flexion/knee extension on a step at home, he was a bit reluctant, then I realised that he lives in a tent, I felt a bit insensitive, oops! I later met the same gentleman desperately begging on the street.

Eimear May 3, 2012

It occurred to me today, as my patient stood up instead of lying down, then took off his shirt, instead of his shoes, that I will never take communication in the same language for granted again.

Although my Creole is improving (by about one sentence a day!), I find it particularly difficult to piece together a fully comprehensive history of a presenting problem.

As a physio, I rely heavily on my ability to communicate verbally, and non-verbally. Listening, reading body language and interpreting the presentation of a problem enables me to come up with a good idea of the probable diagnosis, before I even touch a patient.

Subjective assessment is probably the most important aspect of a physios work because without a good questioning and answering session, there is almost no way for you to get a handle on what is actually happening with your patient.

Taking this tool away from a physio is like taking a spanner off a mechanic, or a ladder off a builder. 

Although my translator is excellent at relaying all the relevant information, we seem to lose the fluidity of questioning and answering. I lose my train of thought (especially when the occasion turns into a group discussion with all the random waiting punters) and presumably miss out on vital pieces of information. 

Despite my best efforts at learning Creole, I get the distinct impression that much is lost in translation. I feel a bit guilty about this and I hope it doesn't effect my standard of care too much.

I just wonder how many people I've treated for stroke when they've  actually sprained their ankle, or for a sprained ankle when they've actually had a stroke...whoops! Let's just hope that my objective examinations are up to scratch!

However, they do seem to be coming back for was another fun and busy day at the clinic:
On a lighter note, I learned today, that in some Haitian cultures, if a woman marries a younger man, then she becomes the age of the husband, and he becomes her age....sweet! An easy solution to the aging problem. Way to go Haiti!

Signing for some frizz control and mango eating...

Eimear May 1, 2012

I have had an awesome week at work, it is such a pleasure to go to work each day to be greeted by these two beautiful smiles: 

However, I have been a bit perplexed about how my Haitian patients have been receiving my treatments.
I have fleeting moments of immense job satisfaction when I feel like the best physio in the world EVER!! 

Another patient delighted and excited about the outcome of their treatment.  My ego swells (albeit momentarily!) and I love my work more than anything in the world!
But I get to thinking about the outcome of applying the same treatment technique to a patient with the same pain or disability at home. The positive outcomes here are so much more positive! It doesn't quite equate. Somewhat a paradox.
I interrogate my translator Andrew, assuming that I am being told what I want to hear in order not to disrespect or disappoint me. I can see the objective improvements, and Andrew assures me that all subjective reports of improvement are genuine!
Maybe Andrew is also too nice to tell me otherwise?!!
Why is it that basic physiotherapy management works better here?
It got me to thinking about assumptions and expectations of intervention.
Perhaps if you expect less, or don't know what to expect, you get a more positive outcome.
Perhaps the awareness and belief in physiotherapy is yet underdeveloped so that the "magic wand" phenomenon doesn't yet exist. 
Perhaps people are so unaccustomed to professional help that any little difference creates a much more pronounced physical and psychological benefit.
Has anybody got any thoughts on this?
As Jo Ann Roberts (one of the founders of the Global Therapy Group) informed me when I raised this perplexing  matter: "they listen to us, do what we ask and actually get better". What a delightful way to work! 

Friday, May 4, 2012


The first 3 days 
I arrived safe and sound at Port-au-Prince. The view from the plane gave me a great appreciation of the size and population density of the city. The city sprawl appears to be limited on the west by the sea and to the east by the mountains. There is a wonderful chaotic Caribbean vibe with endless street sellers carrying their produce on their heads.

My host family sent a lovely tap tap driver named Anel to pick me up. He spoke no English, I spoke no Creole. Despite this, Anel felt obliged to give me a comprehensive language lesson. I smiled, nodded and repeated some random sounds!

It took two hours of proper four wheel driving on worse than country type roads through the city to get home (it's probably about 20km). There is no apparent use of any road rules. The nature of the roads reminded me of driving up the McCauley riverbed to access the Godley valley in New Zealand, just throw in a few million Haitians for effect. There appears to be no observance of any road rules. I have to admire the spatial awareness of Haitians. Trucks, tap taps, cars and people all miss each other by fractions of a millimeter!

Despite my exhaustion after a sleepless night at Fort Lauderdale airport (where the airport sheriff told me to “expect the worst down there” thanks mister, that added nicely to my nerves!), I went straight to the clinic.

Global Therapy have done a great job at getting an indoor clinic up and running. The clinic itself resembles a shed in the backyard of a house. It is small but functional. There is no toilet for patient use and to wash your hands, you have to go outside to the store room.

I'm working with two very enthusiastic Haitian guys called Andrew and Frantzo, they have made me feel very welcome and are very eager to learn. Andrew is the clinic manager and my translator. He has done such a good job that he will be funded this year to attend university in Minnesota to study a Physiotherapy Assistant program. Frantzo had recently graduated from a 9 month rehabilitation technician program in Haiti.

To date, the majority of patients I have treated have suffered CVAs. This is due to a large incidence of uncontrolled blood pressure as a result of a lack of primary healthcare. We also see a number of traumatic orthopaedic injuries and I have ordered a prosthetic lower limb for a lady who sustained a below knee amputation.


Today my heart broke

A six year old boy presented with the classic symptoms of Duchenne Muscular Dystrophy. This is a rapidly progressive neuromuscular condition with a life expectancy of 13 years (in developed countries). His signs included a positive Gowers sign, a trendelenberg gait, frequent falls and an inability to hop or run. 

I turned to my Physical Manual for Neurological Conditions text to read “informing patients that their child has DMD causes extreme distress and should only be undertaken by the most senior member of the team, in an appropriate environment, with a support worker present who can maintain contact with the family”.

I felt so ill-equipped without the back-up of a whole multidisciplinary team. This really hit home the lack of basic services available to the Haitian population. The Neurology service is particularly limited.

The mother has approached various doctors but has no appreciation or understanding of the disorder. Perhaps she has seen a western style Doctor and has an acceptance issue, or a lack of understanding due to a cultural or language barrier, I am unsure. It worries me that empathy is lost in translation. I shed a tear of frustration on my way home from work. How do you give hope to someone, third party, when there really is very little hope to give? I can't imagine the desperation and pain of the family.

I went home to my mango tree with very intense feelings of loneliness and isolation, faced with a whole weekend of nothing to do and nobody to do it with. However, to my rescue came the adorable Jessica. She is a teenage daughter of the family I am staying with. She entertained me all evening with her bubbly personality and chatter. She even taught me how to count to 100 in Creole!

My light of life - the Mango Tree!


There is a rooster who greets me each morning and calls my next patient. I think I'll call him “The Secretary”!
The Clinic "Secretary"!

Inside The Clinic!

The following are some images from outside the clinic:

The kids from the house next door! They couldn't afford to continue school after the earthquake  so some kind Global Therpay volunteers are funding them.

Overcrowding due to a large population density.

Poor living conditions.

Hanging out the washing before the rains come.