chemo day in haiti

I just realized I didn't send this a few days ago...

SOP (Standard Operating Procedure) for mixing chemo in Haiti:

wear gloves, closed-toed-shoes, and face mask (if available). Do procedure in the parking lot, not in an enclosed, non-vented space. DO NOT get pregnant anytime soon...

I'm typing this as I'm waiting for the pre-chemo IVFs (a liter of normal saline with 20 MEQ of KCl and 2gms of MgSO4) to run into my patients veins. She looks like a pin cushion; came in super dehydrated and we had to start the IV at the wrist, but we can't infuse the chemo that way. I'm praying the fluids will "plump her up" so we can find a good vein on her arm. Otherwise, it's an IJ (intra-jugular) on the right side so it dumps into the vena cava (thanks, Anu, for that clinical pearl!)

For the record, we don't do chemo at our facility in Haiti. But the Haitian oncologist who agreed to carry out the palliative chemo plan for this lady designed by the providers in the states totally bailed, and, well, I'm a softie for cancer patients. Always have been.

I was sitting there talking to her parents through a translator, holding back the tears.  This isn't my first rodeo, and while it gets easier to hold on, it's still a bumpy ride.  Palliative chemo is not curative, which is a hard concept to get in the states, much less through a translator in a third world country. We're doing some sublingual morphine intensol to help with the pain, and have nausea meds on hand just in case.

Chemo isn't something I normally "play with", and I got nervous about the base IVFs suggested by the doctor - after some research and a "phone a friend" call to Toni at Samaritan, we changed it to the correct ones.  I am so grateful to all of the teachers and mentors I have had along the way.  It really does "take a village," and mine is a global one.   So with the right recipe in hand, time to wait to see what sort of access we were going to get.

... a few hours later...

A liter and a half of fluid, and still no luck getting good IV access in her arm.  An IJ it is then.  Well, actually, to be precise, an EJ.

Per our "SOP," I mixed the chemo outside.  We have no hood, no real ventilation in the pharmacy, so it's actually safer for me to mix outdoors.  It was quite the show, quite the drama for a few needle punctures, but there needed to be some safety measures beyond what is normal in Haiti.  On went the closed-toed-shoes, the face mask, and gloves.  Rony, Shane, Hannah and Sam stood watch - both to watch me, and to keep others from coming to "hang out" while I was mixing poison (or as I explained it to Shane, mixing radioactive waste).

The bag was hand carried over, and I hung it myself.  Spent the rest of the day checking in on her - monitoring pain and nausea.  We kept the pain at bay, and the nausea too, so I'd chock it up as a success.

After the chemo, we did more supportive fluids, and I chatted with the parents about making sure she is well hydrated before next month, so we don't have to do another EJ.

I emailed Matt, the doctor whose overseeing care from the states.  His email back was short, and the lyrics brought a smile to my face:

"Some will fall in love with life and drink it like a fountain that is pouring like an avalanche coming down a mountain. I've only met you once, but I think it fits you. Thanks."

~PJ

my 15 minutes with anderson cooper

Okay, for the record, I never get "star-struck."  It's not that uncommon for celebrities to come through the Medishare Hospital.  But this was different - this was ANDERSON COOPER.  I got to meet Anderson the other night at The Plaza, and spent about 15 minutes chatting with him.  He held out his hand - "Hi, I'm Anderson" - very genuine, personable, and it was all I could do to carry on an intelligent conversation without giggling.

He had been in Port au Prince earlier in the week to cover the six month anniversary of the quake, flew back to New Orleans to cover the capping of the oil spill for a few days, then came back for a personal visit.  I mentioned that I hadn't heard the news about the oil spill ceasing - when I'm working long days in the hospital sometimes I forget the rest of the world exists.  So he filled me in on what's happened since I left the states.  Yes, my friends, Anderson Cooper gave me my own personal newscast.

He mentioned how sad it is that so many of the NGOs are pulling out of Haiti, and I was quick to mention that Medishare is still here.  "Oh yeah, I love you guys!  You do great work!"  When we parted ways, he thanked us for our continued work down here, and reminded us that we are making a huge difference for the people of Haiti.



Anderson Cooper 360

~PJ

say "aahhh"

It's funny how we sometimes end up exactly where we're supposed to be, even if we don't know we're supposed to be there.  The other day while sitting in the logistics office, waiting for my caffeine to set in, I started talking to a couple of University of Miami students about their project.  They were here field testing a very interesting "tele-medicine" software developed by MIT.  Their plan was to head out to New Life Children's Home (www.newlife4kids.org) to shoot some video footage and talk with Miriam, the Missions Director, about how the software might be useful in Haiti.  Janet (a teacher from Oregon whose "alter ego" is a warehouse pixie in Haiti) had brought a bunch of school supplies to donate, so was heading out with them.  One of the UM students, Sean, seemed a little disappointed that they weren't able to do more for the orphanage they'd been working with, so I suggested we "de-worm" all of the kids.

Miriam estimates that approximately 90% of the children in the tent cities have some sort of intestinal worm.  The living conditions are filthy, with many people sleeping on the dirt, and there is really no way to have anything be "sanitary."  When a worm infestation isn't treated, the worms migrate out of the intestines and into other areas. Seeing a kid cough up worms that are 6 inches long is one of those things you never forget.  And in a country where so many of the children are already malnourished, parasitic worms are even more deadly.  Many organizations and school will periodically de-worm all of the children as a precaution.  Anti-helmintics (de-worming medicine) are worth their weight in gold in Haiti, and I'd just been gifted a few thousand mebendazole chewable tablets, and playing with orphans is always a fun way to spend half a day.

Sean and Janet assisting with de-worming orphans

It was so sweet - the kids all filed into the classroom, and sang a song in Creole welcoming us and thanking us for coming.  Then they were seated and a translator helped me explain what we were going to do.  One of the hardest things for me to explain, even through a translator, is the concept of "chewing a tablet".  Remember, most people in Haiti have never even seen a doctor.  So I demonstrated for them.  (hey, it's been a while since I've been de-wormed)  Crunch, crunch, crunch, then I opened my mouth and stuck out my tongue and said "aaaahhhhh" to show the white paste that was covering my tongue.  All of the kids laughed.  As Janet, Sean and I gave each of them their dose, they chewed it up and stuck out their tongues and said "aaahhhh".  Much much giggling, and I'm sure the teachers were less than thrilled at the new game I'd taught their students, but it got the kids to laugh and not spit the tablets out.  I can tell you from experience, they taste HORRIBLE.  Well, horrible with a mint aftertaste.

After "dosing" all of the orphans in the classroom, I walked around and "dosed" some of the handicapped kids - it was much easier to come to them than get their wheelchairs inside.  The children from the classroom followed, clapping and laughing, continuing the game.

After the "de-worming party", Janet gifted the teachers at the school some much appreciated school supplies for the children.  From one teacher to another, even with the language barrier it was clear the gratitude for the gifts.  I spoke with Miriam and her daughter about medication needs for the Home, which has clinics for quadriplegics and paraplegics under their mango tree every Wednesday.  We're all in this together, and if we can provide help, we will.

 
~PJ

blood drive

Practitioners who are new to Haiti often ask about the blood supply; more specifically, if there is a supply. The answer is kind of, sort of, it's complicated.  Today was a perfect example.

We had a news crew show up at the hospital, and in the middle of "show and tell with Sanjay Gupta," the CNO came into logistics asking about our blood types.  A patient was just admitted who would die tonight if she didn't get blood.  When someone needs blood down here, the first thing we do is ask family to donate (if there is family).  If they're willing to donate, we type their blood to see if they match.  If they're not a match, or if the patient has no family, we look to our staff/volunteers to see if anyone is a possible donor.  No one who knew their type was a match, so those of us who haven't been typed yet (or couldn't remember our type) headed off to the lab to find out if we were a match.

It's a fairly simple procedure to be typed; lance the finger, a few drops of blood in each reservoir, add the chemicals, and spin around.  Jen, our PR person from Miami, ended up being a perfect match.  She hates needles, and it was clear that even being typed was a little out of her comfort zone.  But as she put it, a persons life literally depends on her donating - how can you say no?  I handed her a package of pop-tarts from my uuber-secret-stash on her way to donate...  It's not like the Red Cross back home where you get cookies and punch...

Of course, the work is not done once you find a match. Turns out today we had bags for blood donation without the chemical-anti-coagulants to add to the blood to make it useable...  So a new game begins...  Calling Big Paul from MMRC to see if he can locate some, or maybe we can sweet talk the Haitian Red Cross out of some.  Then there's the excitement of a trip to Hospital General to do the actual donation, and praying that #1, they don't loose the blood you've just donated, and #2, that you make it back in time to get the blood to the patient while it can still do some good (have I mentioned that traffic SUCKS in Port au Prince?).  In this case, the Gods were smiling on us.

Later on I caught up with our heroic donor, and she told me about meeting the girl whose life she saved, and how her eyes had lit up when the translator explained what was happening.  In her own words:

"After all the anxiety I went through---The cool thing-- I got to meet the patient. 'Mesi anpil,' she said. She grabbed my hand and pulled it to her chest. She was weak, but her smile and her eyes said more thanks than her words. It is something I will never forget. I know that my one donation may just buy her some more time. I hope that someone else is able to donate so she has enough blood until her medical problem is corrected. Just seeing that little bit of hope in her eyes meant so much to me."

In the states, we donate blood all the time, but it's more of a karmic donation...  We all give, so those who need it have access to it, and the idea is that should we ever need blood, it's there for us...  I can only imagine what it must have felt like to have that connection with a patient...  Although, I suspect, at some point I will know exactly what it feels like; at some point I'll be the match, and hoping there are still some pop-tarts left in the stash...
 

~PJ

back from my hiatus

I’m writing this on the plane, heading back to Port au Prince, after a whirlwind week of family, friends, geocaching, gathering supplies, oh, and a minor operation.  As you may already know, I ended up having surgery when I returned from my first deployment to Haiti (which was in no way a result of anything having to do with Haiti).  Turns out we weren’t aggressive enough, and 2 months later, I had to have surgery again.  I wish it were something glamorous, with a cool story and a neat scar.  But it’s not – it’s been a pain in the butt.  Literally.

People say that healthcare workers make horrible patients.  I am, admittedly, one of the worst patients EVER. (Editors Note:  Yes, she is but we still love her) Rosales, my surgeon, just rolls his eyes at me when I mention I’m scheduled to return to Haiti 36 hours after he’s scheduled me for surgery.  He says he’s committed to fixing me, despite my commitment to “Save the World”…  He also says I used up a lot of “karma points” getting back to the states for my first surgery, so I should probably continue my work in Haiti to pay back my karmic debt.   Who knew karma points were like penny-carnival tickets?  Maybe next time I’ll trade some in for a gigantic, fluffy teddy bear…

I ended up changing my flight – adding a few days on the end of my trip to recover in Oregon.  Now I'm headed back to Port au Prince... to "take it easy"...
 

~PJ

first staff photo at new hospital

Here is our first "staff photo" for the Bernard Mevs Project Medishare Hospital Pharmacy:

Georgia and Michel are missing, but we got most of us in the photo!

~PJ

sherwood gazette article

During one of PJ's stops at home in Sherwood, I contacted the editor of our local newspaper, The Sherwood Gazette, and recommended he do an article on her.  Sherwood is all about "local" and since PJ graduated from Sherwood High School and still has her home base in Sherwood, I knew the residents would love to hear her story.

The article came out in the July edition:

Helping in Haiti



~Cathi

exerpt from an email this morning

I want to send a real "update" - about hiring a new Haitian pharmacist, exploring the J/P HRO tent city, and planning tropical storm evacuation strategies (with J/P HRO, not Medishare... they're still in tents...)... But that may be a few days, and I wanted to share part of an email/friend request I got via facebook this morning that reminded me why I gave up the high paying job in the states and came to Haiti.

The "friend request" said this:

"You dont know me in person but i added you becuase i want to say thank u. Its those of you that help with the project medishare that make inpacts. the team 2 weeks ago changed my life. I am a missionary who was over there and got malaria. One of the doctors saw me and got me out of Haiti in time to save my life. I also saw you where friends with sam (Sam, my medical student) too. he is great he took care of me when i was there for that one night. He is like a big brother."

I never met her in person, but I do remember helping with her care - suggesting treatment options for malaria with one of the doctors for someone that we were talking about shipping to Miami. And it doesn't surprise me that Sam took great care of her - it is my firm belief that he will become the best doctor Haiti has ever seen.

Many of you who read my updates have not been down here to Haiti, and may find it hard to believe, but we are the height of medical technology in Haiti. Even now, when we're technically "closed" to new admits, we accept all of the American relief workers who are sent to us. And even when it means dragging the desk out of the nursing station to make room for an additional bed (and turning our supply area into a makeshift ER), we do the best we can with what we have.


~PJ

article published for Phi Lambda Sigma

Between PJ's first and second tours in Haiti, she was asked to write an article for the Phi Lambda Sigma's newsletter The Laurel.

It has been published in their April 2010 edition.  As of the date I am writing this, it is not yet posted to their website yet.  But I have put it up on my file server and can be downloaded from the link below.  PJ's article is on page 6.

April 2010 The Laurel


~Cathi

a day of rest

I finally did it - I took a whole day off, turned the blackberry off - no email, no antibiotic dosing, no contact with the outside world from 9am until 6pm (other than posting a photo of my feet by the pool to facebook).

It was glorious. About 45 minutes away from the hospital is Wahoo Bay Beach Club and Resort, which felt like a paradise in the middle of the Caribbean. I ate the largest lobster I've ever seen, napped by the pool, and let my brain rest for a while.


~PJ

chemistry lesson

Sam, my medical student, got to have a "learning experience" with me the other night. One of the nurses asked him to grab 10mg of morphine, and all we had was the 50mg/ml uuber concentrated vials. Normally I dilute it to 1mg/ml, but none was made up. When it became clear that there was some confusion with the concept of mg vs. ml - more specifically, with the distinction "volume vs. weight" - I saw a great teaching opportunity.

Since the patient was in acute pain, we took care of the dose, then I sat Sam down for a chemistry lesson. "If I have a pound of feathers, and a pound of lead, which weighs more?" was my first question. Then I remembered, I'm in Haiti - metric system - so rephrased the question with kilogram in place of pound. And, just like all of us, he answered "the kilogram of lead. Metal weighs more than feathers."

A kilogram weighs a kilogram, no matter what the material, but the kilo of feathers takes up more space than the kilo of lead. That "space" is the volume. We discussed it theoretically, but the concept didn't seem to be sticking. So I grabbed a bottle of pills off the shelf, and used each one to represent a milligram of morphine, and a tray as the milliliter. Some of us are more visual learners. Once the idea had sunk in, and he did the math, I let him do the dilution for the 1mg/ml morphine stock solution (under supervision, of course).

Back when I was doing my undergrad, I student taught chemistry, and Jim (Professor Schnieder) would have been proud of me. And I'm so proud of Sam - not only did he master a new concept in chemistry at 3am, he did it in his second language. Because, as I like to remind him, his English is WAY better than my creole.

~PJ

life has a funny way of making sure we're exactly where we need to be

(meant to post yesterday (but I fell asleep typing... gee, imagine that...))

Life has a funny way of making sure we're exactly where we need to be. Tonight, for example, I was supposed to be off, but Shane (one of my assistants) is really sick, so I came in to man the pharmacy overnight. Funny how the compounding pharmacist happens to be here when the nurse comes looking for some concoction to make albendazole taste better (good luck with that!) and alternate dosing forms for a
hospice patient.

The albendazole "taste-testing" can wait for later - when I have more than just myself to do the tasting - plus, hospice care has always been one of my soft spots.

It's about 4am, I'm listening to Tracy Chapman sing about "Fast Cars," and waiting for Lauren to come pick up the "hospice kit" I spent half the night making for Peter. We can't save them all, no matter how hard we try. With Peter (also known as Peterson), we have tried and tried - even flew him to the states for treatment. But sadly, the humongous cancer tumor on his neck (about the size of his head) didn't respond to chemotherapy, and neither did the metastatic tumors that cropped up in his lungs and other areas. When it became clear that he would not get better, the hospital staff at Broward General (the hospital in South Florida that was covering the treatment) asked him and his mother about their wishes. Peter wanted to come back to Haiti, to see his brothers and sisters, and to die at home.

So Lauren brought him back, and tomorrow they will spend about 6 hours driving the 25 miles to take Peter and his mother home. (Did I mention that roads here SUCK?)

I made the usual suspects for the "hospice kit"; morphine in several strengths (both injectable and oral) to help with pain control, injectable lorazepam as well as a liquid lorazepam "with a chaser of haldol" for fear and anxiety, zofran (for the nausea on the bad roads), atropine drops for under the tongue (helps stop  secretions)... And a custom ketamine/baclofen/diclofenac/lidocaine gel...

There is a very good chance that today will be Peter's last day on this planet. Without going into all the gory details, the plan is to keep him alive long enough to return home to see his family one last time. I took Lynden to translate for me - he used to teach kindergarden through 6th grade, so he's good with kids. I had Peter explain where it hurt, and describe the type of pain, and explained what I was going to try to do. The pain Peter is experiencing is excruciating, but not diffuse; it's specific to his neck (under the mass and up the back of it) and the area surrounding his chest tube.

I'd read an article a while back about topical ketamine for hospice patients, and we often compound baclofen/ketoprofen/lidocaine at Broadway (my job back in the states), so I did some research (in 4-point font, on my blackberry), and made a gel to ease his pain.

This was one of the few times in Haiti I've worn gloves... A gel designed to absorb through HIS skin would also absorb through mine. I warned him that the application process might hurt a little - I had to rub the gel into the places that hurt. He was a trooper, not even a tear. When I came back to check on him, he said the pain in his neck was gone. He was a little light headed, but able to carry on a conversation and play with the paints and play dough I brought him. He said he felt more "clear headed" than when he was on all the morphine - goal accomplished.

On my way back to the pharm Sam asked me what I had done. Sam is a Haitian medical student who will be starting his third year this fall. He had never heard of the concept of "hospice" or end of life care - it doesn't really exist in Haiti. Sam doesn't know it yet, but as of this week he will be an employee, not a volunteer. He'll be my "intern," and will have projects and presentations just like an intern in the states... Sounds like I've already found his first project...

~PJ

catching my breath

Day three in the new hospital, and I'm finally able to sit long enough to catch my breath. Moving a hospital in 24 hours was insane, and while most things went smoothly, we will still be "settling in" for quite some time.

Lots of stuff has yet to be uncovered - for the pharmacy, it's a full one-third of our medication supply and all of our references. Well, not all of our references... I'm a good pharmacist - I hoard things and play the "worst case scenario" game in my head. As all the books were being packed, I grabbed my copy of Lexi, and tucked my Sanford guide in my bra strap. I know, I know, not the most professional thing to do, but my pockets were overflowing with the controlled substances that somehow didn't make it in the safe. The impressive pharmacy library I've amassed since February is packed somewhere in the "new Costco"... I'm hoping we'll find it by the end of next week, but I won't hold my breath...

Less than a week ago I walked into my new pharmacy for the first time. Or, rather, I squeezed through the door that would only open half way to look at the floor-to-ceiling piles of boxes and crap and thought to myself  "how on Earth am I going to make a working pharmacy out of this pile?"  We had no lights, no space, and just utter chaos. Georgia and I spent 9 hours that first day moving boxes so we could get the door to open. Now we have lighting, floor space, and my friends from Operation Blessing have offered to custom build the furniture I need including bar-level tables so we have a space to work.

I couldn't do it without my Haitian friends who work the night shift. Due to the low census (about 45) many of the night workers spend a lot of time just hanging out, so I've been finding them projects. Plus, the pharmacy has good music and good chocolate - both key essentials to a happy work environment. My "boys" (Fed, Claude, Sam, Lynden) have been fixing lights, hauling boxes, killing cockroaches, and teaching me Creole. My "girls" (Michel, Marie, Barbara) have been cleaning, organizing, killing cockroaches, and dancing with me in the pharmacy.

It's looking great - I'll post photos later - I'm typing this from the logistics center (on a REAL keyboard - not the blackberry for once!).

This evening I caught an allergic reaction to a drug in one of our volunteers. One of the new nurses had come to the pharmacy to get some cream thinking she might be having a reaction to sun block or bug spray. When I looked at the rash, it wasn't just her arms as she had thought. It covered her whole trunk, and her throat was feeling scratchy.

What's the best diagnostic tool we have? A thorough patient history. Turns out, one of the doctors had started her on Keflex (an antibiotic) earlier in the day. Classic allergic reaction. Luckily, there are drugs for that, and I have them handy at all times. I compounded her some cream to help with the pain and itching, gave her a big dose of benadryl, and sent her to bed with strict instructions to NOT TAKE ANY MORE of the antibiotic.

This morning in the "carpool" Jen made some comment about how awesome our lives are and what a great experience this is, and I have to agree. Hands down, this is the most rewarding job I have ever had, and I am so grateful to be working with such incredible people. As much as I miss my friends and family, I couldn't imagine being anywhere else on Earth.

~PJ

went on another drug raid...

My first day back "in country", and I'm already pirating!

Operation Blessings opened their warehouse to us, and we were able to
fill a flatbed with much needed supplies...

~PJ

photos of the new building

Here are some photos of the new building we are moving into.  It has two operating rooms with a pass through and a real recovery room!

the grounds around the new building...

and some pics of the inside...

a few of the people outside...

and my new Pharmacy!...

~PJ

hello camp, goodbye camp

I showed up in camp today, just in time to pack up the hospital to move out of the tents. Since the earthquake in January, we've had:

over 20,000 patients (in-patients - that doesn't include the up to 400 patients seen on a daily basis at the triage clinic)

almost 3,000 volunteers come through

and have a death rate of less than a tenth of a percent.

I'll miss the MASH tents - especially since I never got a chance to build a gin still - but I am excited for the new building!

~PJ

touchdown!

Touchdown!

Port au Prince welcomed me with 99-in-the-shade heat... Drop your bags, get to work!

~PJ

no sleep, almost there!

At MIA, boarding the flight to PaP now. Let's hope Brett has a limo at the airport, and my "personal AC" cranked up... *giggling*... More like a tap tap and the flaps on the tent open for a cross-breeze... TIH baby!

~PJ

new pharmacy in Haiti

Why is it that I find it easier to find time to write when I'm in Haiti? It must be that I'm trying to fit a months worth of chores into 6 days in the states...

But this couldn't wait! Yesterday I received a surprise - Dan (one of the pharmacists "in country" this week) sent me a few photos from his iPhone of my new "home". It's my first glimpse at the pharmacy I'll be moving into this weekend - a real building!

~PJ

amazing slideshow: Haiti After the Quake

Here is an amazing slideshow of Haiti from the Arizona Daily Sun:

Haiti After the Quake

Soundslide presentation of Hait earthquake aftermath. Photos taken and soundslide presentation put together by Josh Biggs.

~PJ