I told him I was finished, and he scrambled back up onto the chair and began eating his pizza. I was mystified. Could the cyst have ruptured, removing the pressure on the spinal cord? I asked Enel if Davidson had fallen or had any other trauma.
He said he hadn’t.
I asked if he had gotten any treatment, wondering if they’d sought out a traditional healer. I thought most traditional treatments in Haiti involved herbal remedies, but I wondered if maybe they had some ritual where they manipulated his neck in some way that had ruptured the cyst.
He said they hadn’t done anything like that.
“M te priye anpil,” Enel said matter-of-factly. (“I prayed a lot.”)
I sat back down at the table across from them, lost in thought as they ate in silence. Anne and I had spent months trying to convince Mark (the neurosurgeon who offered to operate on Davidson) and the Boston Children’s Hospital staff that we would come through with the passports. Now the patient we’d been advocating for didn’t have anything wrong with him anymore! Anne and I had both had several staticky calls with Enel over the past few months to see how things were going with the passport situation. Why hadn’t he ever mentioned that Davidson had gotten better?
My thoughts were spinning. I tried to think rationally. As a first step, we could repeat the CT scan. If the cyst had disappeared, perhaps Davidson had lucked out and the delayed passport was a blessing in disguise, saving him a risky surgery for a problem that would have resolved on its own. But what if the cyst was still there? I had to know.
Once they had finished their pizza, we set off through the open field that leads to the dirt road to the hospital. We passed the tree-branch soccer goalposts, some scrawny sleeping dogs, and a few bony mules and cows tethered to wooden posts, lazily swatting flies with their tails. I asked Enel what kind of work he did, and he told me he was a middle school science teacher. He had three other children aside from Davidson who all lived with him. I asked who would take care of them if he and Davidson came to Boston. He said their mother’s sister would stay with them. He didn’t mention their mother, and I didn’t ask.
When Davidson’s scan was finished, I brought him and Enel back to the staff house to rest and then jogged back to the hospital to wait for the images to be ready for review. If the cyst had somehow vanished, this would be miraculous and simplify the situation. But suppose it was still there—would Mark perform this delicate and risky operation if the scan was abnormal but the child appeared normal?
I imagined how I would react if I was meeting Davidson and Enel for the first time. Enel would recount the history of Davidson becoming quadriplegic over three years and then recovering spontaneously. He might bring a report from a CT scan revealing the cyst. Or maybe he wouldn’t have been able to get a scan. I probably wouldn’t even think about sending a normal-appearing child for surgery. “I have no explanation for what happened,” I might say, “but I’m glad he’s better and I’ll keep following him.” Another neurologic mystery, I would think. Haiti has plenty of them.
But today wasn’t the first time I had met Davidson. I had seen him when he was severely disabled. And the clock was ticking on funds allotted for him to get neurosurgery for free. Would there be a bias to intervene, given all we’d been through—Enel for his passport and Davidson’s, Mark and the Boston Children’s administration for their efforts to make good on their soon-to-expire free-care budget for the year?
I thought about how I had imagined Janel to be a walking, talking college student only to discover just how bad off he was the moment before we brought him to the US for surgery. But Davidson’s case seemed to be proceeding in the opposite direction—he had been fully paralyzed from the neck down when I met him, and now he was completely normal at the moment we were going to send him for surgery!
As I had progressed from medical school through residency to independent practice as a neurologist, I grew increasingly aware of how often things seemed ambiguous in medicine. Patients’ cases were almost never straightforward, diagnoses were rarely definitive, treatment decisions were hardly ever clear-cut. In Haiti, practicing medicine felt even more perplexing, the patients more enigmatic, the clinical reasoning more baffling. There were no cases in the textbooks like Davidson’s. And I had no idea what the right thing to do for him would be.
The CT scan showed that Davidson’s cyst was still there. It looked exactly the same. I let Mark know that Davidson had miraculously recovered, but his scan showed that the cyst was unchanged. I asked him what he thought we should do. He replied:
I don’t know what the right answer is. I would say that, unequivocally, for a child that was here in the US we would operate for a large cyst that had caused such profound symptoms. My main concern is that his neurological decline, from which he thankfully recovered, will not be an isolated event, and that the next time, or the one after that, he might not recover. I do suspect that the care would be easy, with one surgery and not a lot of follow up, but the case is so unusual that this is hard to predict. It is definitely reasonable to wait and see what happens, but the trouble is a local Boston case could get right back in for emergent treatment if something happened, and we know this child cannot.
I felt reluctant to send a normal-appearing child for surgery. But I’m not a neurosurgeon, and so I couldn’t trust my risk-averse anxiety, an anxiety made worse by all that had happened with Janel. If an expert pediatric neurosurgeon like Mark thought Davidson was at high risk for recurrence of his paralysis and the surgery was straightforward, I trusted his judgment.
I was headed back to Boston and thought it was best that the local pediatricians present the neurosurgeon’s impression and recommendation for surgery to Enel, communicating the caveat of the no-right-answer scenario and that this might be a unique window of opportunity in which he could get the operation for free.
As I waited at the staff house for my ride to the airport, I got a text message from the HUM pediatricians that they had discussed all of this with Enel, and after thinking it over for a few days, he decided to go ahead with the surgery. They said our colleagues were working on expediting his passport.
* * *
“You know Dr. Michelle?” the driver asked me in English as we pulled out of the staff house onto the dirt road toward the route out of Mirebalais.
“Yes, she’s one of my heroes!” I said. “She’s the person who got me started working in Haiti.”
“Yes!” he replied enthusiastically. “She has done so much for Haiti! Tell her I said hello when you see her in Boston.”
“I sure will,” I replied. I leaned my head back on the headrest and dozed off as we made our way to the airport.
“Gade! Moun mouri!” the driver said, pointing out the window of the PIH van. (“Look! A dead person!”)
I opened my eyes to see what he was talking about. We had just made it to the straight highway into Port-au-Prince after whipping through the winding mountain roads from Mirebalais.
On the side of the road, a few feet from a motorcycle, there was a man in a red T-shirt and gray pants lying facedown. A small crowd of people had gathered around him.
“Motorcycle accident?” I asked the driver as we drove past. I presumed the unfortunate man had gotten thrown to the ground from the motorcycle that lay on its side nearby.