“M pa gen pwoblem nan tèt mwen?!” she asked, looking surprised and relieved. (“I don’t have a problem in my head?!”)
“Boul la pa nan tèt, no,” I assured her. (“The bump is not inside your head, no.”)
“Mesi anpil!” she said. (“Thank you so much!”) She stamped my passport with an enthusiastic flourish and handed it back to me with a broad smile.
My first consult of the trip, I joked to myself as I walked past the two-banjo-one-accordion-two-percussion welcome band playing at the entrance to baggage claim.
Once I found the driver and we were on our way, I leaned my head back against the headrest and closed my eyes. The interaction with the customs agent reminded me of a patient I had seen on a previous trip to Haiti who had wanted to be evaluated by a neurologist because she thought her brain was coming out of her nose. It turned out it wasn’t her brain, just some mucus—she had sinusitis. We didn’t know how or where she had gotten the idea that the mucus coming out of her nose was her brain, but she was very relieved when we told her that her brain was just fine. Maybe the customs agent had similarly thought she had some dangerous growth coming out of her head.
I remembered a conversation I’d had with Dr. Kerling Israel—a leader in Haitian medical education working at PIH/ZL—on one of my first trips to Haiti. Kerling had told me how important she thought neurology training was for Haiti. I presumed she meant because there was only one neurologist in the whole country, leaving patients with limited access to neurologic care and patients’ doctors with no training from neurologists. Yes, she acknowledged, doctors in Haiti often failed their patients with neurologic disorders because they had minimal training in how to diagnose and treat these conditions. But she saw the problem as much larger than that.
“Many Haitian patients seek help from traditional healers like voodoo priests,” she explained, “especially for neurological problems like seizures and paralysis that can look so strange—like spirit possession—to patients and their families. If a patient comes to our hospital with a neurological problem and the doctor isn’t able to provide a diagnosis or treatment, the patient will think, This is not a problem that can be taken care of by a medical doctor. So the patient will go to the traditional healers only and may never come back for primary care or prenatal care or surgery or anything. We might even lose these patients from the entire healthcare system. We need to improve our neurologic care in Haiti not just so we can help these patients but so we don’t alienate them from the whole medical system by our lack of knowledge in this area. So neurology is a big priority for us.”
Neurology in Haiti had seemed to me to be so small and inconsequential compared to huge problems like tuberculosis, AIDS, and malnutrition. But Kerling suggested it was important in ways I hadn’t imagined. Her perspective was an inspiring and humbling welcome to my work with her and PIH/ZL in Haiti.
* * *
The wards at HUM are housed in a square section of the building with an outdoor courtyard at its center. In the courtyard, a flower garden surrounds a concrete fountain with a small stone footpath leading to it. During my first visits to HUM, the fountain had fish in it, but they had since disappeared. Someone told me they had been stolen.
During my first morning back at HUM, one of the medical residents named Nathalie asked for my help in evaluating an eighteen-year-old patient named Francky. She led me to his bed, which was in the corner of the adult ward, right next to the nurses’ station. At first glance, Francky looked like a healthy young man. He was tall enough to fill the hospital bed and appeared fit and strong in a tight white tank top and jeans. He was chatting and laughing with family members, who were sitting on and around his bed. Nathalie asked Francky what had brought him to the hospital.
He said he had developed a headache about a month ago. Over the last week, he had gone blind. His headache had gotten worse too, and his neck had become stiff and painful to move. The resident asked if he’d had any fevers. He said he hadn’t.
As I looked at his eyes while he spoke, I noticed he didn’t move them at all, and his pupils were fully dilated. When Nathalie shined a light on his pupils, they didn’t constrict. She asked him to follow her finger with his eyes.
“I can’t see,” he reminded her.
She apologized.
“No problem,” he said and chuckled gently.
She asked him to look to his left and right, but his eyes didn’t move. She asked him to touch his chin to his chest, but he couldn’t—his neck was as stiff as a board. Otherwise, he looked well. He had no problem speaking, and he had full strength in his arms and legs.
As Nathalie took out her stethoscope and reflex hammer to examine Francky, I looked up at the row of patient beds that stretched beyond him. In the next bed, an elderly sunken-eyed man lay sleeping on his side, his tightly distended, pregnant-appearing abdomen starkly off-setting his emaciated chest, which was so thin that every rib was visible. Three flies landed on his belly, flew above it and regrouped, landed again. The man’s arm hung limply over the side of his bed, his dangling hand held by a young woman sitting on the floor who was cleaning under each of his fingernails with her own thumbnail.
I looked back at Francky. In contrast to his neighbor, he looked healthy and vibrant. His symptoms had evolved too slowly for a stroke but seemed too quick in progression for a tumor. He hadn’t had any fever to suggest an infection, and an HIV test had been negative.
After Nathalie finished examining him, she and I went to look at his CT scan at the nurses’ station. I was unsure of what we would find. The first thing that jumped out as Nathalie slowly scrolled down from the top of his brain was that his ventricles—the fluid-filled cavities deep in the brain—were massively enlarged: hydrocephalus, like Janel had. But why? Continuing to scroll through the scan, we discovered the reason. The left half of the cerebellum was massively swollen, so swollen that it was compressing the outflow of the ventricles. In the center of the swelling was a tumor about the size of an olive.
The tumor must have been there much longer than the month during which Francky had developed symptoms. So why had things progressed so rapidly over the last week? The pressure in and around his brain must have reached a tipping point, first causing headaches, then causing compression of all the nerves to his eyes, leading to blindness and his inability to move them. Although the blindness was probably the most concerning to Francky, it was his profound neck stiffness that was most worrisome to me. This signified that the tumor and the pressure it was causing were crowding the foramen magnum. Meaning “great opening” in Latin, the foramen magnum is the passageway through which the spinal cord exits the base of the skull. If the swelling increased any further, vital brain regions that controlled his heart rate and breathing would be crushed as the great opening closed off. This would be fatal.
Since Francky had become blind over the preceding week, it was possible his vision could be restored by removing the tumor. I saw the possibility for a big save here, a much more straightforward one than Janel. Francky’s surgery would not be nearly as complex as Janel’s had been, and Francky looked so well compared to Janel. But the need for surgery in Francky’s case was more urgent than it had been with Janel, since Francky’s symptoms had emerged and worsened so rapidly. We had gotten Janel successfully to the US, so hopefully we could pull it off for Francky too.