Isn't it ironic

Port au Prince is a city of hyperstimulation. Sounds and smells and sights, some so overwhelming and some mundane. They mix to form a strange, bemusing symphony of irony, cynicism, depression, laughter.... Like a fabulous curry, of never before experienced potent spices... Sensory overload.

Views from the top of the truck as we make our way back to the City of the Sun. A darkly dressed, intimidating man stands with a broad-legged stance in the back of a pickup truck which speeds to pass us from behind on the winding road; he wears a scowl and a pair of dark glasses. I would fear him, thinking him an intimidating gangsta' or security enforcer...until the truck passes and we catch a view of him from behind. He wears a pink backpack with a white Japanese cat drawn boldly on the back. "Hello Kitty!" I call out to him. My colleagues catch sight of him as well, and we all snicker.

We pass a partially collapsed building with the words "God is Good" painted on the front. Someone has climbed up the treacherous balcony and spraypainted the word "NOT" diagonally across the proclamation.

A now lopsided funeral home, with a crumbling facade, proclaims, "We treat death with dignity."

Ironically, a bit farther down the road, a fleet of large shiny-new white dumptrucks. The dump trucks used to remove the dead bodies from the city, I am told.

A sea of faces on the streets as we pass by. Heyyyyoooooooo..... Heyyyooooo..... I feel mildly anonymous in my perch atop the truck as we speed through the city. We pass a US Military HumVee with two tan, blonde, white, All American soldiers in the front seat. I stare at them and wonder what they're up to. From across the wide intersection, one soldier meets my eyes and waves, singling me out of the crowd. I wave back. A familiar face of a stranger from home.

We park at the neighborhood of the plastic bottle river. There is a pig and two children half wading/half floating through the debris. I look down at the bubbling black water and turn to Johnathan, our translator. "Would you like to try kayaking sometime?" I ask. In my mind, I imagine paddling through this sea of trash. Would my Eskimo roll be distrupted by a pig grazing on the floating trashpiles above me? "Uh, no," he says, looking at me with great seriousness. "Too bad," I reply. "I think this would be a perfect spot..."

We are stopped by a man with a rant. "Who do you think you are, coming in to our neighborhood? Do you think we need your help? We don't need you outsiders here." I am sensitive to and respectful of his point. Who the heck are we, this small group of foreigners, wandering through his neighborhood. Are we doing any good here? I think so. I hope so. But I understand his distrust of the outsider. A very human trait. I am reminded of living in Island Maine. If you were not born there, you were considered not from there....or, as the locals used to say, you're "From Away". Today, I am feeling very much "From Away." I am wondering if this community is transitioning through its stages of grief. Is today's stage, at least for some, anger?

We wander to check on a young girl, seen in our clinic two days before for a partial thickness, blistering burn across the entire backside of her dominant hand. It was debrided and dressed by our pediatrician yesterday. Today, she sits on her stoop and stares untrustingly at me. Perhaps because the procedure had been painful, peeling off the dead skin to prevent infection of the wound. I can see a crusting oozing mess which was once the back of her hand; it is now plastered centrally with a bluish/brownish crust.

"Oh, boy," I say to my translator. "That looks really bad...where is her dressing? Can you ask her what happenned?" An exchange in Haitian. Girl still appearing distrustful.

"She says her mother removed your dressing and put goat poop in the wound," said my translator.

"Goat poop?" I say with a near squeal. "Oh, noooo....why???"

"Voodoo..." says my translator.

I want to be openminded to alternative medicine practices. I cannot say that I have read the medical literature and the evidence based medicine on the use of goat poop as an antibiotic burn cream. I have not been privy to the controlled clinical trials. But, my western medical mind takes a pretty firm stance, on gut instinct alone, that this new fangled first aid creme will not soon make its ways to the shelves of American drug stores. I imagine writing that one as a script..."Apply a thick layer of goat poop to wound, BID x 7 days, or until infection resolves, #1, Refill: 2." It's funny. But it's not. Similar practices are performed around the world on the stumps of babies' umbilical cords -- animal feces are applied to dry up the cord; infants subsequently die of tetanus.

Child and family firmly resist offers to return to our clinic for further wound care. They will treat this injury in their way. I can do nothing but advocate gently, and then accept. I cannot force them. But I will return on Wednesday to see if this girl might subsequently need admission for raging cellulitis.

We move on to our second neighborhood. I am now in a funk. Are we making a difference here? I think so. I hope so. I want to respect local culture. I am aware of the importance of that. I do not want to come barrelling in like the ugly American, telling people to do it my way. But I do want to share what I know medically.

An old woman who now sleeps on the ground approaches with trapezius neck spasm. We are seeing tons of this same complaint....likely related to stress and awkward sleeping positions. She wants a pill. I try to show her how to do trap stretches. "Medicine!" she demands. "A medicine will last two days," I reply. "These stretches will last you a lifetime..." She glares at me. I am holding my hand on my head and pulling it laterally. I feel the stretch myself as a warm, satisfying pain down my neck. My sideways stare, like the sideways look your dog gives you when he just doesn't understand you, is met with distain. She shakes her head at me in disappointment and walks away. I am dejected.

We have a busy stop in this neighborhood. We remove 5 casts; tend to 13 healing skin grafts. Bones are healing. Wounds are healing. Perhaps we are not the ugly Americans that a few are perceiving. Would people do just fine if we were not here, I wonder. Are we just arrogant westerners From Away?

A man comes running to our truck, carrying a boy of 10 on his back. The boy is screaming in pain. He is dropped at my feet, and curls up on his side, wailing. We are surrounded by a sea of curious bystanders.

"What happenned," I ask. The boy is hysterical. And sweating. He grabs at his leg... "Why, why why....." he cries. Ironically, the Haitian word for "ouch" is "why". I actually find that a little amusing, a cynical commentary on pain, which is currently too familar to the people of this country.

"Where does it hurt?" I ask, trying to break through his hysteria. "Calm down. Point with one finger where it hurts." He continues to scream.

"Whyyy...why....whyyyyy....."

I try to touch his leg. He violently bats my hand away. He is rolling on the ground. I turn on my authoritative voice that I use for just these sort of patient encounters. The crowd has circled us.

"Look at me," I command. "Stop rolling and look at me."

He opens his eyes and they meet mine. Tears roll down his face. "Why...." he squeaks in a soft whisper.

"What hurts. Point with one finger."

He points to his knee. He watches me nervously. I gently pick up his leg and begin a knee exam. His thigh is dramatically swollen. When I test for ligamentous strength, his knee dislocates easily at a nauseating angle, and I feel bone on bone grinding.

Oh. I'm shocked. How has this happenned?

"He's broken his femur...and has disrupted the ligaments in his knee," I tell my team.

An exquisitely painful injury. Requiring a pretty sudden and massive force to achieve. Also a potentially deadly injury, due to the risk of large blood loss. We've seen too many of these in the days after the earthquake.

"We need to splint him and go now."

The boy begins to cry and scream again. "Why why whyyyy....My mother is going to kill me!"

Ha. Not funny, but funny. In the cloud of pain, he fears not for his leg, but the reaction of his mother. As we splint the boy, mother comes barrelling in, a large, forceful looking woman; certainly potentially intimidating, but nothing but motherly concern in her eyes. The boy does not have an exact story for how this happenned. "Playing soccer," he starts. Then, "I was attacked..." Trying to find the exact story to push mom's perceived anger into sympathy? He settles on, "I was attacked."

I hope he wasn't attacked. He has no details about who might have attacked him, and the story is fishy. I have a feeling he was climbing on something unstable in his neighborhood, amidst the teetering structures, and something fell on him. Perhaps a wall, or a block. Perhaps made unstable in the aftershock which shook the city again this morning. He is covered in sand and grime. Something he wasn't supposed to be climbing. Something his mother had told him, again and again and again. Something teetering, and waiting to fall, yet so tantalizing to a young boy in his very own neighborhood.

We load boy and mother into our white truck and make our way back across the city to the hospital. I kneel beside him on the floor and try to stabilize his splinted leg on the bumpy journey, checking his pulse for signs of impending hypovolemic shock from internal bleeding.

There is no emergency room or ambulance service here in Port au Prince, or so I am told. What would have happenned to this boy if we hadn't been in his neighborhood today? I am reassured that our presence here is still worthwhile.

*****

The Haitian government declared today that they no longer want their citizens to live in their makeshift tent cities. (Note that it was the Haitian goverment that initially encouraged the tent city formations.) Today, after no process of building inspection nor condemnation, they commanded people to return to their houses before the oncoming monsoons. Houses that are leaning forbodingly into streets, and angulated akwardly like my poor young boy's knee. Unstable buildings. With giant, cracks and teetering walls and crumbling ceilings. Houses just like those that we have seen fall, just this week, in the aftershocks of the earthquake. Houses that fall and crush children.

This declaration is insane. And unacceptable. I fear an oncoming second epidemic of "A house fell on me."