March 2012 Archives

This Too Shall Pass

The following was written by Ben Trappey, MD, fourth-year medicine pediatric resident.

Last week was tough. It seemed that death was everywhere. And I was all alone. Nearly every afternoon last week, after the Haitian doctor who works the day shift in Urgence, as well as several of the nurses, had gone home, and I was preparing to end my day, someone--a father, an aunt, a grandmother--would hurry in carrying an infant wrapped in a towel. I've learned to fear the sight of a small bundle wrapped in a towel.

It seems that most women in Haiti give birth at home. I suppose the majority of these home-births go well and the babies do fine.

I don't get to see those babies.

In Haiti, it's not easy to get anywhere quickly, and most people don't own cars. So when something goes wrong with a birth at home--the baby too small, too weak to cry--these family members make their ways to St. Damien however they can: on the back of a motorcycle or in the back of a tap-tap (the garishly-painted vans and pickup-trucks with seats in the back; the Haitian equivalent of a bus), holding their bundles wrapped loosely in towels, moving as fast as Haiti will allow.

But it's rarely fast enough.

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The Haitian tap-tap

Last week, when I would look into the towel, I would invariably find a dead or near-dead infant--cold and cyanotic. Usually premature. All born hours earlier. If they had a heartbeat, I would give them artificial breaths and try to warm them up to see if they would start breathing on their own. Unfortunately, none of them did. Every day last week ended the same way. Any victories, any "saves" made throughout the day, any feeling of accomplishment over a child helped were wiped out at the end of the day by the crushing sense of hopelessness as I tried (despite being aware of the futility) to save those babies who had been so cold and so blue for so long.

This week has been much better.

A group of two residents and two attendings from the Children's Hospital of the King's Daughters in Virginia arrived on Sunday, and at least two of them have been in Urgence with me at all times this week. Fewer of these infants have come in this week, but we've had our share of very sick children, several of whom have died. Still, it has been different with extra people here. Extra hands to help with procedures. Other minds to discuss treatment options. Other souls to share in the joy of the victories and the grief of the failures.

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Yesterday, an 8-month-old came in with severe respiratory distress, to the point of being unresponsive. Less than 5 minutes later, a mother brought in a 9-day-old infant who was also unresponsive, hypothermic, incredibly pale, and had been transferred from another hospital because he had been bleeding out of his umbilical cord stump for 2 days.

Luckily, we had enough people available for one to be able to stand there for 30 minutes and give the 6-month-old continuous breathing treatments, to which she, thankfully, responded, another to hold pressure on the umbilical cord and warm the baby, and another to run the 9-day-old's blood to the lab and insist that they check the hemoglobin and blood type immediately. The hemoglobin was 3.5. (Hemoglobin in a child that age should be somewhere around 12 or 13, and back home we typically transfuse before anyone gets much below 7.) We were able to transfuse her within 30 minutes of her coming through the door, and she quickly woke up and started crying.

Today, both children were alive and well. I have little doubt that if there were not so many of us there, at least one of those children would have died. So, those were saves. Victories. I'll enjoy them while I can.

Friedman: On To the Next Adventure

The following was submitted by DeAnna Friedman, 3rd year pediatrics resident.

Got behind on my blogging because I was trying to cram as much as possible into my last few days in Chiang Mai!

Monday was great - we saw some patients in clinic again, and then made rounds. There was a patient who had SLE and got zoster, and then it progressed to SJS and then TEN. 

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While there is not a separate burn unit here, they were doing some interesting things. For instance, while this was not my patient, my attending showed me how sterilized banana leaves are used for patients to lay on because it does not stick to exposed skin. It looked like it worked well. (Photo used with family's informed consent.)

We also got a consult in the afternoon about a child in the surgery ward who had schizencephaly and was admitted for VP shunt placement. Shortly after admission and before surgery, the nurses noticed some new skin lesions that ended up being varicella. This child was in an open ward, unfortunately, so nine other children were possibly exposed. Only two had a history of varicella infection, and none of the rest were vaccinated.

The vaccine is not a part of the free vaccine program through the government and costs about $30, which is prohibitively expensive for most families. The good part is that, since they were exposed in the hospital, those who can receive the vaccine will get it for free. Two of the patients were only three months old though, so hopefully they do not contract it.

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Most of the original patient's lesions were healing, but I did get a picture of one of the feet with a few good lesions.

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Today, my attending took us all out for lunch, which was very nice. Here's a picture of the people I worked with here in Chiang Mai. She told me that I should come back sometime - very tempting!!

Tomorrow I leave for Siam Reap, where Amy Schminke will be joining me, and we will be working for 4 weeks. So, on to the next adventure!

Friedman Continues Experience at Chiang Mai

The following was submitted by DeAnna Friedman, third year pediatric resident.

Today, I spent the morning in the outpatient Pediatric Infectious Diseases Clinic. We saw many children with HIV, some doing well and some not. One 17-year-old boy had a falling CD4 count and a rising viral load, so was stopped from his ARVs months ago.

They did resistance testing and found that he is resistant to all NNRTI's as well as 3TC (which was part of his initial regimen). Before starting him on a second line, they were trying to get him to commit to being adherent, and he kept stating that he was not ready yet.  His CD4 count is now down to 6%, so the doctor that I'm working with stated that she hopes that he will buy in soon before he gets a bad opportunistic infection.  I would have to agree.  

One interesting appointment was the first one of the day. It was a girl who presented because she was exposed to TB. Her skin test at the last visit was 20 mm induration, so she was started on INH. She was having some nausea and vomiting with the medication sometimes, and my attending stated that her dose was high for her age because she was above her ideal body weight.  The parents wanted to know how to get her to lose weight. We then spent about 10-15 minutes counseling on healthy eating and lifestyle habits.  Very much like an appointment back in the US.  

We also saw an HIV-exposed infant who was HIV DNA PCR negative at 1 month of age. She will get a repeat at 4 months and then antibody testing at 18 months to confirm that she is negative. Also, very much like the US. The government has really done a good job of committing important resources where they need to, even if they are more expensive tests/therapies.  

On the inpatient side, we saw an interesting case of endocarditis from S. aureus who presented with longstanding fever and inability to walk due to painful nodules on her feet (Osler's nodes). Her ESR and CRP were now normal (after 6 weeks of therapy), so she was being discharged home and will follow up with cardiology in a month.

That was just a smattering of the cases I saw today that I thought you guys might find interesting. I haven't had any opportunities to take good pictures of any visible pathology yet, but I'll keep you updated.

I had this past weekend off, which was much needed given all of the traveling earlier in the week. Plus, the place where I was staying at first only had a room available until the weekend, so I had to move to another hotel (it's okay, this one's much nicer). That ate up most of my Saturday.  

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On Sunday, I took a cooking class (highly recommend if you ever find yourself in Chiang Mai)...

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...and then went to the Sunday night market (also a fascinating cultural experience).

I hope you are all enjoying what I hear is very beautiful weather in Minnesota for this time of year!

From Dawn To Dusk

At St. Damien's, there is a mass every day at 7 a.m. It almost always also serves as the funeral service for those patients who have passed away at either St. Damien's or St. Luc's (the affiliated adult hospital across the street) and who do not have family to take care of their remains.

"The Destitute" are wrapped in cloth and lain in the center of the small chapel just next to the hospital. Father Rick, the Passionist priest/physician who founded and oversees St. Damien's (as well as numerous other projects throughout Haiti) presides. He does so with quite a flourish in a mixture of Creole and English, as the early-morning sun rises above the compound walls and light streams through the windows on the right side of the chapel.

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View toward the inside of the chapel at morning mass

When mass ends, the bodies are carried out of the chapel on battle-field stretchers amidst the sounds of joyful Creole hymns and lain next to each other in the back of a flatbed pickup waiting outside. Father Rick and the Haitian men and women who helped carry the bodies climb into the back of the truck, still singing. The sounds of voices finally give way to the sputtering of the diesel engine as the truck disappears around the corner of the hospital and the morning sun fully emerges above the compound walls.

"Our every sunrise is someone else's sunset."

These masses have served as a stunning example of the contrast between life back home and life in this country. Death is much closer here.

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The sky above St. Damien's compound at sunrise

This afternoon, a young mother showed up to Urgence with her baby wrapped in a thin blue blanket. She didn't have to unwrap him for us to realize that he was not doing well. He was very small and was grunting with every breath. When she did unwrap him, it was obvious that he was burning up with fever. Also obvious were his bulging anterior fontanelle and jaundice.

He had been born at home 4 days earlier. The mother had had no prenatal care, and the baby had not seen a doctor since he'd been born. He was so small that he'd not been able to figure out breastfeeding, so he'd not had any nutrition since the mother had tied off the umbilical cord with a string after cutting it with a box cutter. She finally brought him in today because he had stopped waking up and was having trouble breathing.

There were no beds available for him in the main area of Urgence, so we laid him on his blanket on the mint green countertop between the sink and the infant scale. We corrected his hypoglycemia with IV fluids and got antibiotics into him relatively quickly. When I was finally able to get someone to help hold him for a lumbar puncture, pus poured out of the needle. The nurse drew his labs, and I left him in the care of his mother while I went to work admitting another child just a few feet away.

About an hour later, he stopped breathing--the infection finally overwhelming the breathing center of his brain. We used a bag-mask to breathe for him for over an hour, stopping periodically to see if he would take a breath on his own. Back home we would have put a breathing tube in and put him on a ventilator until the infection was well enough under control to give him a chance to breathe again on his own. That wouldn't be an option here, since the only ventilator in Urgence is made for adults and cannot be set low enough for any baby, much less one his size.

Without us giving him breaths, his heart finally slowed and then stopped. He lay there on the green countertop, tiny and cyanotic, while his mother sat stoically at his side in a metal folding chair and the Haitian doctor filled out the death certificate.

It was only then that I noticed the 5-year-old boy who I had been seeing for pneumonia when this baby stopped breathing. He was sitting in his mother's lap a few feet behind us, staring at the tiny body on the counter. He and his mother were both looking on, not with faces of horror or curiosity, but with what appeared to be grim acceptance. I'm sure that the boy didn't really understand what had just happened, or the permanence that this tiny body represented, but his mother made no effort to turn him away. It was as if she were saying to him, "This, too, is part of life."

Death is much closer here.

Patience

The following was submitted by Ben Trappey, a fourth-year medicine-pediatrics resident:

Urgence is an amazing medical hybrid: part Emergency Room, part Urgent Care. Part short stay, part inpatient unit, part NICU. It consists of one long room with a smaller area sectioned off in the back and a hallway running the length of it where another 5 to 12 patients are housed. The main room holds 15 or so stretchers, where the sickest kids, ranging in age from a few months to 13 years old, are housed. Along one wall are another 15 or so newborn babies, many of them premature. (St. Damien's has a separate NICU, but it is open only to babies born at the hospital. Those born elsewhere are initially managed in Urgence.)

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Outside the Urgence department at St. Damien's Pediatric Hospital

Each patient is accompanied by a family member who sits patiently beside him/her and provides much of the nursing care. The back room is home to 8 of the more stable children. The hallway holds the overflow of children for whom there is not room in the main or back rooms.

The other American doctors (if there are any) and I start our day in the back room, and when we finish rounding there, we move on to the hallway. The hallway is full of kids who had been seen overnight and are either waiting to be sent home or to get a bed in one of the main rooms. Some, however, end up staying in the corridor for several days. Their maladies range from pneumonia to seizures to severe malnutrition, and some of them would probably qualify for ICU care in the U.S. The hallway ward is furnished with a long row of connected metal chairs, a few moveable chairs, and one padded table. The sick children sit or, if there is enough room, lie on blankets or towels in the chair next to or in the laps of their family members. The table is usually occupied by the child whom the mothers somehow seem to decide needs it the most.

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Inside the Urgence department at St. Damien's Pediatric Hospital

The patience of these families is, perhaps, the thing that I've seen here that astounds me the most. Many of them sit in this hallway for days, waiting for a bed to open up, for the doctors to round on them, for the one nurse who covers both the back room and the hallway to carry out our orders, for lab results that usually do not return for at least 24 hours.

And so they sit and fan themselves and talk to each other and lean upon each other for a nap, and watch each other's children while one of them takes a bathroom break.

What they do not do, apparently, is complain. In the four days I've worked so far, I've not had one parent express concern about the wait or about being tired or hot. Two have let me know that the antibiotics have not yet been given or the fluids have not yet been hung for their child, but these were the mothers of two of the sicker children, to whom I had expressed concern and stated that we needed to move quickly to get treatment started. Neither of these mothers seemed angry or put out.

Nor did the grandmother of the very small 11 year old girl who presented three days before I got here with low-grade fever and yellow eyes. Her fevers resolved quickly, but when her blood counts returned the next day (day 2 in the hallway), she was severely anemic. Her other blood counts were normal, as were the remainder of her labs. Her grandmother had been told in the past that the child was anemic as well. The most likely cause of her anemia was sickle cell disease, which runs in their family. She received a blood transfusion the day before I arrived (day 3 in the hallway), but when I saw her the next day, her follow-up hemoglobin had actually dropped. So we ordered another transfusion and waited for the results of her sickle cell labs.

Unfortunately, St. Damien's did not have any more of her blood type in stock, and the family had to find a family member to come in to give blood for her. On the evening of the fifth day she had spent in the hallway, she finally got the blood transfusion. We repeated her hemoglobin the following day. The result, along with that of the sickle cell test, finally returned yesterday.

She'd responded well to the second transfusion, and we were able to confirm that she has sickle cell anemia and to arrange follow-up in the sickle cell clinic here. She had spent an entire week of her life in that hallway.

When I was 11 years old, a few hours of not being engaged or entertained seemed an eternity. This child sat patiently on those metal chairs for seven days, while younger children beside her cried and coughed and vomited and had diarrhea and seizures. Every day when I would see her, she would grin broadly and tell me that she felt well. I would tell her and her grandmother that we were still waiting.

And they would smile and say "dakò" and "mèsi", which means "agreed" and "thanks".

DeAnna Friedman Arrives at Chiang Mai University

The following was submitted by DeAnna Friedman, 3rd-year pediatric resident:

Hi everyone!

Made it to Chiang Mai safe and sound. I'm staying in a hostel right now, but I have more permanent accommodations starting on Saturday. Everything is new and different, and I've been finding my way around. I've never been in a place where so few people speak English before - wait, that's not true - I've never been ALONE in a place where so few people speak English before (I've traveled through Central America plenty, but I usually have a Spanish-speaking friend with me). I'm getting by with some pantomiming and brand names and such, though.

I've already had the chance to take lots of great pictures, which I'm posting on a public gallery. There are all kinds of old beautiful buildings here in Chiang Mai. I'm still trying to learn what everything is (again with the not-a-lot-of-English thing, I can't just ask people). I hope I haven't made any missteps as of yet with my picture taking - again, still learning.

I started work at the hospital today. Everyone here is very nice and very accommodating. They helped me find a place to stay from Saturday on, and showed me around the campus. I attended wards rounds, and they were nice enough to do them in English for me for today. I am to be paired with an ID fellow starting on Monday, but he's out of town right now, so they paired me with a neurology fellow doing general pediatrics wards rounds with one of the resident teams that speaks English well. The residents were a little nervous about doing rounds in English, I think, but it all worked well.

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Photo of the outside of the Faculty of Medicine at Chiang Mai

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Outside another of the Faculty of Medicine buildings at Chiang Mai University

I saw several children with issues similar to what we have back in the U.S.: a 15 month old with medulloblastoma with an infected extraventricular device, on meropenem and colistin and still spiking fevers; a 7 month old, ex-28 week premie who came in with hematemesis and was found to have esophageal varices and portal vein thrombosis, likely from his UVC at birth; a 15 y/o with a suspected brain abscess, although it seems to not be improving well on cefotaxime.

We ended with a girl with high-risk ALL who's relapsing while on her induction therapy. This child would have been on the BMT consult list back home.

Overall, things here are similar to the setup back home. CTs, CSF studies and cultures, phenotyping for the ALL, and meropenem are available. We have morning report or other conference first thing (8:30-9:30), then wards rounds until noonish, then an afternoon conference for teaching. It should be an interesting 2 weeks!

DeAnna

John Heimerl's Last Week In Haiti

The following post was written by John Heimerl, M.D., 3rd year pediatrics resident at University of Minnesota

Most days at Saint Damien's begin with 7 AM church service, and most days there are several bodies nicely laid out on the church floor to receive a final blessing. On this day there is a small group of family members in attendance. One woman wails, and Father Rick takes time to explain to the foreign visitors that she is the mother of a 12-year-old boy whose body is in one of the caskets. This day also happened to be Ash Wednesday, which marks the beginning of Lent on the Catholic calendar and where ashes from last year's Palm Sunday palms are applied to attendees' foreheads to remind us of our eventual mortality.

I have been attending Ash Wednesday services my whole life, but never before had it coincided with a funeral mass; therefore the homily hit home all the more. Father Rick warned those in attendance that the caskets would be opened and the family would have the opportunity to see their loves ones for the last time. Visitors in the past have found it difficult to watch, so we were all free to leave following the final blessing.

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Chapel at St. Damien's.

Also in attendance at mass is a group of fundraisers from California who I think, judging by their clothing selections, appear more prepared for a day of shopping in San Francisco than a day in Haiti. It is yet another example of a form of tourism that occurs daily in Haiti: people traveling to see how bad the conditions "really are", but never taking time to fully immerse themselves in the lives of the local people.

I, too, have been part of this.

A couple weeks ago I toured Cité Soleil with the sole purpose to see one of the poorest parts of the city. We were not there to provide help, but there to satisfy our own curiosity and photograph the conditions for others to see. The photographer and journalist I accompanied recently published their experiences in a Chicago newspaper. You can read the series of articles and view pictures here.

Having been present for part of these photographers' trip to Haiti, it was interesting to read their experiences and compare it to my experience of the same event. Much like a witness to a crime, we each view events from different perspectives.

A couple of days ago I was given the opportunity to visit the dedication of a new district clinic. The drive was about 3 hours from Port au Prince. We left before dawn and made good time. I spent a majority of the trip riding in the back of a pickup with Dr. Phil, a dentist from Vermont, who has been coming to Haiti since 2004.

We drove by the coast and could not help but think that in other places the sand and beaches would be lined with massive hotels and tourist attractions. Instead, the sand was littered. The last hour of the journey took us down a dirt road, and before reaching our destination we had to ford a river with the truck. I hear the crossing is much different in the rainy season when the river is much higher.

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On the drive to Fonds des Blancs 

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Crossing the river on our way to the new district clinic opening ceremony

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The new clinic is freshly painted and is largely empty, but beautiful. There is space for a pharmacy, dental office and multiple exam rooms.

A local man named Farell who had grown up in the area financed and organized the building of the clinic. He has been finding ways to give back to his community now that he is financially set. His thought was that if he built the clinic, patients and doctors would come. The clinic is built, but no one is there yet to work or run the clinic. He asked me to work in the clinic on my next trip to Haiti, which would be a nice change of pace from the city.

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Clinique Sainte Joan Margaret, the new clinic at Fond des Blancs

The dedication service included a mass and a plea to the community for nurses and a physician to work in the clinic.

Then there was music, dancing and food for the 100 people in attendance. When the music and dancing started we took the opportunity to head further up the road to Fonds des Blancs, where Farrel is from. We saw his parent's house, his construction business, a bakery he was instrumental in establishing, a potable water filling station, and at the end of the road, the Fonds des Blancs Catholic hospital. We arrived unannounced and toured the facility. The Haitian physician in the Urgents spoke amazing English, and as it turned out, had attend Dartmouth for a time (as had Dr. Phil).

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A Fonds des Blancs physician

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A washing station at Fonds des Blancs

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Me and Dr. Phil at the bakery in Fonds des Blancs

We made it back to the clinic dedication in time for the recognition of the 50 people who had helped ensure the completion of the clinic. Sister Judy (of St. Damien's, where I have been working these past six weeks) was given a plaque for her part of the project. I had taken a couple of pictures and asked Sister if she wanted any. She only wanted the picture of her with the plaque to remember the day. I believe that it was not so much the plaque she wanted to remember, but the positive impact that day will have on the community.

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Sister Judy received a plaque in recognition of her efforts toward establishing the new clinic

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Children attend the opening ceremony at the new district clinic

I had initially planned to get two posts out this week before I headed back home, but it is now 14 hours before I start my journey back to Minnesota. As I type this, I hear the screams and moans of another woman giving birth to what is hopefully a healthy baby.

This has been a rough week for me.

When you come to do a rotation, you have a return flight and ending date. This week it became clear that I was nearing the conclusion of my trip. I had been looking forward to this week for many reasons. A big part of it was getting Kesley back as my interpreter. He is not only an amazing interpreter but exceptionally smart. Today I asked him if he makes good money and he replied that he does this work for the opportunity to learn better English (he also has been accepted to start a master's program at Washington University this year, if he can fund his living expenses). To the others, their work may be just a job, but to Kesley it is a chance to learn better English.

There have been some interesting patents this week. Unfortunately the interesting patients, due to their pathology, are also extremely difficult for me to deal with on a human level.

Yesterday, a boy presented in the morning who Doctor Augustin wanted me to see. He told me that since the age of 6 months this boy has had lesions on his face. He is now 6 years old, and the lesions now are everywhere. This child has been to other doctors, but nobody has been able to fix the lesions. I had no clue what this was. It was clearly a chronic process and looked both infected and inflammatory at the same time.

When in doubt, phone a friend.

I took a couple pictures and sent them to global health faculty in the states. I got some good responses, but it was not until I returned to work yesterday that Dr. Augustin told me one of the brilliant HIV attendings thought it was xeroderma pigmentosis. I was not completely convinced, so I Googled it.

Sure enough, it was as if I was seeing this patient in the pictures. Thankfully the initial email had been forwarded to a couple of dermatologists who felt it was consistent with XP.

A biopsy still needs to be done, but then again we are in Haiti, which means a trip to the general hospital. I have heard numerous stories about this place, and some are not so positive. Jamie, my roommate for a couple of weeks, told me about a shootout he had witnessed on a trip there, but the general hospital is the teaching hospital and likely has one of the only dermatologists.

I got an email from Dr. Mike at Brown who forwarded the email to the dermatologists there, and apparently there are some philanthropists who are interested in possibly paying for the patient's treatment in the States. This remains a long shot, as the diagnosis is not confirmed, and if this is XP, it means he has skin cancer on his entire face. (I will not enclose his picture, but if you google XP and look for the worst image you find you will see something similar).

Yesterday I was working an afternoon Urgents shift when a nurse asked me to see a patient because his heart had stopped. There was no code blue alarm or code team, only me and two nurses, and twenty parents looking on. No pulse, so CPR was started after one cycle, there was no pulse, I examined his eyes and there was no pupil response. Pneumonia and severe anemia had claimed another 6-month-old.

No sooner had I finished his death certificate when I was asked to see another child, a newborn with pallor and clearly severe anemia. His labs were not back and until the labs are back one cannot go to the blood bank to get blood. He had some respiratory distress and poor perfusion, but otherwise looked well. I sent my interpreter to the lab to ask about the sample. They had received it, but could not be run it until the morning, as the machine was not functioning.

I again ordered blood STAT O-blood hoping that if it were ordered multiple times that it would happen. In the meantime I made him NPO and gave him a small bolus. He looked decent, and I thought he would make it till he was able to get blood in a day or two.

Today Dr. Augustin informed me that this infant had died due to severe anemia. Unlike back home, there are no continuous monitors and infants are not checked routinely. A third child also died, which Dr. Augustin was upset about, as that child had been doing well the previous day. What a way to start the day.

Fortunately, my attention turned to a 9-month-old who was carried in by the security guard. He had been seizing in triage, but had now stopped. I did a history and exam and, for the first time, actually thought his neck was stiff on exam. I did a lumbar puncture, and when he was getting an IV he had another seizure, which we were able to stop. Before long he was tucked in for the day. I have been working on a seizure management protocol and followed the protocol exactly as I had written it. Ironically, I would be presenting the protocols to the staff in a few hours.

The next patient was a 10-year-old who weighed 30 pounds and was severely malnourished. It was almost too much to bear on my last day. There are so many levels of complexity in caring for each patient--cultural, financial, transportation logistics, etc.

Around lunch I was able to excuse myself. I had a presentation to prepare for and had seen enough pathology for one day. I spent the evening with a couple of volunteers at a restaurant as my final goodbye. Haitian food sure has a spice that I am going to miss.

Just prior to heading to the airport, I was able to go to a celebration at the nearby school. They had completed construction of a gymnasium, and a celebration and dance followed mass. The children were super cute dressed up for the occasion.

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Children at Father Watson Angels of Light School (FWAL)

As I complete this letter, I am nearing my arrival to Miami.

My first trip to Haiti was an adventure. It was the international experience I had been looking for: a diverse patient population and resources to treat them with. Prior to leaving today, I stopped by the Urgents to say goodbye to Dr. Augustin. I gave her my Pediatric Emergency Drug Reference Card from Amplatz. She thanked me for my assistance and for the "very useful gift". I already miss Ayati! Hopefully, I will be able to make it back next year.

When I told Sister Judy I would have to find another niche, her reply was that I could work in the New Saint Mary's hospital in Cité Soleil with her or work in Fonds des Blancs. Both of those options sound amazing, and I look forward to my return trip.