A bike ride and a story

I am at a new site for my clinical pediatrics rotation, La Crosse Wisconsin, and we have been having uncharacteristically warm and amazing weather for October. Not that I am complaining by any means!




(Looking over La Crosse from the bluffs above the city. Far off you can see a shimmer of the Mississippi River)



My former roommate Anst (yes, sadly I no longer live with Anst but we obviously still keep in touch) and I decided to celebrate the day with a long bike ride through the countryside. We had heard stories of huge hills and beautiful scenery and so we went searching.




(Anst on the road!)




(It wouldn't be Wisconsin without some corn!)




(Anst leading the way into another round of hills. There were three main climbs each one a good 10-15 minutes of solid uphill)




(There were lots of neat old barns and farmhouses along the way.)



(Me riding along. Anst and I began experimenting with taking pics with both of still riding. The sun was nearing the horizon as we drew close to home - what an incredible ride!)


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And now, switching topics, I have an experience I want to share. This happened last Friday and I've been thinking about it a lot so I decided to try and put some of it in a more concrete form.

The Message:

How do you tell two parents that their darling 4-year-old son, who they brought in for mild shortness of breath, in fact has a tumor occupying his entire pelvis, much of his abdomen and extending into his chest?

This is not a question I usually ponder, but last Friday I was doing exactly that.

I followed our pediatric oncologist Dr. Ettinger, or Dr. Bob as he is known by his patients, into the conference room with Charles' parents and one other medical student. We all sat around a small circular table. It was late in the day and the sun's last rays streamed into the corner room and lit up Dr. Ettinger's dark brown eyes and wisps of his beard as he gazed across the table at Charles' parents. Charles' mother's sweater bulged noticeably, denoting where the couples' next child had been growing for the past 35 weeks.

"Why don't you tell me when you first noticed something out of the ordinary," Dr. Ettinger began softly.

Their son, we will call him Charles, had been feeling well until the Monday before his admission. Maybe a little more tired than usual but nothing too out of the ordinary. Then he started to complain that it was a little harder to breath. But still nothing too bad, nothing to really worry his parents. A visit to their pediatrician had concluded with no remarkable findings. However, the shortness of breath persisted and they took him back to the doctor on Friday. On physical exam he had a clinical picture of pneumonia: shortness of breath, crackles upon auscultation of the lungs, fever and on chest x-ray some fluid building around his lungs. His abdomen also seemed a bit full. On the hunch that something didn't seem quite right his physician ordered an abdominal ultrasound. The technicians running the scan immediately called the ordering provider. As a doctor you never want the scanning technicians to call you immediately. It is never good.

The CT scan that was done immediately after gave a sharper image of what was going on. Tumor everywhere. But even with the tumor compressing Charles' bladder to the point where we could barely identify it on the CT scan, encasing much of his liver and bowels, and wrapping up into the anterior portion of his chest his body had compensated well. As they have been teaching us since day one, kids will compensate until they crash. And now Charles had massive amounts of fluid in both lung cavities and arguably more tumor than internal organs.

Dr. Ettinger took notes quickly in a typical unintelligible doctor scrawl. After relating the story Charles' mother spoke again, "we should have noticed something sooner, now that I think about it he had seemed a little off the week prior to all this. But you know, kids are always getting sick this time of year and..."

Dr Ettinger broke into her spiraling thoughts, "I am going to tell you something and you have to believe me. You got him here as quick as you could.” His deep voice was firm. “There was no way you could have noticed this earlier. Charles' first sign that something was not right was his shortness of breath, and you got him in just when it happened. You did a good job and you must not go down that road of what ifs. We need to look forward now."

Charles's mother choked back tears but seemed to steel herself.

"Is there any information you can give us about his chances?" Charles' father asked.

Dr. Ettinger cleared his throat, "right now we do not know what kind of tumor this is and that makes all the difference for what treatment we use and what the statistics are. But I want you to know this. If the tumor Charles has, has for example a predicted survival of 60% it really doesn't matter to Charles. For him, he will either get better or he will not. And I am going to do everything in my power to make sure he does get better; until he tells us he cannot. So for all of us, what we need to do is focus on helping Charles."

"There is something else you should know," Continued Dr. Ettinger, "I will never lie to you. The truth will at times be very painful but if we do not trust each other there is no way we can work together for Charles' best interest."

"And what should we tell Charles about all this?" his mother inquired.

"Right now we tell him nothing.” I was shocked to hear Dr. Ettinger say this but then he continued, “We tell him we are doing tests to try and find out why he is not feeling well. However, once we find out what we are dealing with, probably midweek of next week, we tell him everything but in terms he can understand. Trying to hide the truth from a child never works. I have been through this scenario many times before and you must know this is not like the movies. Not everyone gets better even when we do our best and the hard times to come more often divide families than bring them closer. You will both need to support each other like never before and be able to rely on those that care about you.”

Dr Ettinger continued, "We have a team of doctors, nurses, social workers, child therapists and more here who will all be working on Charles' behalf. I have one partner, Dr. Peters, who I co-manage patients with but I want you to know you have 24/7 access to me. And above all, I want you to know that I am your child's advocate. If you want to seek a second opinion I will help you to do so. Myself, and everyone you will meet here, will do whatever we can to help Charles.”

As we left the conference room I watched Charles' parents walk down the empty hospital corridor. They each placed an arm around the others back for the final stretch before turning into their son's room.

I knew I had just witnessed something very sad and very powerful. There are many ways in which one can witness an inspirational masterpiece. Some individuals can play a piece of music so beautifully as to bring people to tears, others can use simple paints and a canvas to take a person's breath away, while some gifted humans can make a one-handed diving grab into the end-zone. What I had just experienced felt like a masterpiece of a different sort. Dr. Ettinger's kindness, honesty, experience, and compassion had been woven together to provide perhaps not what Charles’ parents wanted to hear, but what they needed to hear, and formed a foundation for what would arguably be the most intense experience of all their lives.

During the entire conversation I had remained silent but my body felt like it was humming, vibrating at an imperceptible speed. I felt hyper-focused and infinitely present. That moment, being there to work with a family like Charles’, this is why I am becoming a doctor. Having the knowledge to counsel a family is one thing. Having the experience, humility, honesty, and empathy to deliver that knowledge to a grieving family is quite another hurdle. But one I look forward to building towards in the years to come.

Haiti

Haiti. The poorest country in the western hemisphere. Ravaged by an enormous earthquake in 2010 and struggling with cholera outbreaks more recently. I had read a fair amount about Haiti over the past several years and when the opportunity to go there with my roommate Anst (who is from Haiti) arose I jumped at the chance. The purpose of our trip was not medical in nature but rather an opportunity for me to see where my roommate had come from, meet his family, and explore the mountains where he was born. To see if the Haiti I had read about would match my reality of it. I expected to see a great many people scrapping out a living amidst refuse and dust, and this I did encounter, but what I did not necessarily think to expect was the beauty of the mountains or the incredibly kind welcome I was given by Anst's family.

Below I have shared a number of select stories and photos from my week in Haiti during March 2011.

stories:

1. Border Crossing

2. Running From?

3. Family

4. The Citadel and…

5. The Mountains of Anst’s Birth

6. Community Mental Health in Haiti
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(A coastal view on the way to visit a clinic Anst has worked at in Borge.)


1. Border Crossing

Anst's family lives in a town close to Haiti's border with the Dominican Republic (DR). Thus, to expedite our arrival we decided to fly into a city in the DR and cross over from there. We planned our flights to make sure we would be in plenty of time to get to the border before it closed at 6pm. At least, we had enough time until our flights got horribly delayed, we slept the night in the JFK airport on the floor, and arrived quite a bit later than planned. The race was on and we caught a taxi to the bus station and then got the first bus available to the border crossing. In the DR I actually got to feel useful as my Spanish was understood and I could make out the fast/slurred DR Spanish well enough.

Exiting our bus in the small border town I could see the sun setting in the west where we needed to head. We didn't have much time. Anst signaled a man on a motorcycle over and after we failed to get both of us on the back with all our bags he called over a second man and we took off through the streets, the rays from the lowered sun blinding me as we headed out. I was doing a fair amount of praying at this point that (A) I wouldn't fall off, (B) we wouldn't get blind-sided by a truck as we blazed through intersections and (C) this man actually knew where we needed to go and had understood our request for said destination. Fortunately, A,B, and C came to pass and we jumped off and paid the men at the start of a large bridge which I reckoned would take us into Haiti. We started running toward the gate and hit a crowd as we neared it. All of a sudden a man in camo was jabbing a large gun in our faces and demanding our papers. I showed him my passport but Anst didn't understand the man who was speaking in Spanish and it took him a second longer. The man shouted louder and I told Anst what he wanted which got the gun lowered (it seems to be a universal communication strategy that when someone doesn't speak your language if you just say it louder then they will get it). After perusing our passports for 30 seconds he deemed us "worthy" and let us cross even though I was now pretty sure the border was closed. Anst would later tell me they do this for white people which is why they can be useful traveling companions for border crossings.

As soon as we made it onto the Haitian side of the bridge we were enveloped by an even larger crowd, now all black, with people cleaning up from market, motorcycles revving and people shouting at us. I was a bit taken aback and tried to focus on making sure I had my bags tight on me. Anst looked upset and as I couldn't understand a word of Haitian Creole this made me pretty worried. Eventually we both got onto a motorcycle with a man named Judah who took us to get our passports stamped. Unfortunately the office was closed as we had crossed too late. We would return a few days later to straighten things out but I can now say I have illegally crossed a border.




(A typical view of road traffic. In two words (at least to me) absolute mayhem.)




(Kids coming back from school. In Haiti uniforms are the rule.)



(UN tank. The closer we got to Port au Prince the more we saw. Anst was not happy about the UN's presence.)


2. Running From?

On our second day in Haiti Anst took me the country’s second largest city, Cap Haitian, or just "Cap" to the locals, to meet his mom and cousins. Once in the the city we headed out from one cousins apartment to go visit another cousin that Anst wanted to check in on (Anst has an insane number of cousins!). It was market day and the already narrow streets had become walking room only with various stalls made of old sun-baked wood or even simpler setups comprising black plastic laid out with wares upon it. Shoes and various pieces of unidentifiable metal are two vendors I recall.

All of a sudden there were people running toward us and screaming. Anst turned and told me to run and keep my head low. We surged along in the mob, my heart racing, finally taking a side street and escaping the stampede. "what was that?" Anst said he didnt know and that he thought he heard rocks were being thrown. My mind turned to the UN force here and I wondered if people had been attacking them in anger. It had recently been discovered that the strain of cholera infecting Haiti came from Nepal and there were several units of Nepalese in the UN force. Some Haitians had accused the UN of infecting Haitians on purpose and Anst had told me before arriving that things were tense in some areas.

We decided to head a different direction. Within 2 minutes, wham, another screaming crowd surged towards us and this time Anst grabbed my wrist pulling me along at a crouched sprint, stepping through people's wares, half jumping as they scrambled to get out of the way, once again my eyes wide and breath racing. As before, we didn't see what had caused the mob and Anst decided he would see that particular cousin another day.

I had never been in a mass mob running from some unknown fear and it was an experience unlike any other I have had to date. Suffice to say I don't feel the need to do it again. I can only imagine what it might be like to live in a place where of the sort of fear I experienced in those brief moments is a daily occurrence.




(A stream close to where Anst mom lives. I don't think I saw a single garbage can the entire trip. Everything got thrown wherever. One memory that sticks with me in this regard is the ground around the "bus station" (gas station designated as a ride transfer point). There were so many squashed plastic bottles on the ground it felt like I was walking through fallen leaves in the fall time.)

One of the things I kept thinking about after returning to the states was how much space we live in! It's insane! By Haiti standards I should be housing at least 15 ppl in my apartment. Gosh...


3. Family


My previous two stories might give the impression that my time in Haiti had me constantly fearing for my life but this was not the case. Being with Anst, in areas he knew, made me feel quite comfortable and everyone I interacted with on a more involved level was kind to me. Anst’s family in particular was most welcoming and I tried my best to learn a few phrases such as "manje bon apil! - very good food!" and "bonswa, komon ou ye? - good afternoon, how are you?") to express my gratitude for their housing me and treating me well. I got to the point where I could fire off a few introductory phrases and people thought I spoke some creole but then when the follow-up questions came it was immediately obvious that I had reached my limit:) Anst's family seemed huge to me and every other second there was a new cousin or uncle to meet. Anst's cousins who we spent the most time with seemed to take the view that because Anst had deemed me worthy of bringing to Haiti I must be ok and thus they accepted me. This was much different from my time in Ecuador where it took much longer for me to come to know the people around me (as I was an outsider). I did my best to fit in, eating whatever was presented (which was really quite easy as the food was all delicious), sleeping wherever I was told to, pulling water up from the well and taking bucket showers like everyone else, using pit toilets, etc. To be honest it felt somewhat like I was doing urban camping at times! After the trip I received feedback from Anst that his family had liked having me around quite a bit but that I wasn't quite what they expected from an American as I had for example, climbed trees with Anst and gone on mountain trail runs... and I really seemed to enjoy it!






(This small entryway into the two room bottom floor "apartment" owned by Anst's family in Cap has to be the most versatile space I have ever seen. Besides being an entryway, it also served as a spot to bathe (bucket showers baby!), to urinate, and to wash and hang clothes.)


Being immersed in a language I did not know was an experience I had not had in some time as my more recent travels prior to Haiti had been to Spanish speaking countries where I was just fine language wise. It re-invigorated my desire to learn an additional language and at this point I'm debating between French (useful in France and many African Nations) or Portuguese (quickly becoming the family second language as mom grew up with it and my other two brother are learning it/traveling to brazil). Regarding language utility my English was for the most part useless but as Haiti shares a border with the DR there were a fair number of people who spoke at least some Spanish and this proved a lifeline for initiating conversation of more than two exchanges. Some of my favorite memories are from sitting outside the family apartment in Cap Haitian in the evening with a few of Anst's cousins and friends, watching the light fade and talking about whatever, in a mix of haitian, english, and spanish often with random people from the street who would come over at the sight an unknown pale stranger. Until reaching Port au Prince (the capital) at the end of our trip I saw perhaps 5 other non-very dark skinned people in all our travels. The feeling of being different from everyone else with eyes constantly on me was stronger in Haiti than in any other country I have been to.

The strangest encounter I had due to my whiteness came during a late night visit to a sandwich shop. A quick preface to this that you must know is that during my trip to Haiti my facial hair was the longest it has ever been. While waiting around for our food a party of three came in to order. One of them glanced at me, did a double take and excitedly started whispering to her friend. The group of them all started laughing (always great to make fun of the person who can’t understand right) before Anst asked them something in creole and then he and our group started laughing as well. Now I really wanted to know what was up and finally got Anst to tell me. He said the girl thought I looked like Jesus. It was true I was white and had a beard but that was about it. I tried to imagine how this could be and reckoned that if the only black person I had ever seen was pictures of Michael Jordan and then one day I saw a tall black man with a shaved head, well, I would probably think he looked like MJ!

Since returning to the states Anst has informed that his family often inquires how I am doing and to say hi. I hope to visit them again at some point in the future.


4. The Citadel and…

Ever since Anst and I started planning our trip he had been telling me about an epic super steep/long hike up to an old fortress that we had to do. We completed the hike with a cousin and friend of Anst (both of whom had to get a truck ride part way up as they could not keep up with Asnt and me☺) but it was someone I met along the way that makes the day stick in my mind. First though a few pics:




(the fort)




(A view from the Citadel)




(Anst and me on top of the Citadel)

The hike up was indeed very steep and took us over an hour to reach the top. As the pics show it was an impressive structure and provided a panoramic view of the surrounding area. About ¾ of the way up a young man came out to try and sell us (me) something touristy. I wasn’t interested and tried to politely decline but he was rather persistent. We hadn’t really stopped to talk and he had followed a half-mile or so when I finally tried a new tactic and invited him along to come to the top with us. He was game and we upped our pace. In talking with the young man, Jimmy was his name, I came to find out he was 18 years old and already spoke 5 languages to a relatively high level (Creole, French, English, Spanish and one more I cannot recall). He had completed all the schooling available to him and despite his clear intelligence and love of learning the only employment available to him was selling trinkets on the roadside. His sense of entrapment and frustration was palpable. Jimmy put a face to the hoards of young men I had seen every day just standing around the streets of Haiti with nothing to do. Being a trash worker? The service doesn’t exist. Join the army? There is none (the UN patrols Haiti currently). Become a nurse or doctor? Requires advanced school not available to most (and many institutions were crushed in the quake). In medical school I am certainly busy and stressed at times but talking with Jimmy reminded me of the great privilege it is to be able to continue one’s studies, especially in an area I am passionate about. I’ve talked briefly with Jimmy since returning to the states but at this point don’t really know what I can do to help him with his predicament. I’ve tried to find if there are any scholarships he might be able to receive but so far no luck. I plan to stay in touch and hope I can help him reach his goals in the future. Let me know if you have an idea or know someone who might.


5. The Mountains of Anst’s Birth


Another venture I had discussed with Anst before traveling to Haiti was taking a trip by motorcycle to visit the site where he was born in the mountains and to check in on relatives along the way. From previous readings about the mountains of Haiti I expected most of the trees to be cut down and the rivers to be polluted. This may be the state of things in certain parts of the country but it was most certainly not the case in the areas we visited. Beautiful clear rivers that we swam in, massive wooded valleys, peaks with panoramic vistas and a patchwork of trails and communities connecting it all with some communities accessible only by foot! I was not expecting the beauty we encountered and now understand much better what Anst had meant when he would tell me back in Wisconsin that this was his place to come rest and feel at peace.

Beyond the natural beauty I encountered was the kindness and hospitality of his extended family. Anst has relatives all over the mountains and each one we visited prepared us incredible food and spent time with us joking and catching up. One family’s baby crawled over to me and wanted me to pick him up which after receiving the OK I did. This was a bit shocking to me as I was a complete stranger to them but once again it seemed that if Anst trusted me enough to bring me here I was good enough to hold the baby!




(On the road!)



(A brief rest stop on the motorcycle journey)




(A fairly representative section of the road we traveled on. Let’s just say being on the back of a motorcycle that is too small traveling over extremely rough roads equals very sore legs + butt.)




(Anst standing on the land where he was born. The small house no longer stands but he knows exactly where it was. It was a powerful experience to watch him point and say, “I was born here.” He feels a connection to his birthplace and the lands around it in a way I will never feel about the large urban hospital where I was born.)




(There is nothing like coconut milk/water when you are thirsty. So good!)



(Anst getting said coconuts. The man can climb! In one of the communities we visited in the mountains there is a young man who is mute but known by all because he is the best climber and will scale 50 ft trees with no problem!)




(A view overlooking the land where Anst was born and where his family still owns land. In fact, the day we headed out Anst's uncle was overseeing the construction of a new small home made from branches and adobe they could use in the future.)




(Anst and two of his cousins, Romy and Woodsy, who remind me more of brothers to Anst than cousins. I saw much in their relationship that I see in the connection I have with my brothers.)



6. Community Mental Health in Haiti


This last section stems mainly from our time in one of the remote communities in the mountains.

Pulling up in the late afternoon on our motorcycle an immediate crowd started to gather. Most kept their distance but one lady came right up to me and said hello. I knew that much and answered back, “I am well, how are you?” From there she started talking fast and getting excited. I also thought she seemed to be getting a bit frustrated with me. I asked Romy (who speaks some English) what she was saying and he told me to ignore her, that she was just a crazy lady. She kept talking to me and I finally got Romy to translate a bit of what she was saying and it indeed was more or less nonsensical. I saw the same woman several times over the next few days and she was often talking out loud with no one around. After my second year of medical school I would guess she had a condition such as schizophrenia but at the time I only knew she was not at all like the other people around her. The really interesting part for me however, was to see how the rest of the community treated her. She was clothed appropriately and seemed well nourished. Someone had to be caring for her. The other people in the village didn’t ignore nor did they overly engage her. She would wander around town and people wouldn’t stare or shy away. Everyone just seemed to accept her as she was. She may have been “crazy” but she was a member of this village and everyone was fine with it; they didn’t lock her away or make fun of her… they just let her be… It was a far different model than the one I have grown up with here in the states to say the least where having a mental health disorder is hugely stigmatizing and many of those with more severe illness end up on the street scraping out an existence from handouts and living under bridges. I think we could learn an important lesson from the Haitian community I visited about how to care for and interact with people who have a mental illness.

Well, that is all. If you read to the end, wow, thank you for taking the time to connect with me in this way. Warm regards, Michael.