A different world

As I sit here recovering from our last day in Haiti, I’m struggling with the idea of sharing some of these events as it may seem there is a voyeuristic element in doing so. But then I realize that by sharing the tragedy of this place some change, somewhere, sometime, may be effected. But maybe not…

The day began with only two short cases booked, and ended with us staggering back to the guest house after midnight, with our lobster boat due to leave at 8 am on the first leg of long journey home (into what the news describes as a “catastrophic winter storm” charging up the eastern seaboard).

There was a fellow with a ganglion of the wrist, and a hernia in an 11 year-old boy. Both slickly done, with happy patients at the end. In fact the little boy (like two others before him) grabbed my hand, thanked me, and wished me “bon voyage” home. A sense of gratitude that was as touching as it was unexpected from such a small creature. The clinic team, as I found out later, were in the mountains seeing over a hundred patients on one of the hottest days yet. Ravi was being inundated with requests to do breast exams, and Peter had men lining up for prostate exams. There was a debate as to who had it worse off, as both had done far more of those exams on the trip than anyone would have believed possible! I conveniently failed to mention that as a family doc I could have helped with both, but in actuality I was tied up in the OR. The cases kept coming in…

Out the in door

Out the in door

Chris was asked to see a young pregnant woman with bleeding, and he scanned her with the old but effective ultrasound machine. This was not completely normal, and I captured the video image on my iPhone, and we subsequently emailed clips to one of the neonatologists in Fredericton who helped with the diagnosis of a placental abruption – a blending of old and new technologies that perfectly characterized Haitian tele-heath.

Tumour of the jaw in a young girl

Tumour of the jaw in a young girl

Back in the guesthouse we assumed our trip was drawing to its conclusion and were packing and slowly digesting the events of the past week when Ravi was asked to see a patient with an incarcerated hernia. The case was on.

I headed back to the hospital through the darkening compound with Garth and Avi. In front of the operating room entrance we found an old Toyota pick up truck, with a few dozen people in a quietly agitated state standing around and on the truck. A large oblong blue object was being passed out hand to hand, and was then tossed into the back of the pickup truck with a loud thump. It was with a sudden violent shock of recognition that we realized the blue object was actually a body wrapped in a tarp. This viscerally wrenching and somber act was the final event in a very Haitian story that had begun earlier when we doing the Caesarean on the young lady with the abruption. A woman had just delivered at home (as the majority of Haitian women do) and collapsed. She was brought to the hospital in cardiac arrest and died within minutes, probably from an amniotic fluid embolus, only feet from where we were in the operating room. What we had witnessed in the twilight of the hospital grounds was the start of her final journey home…

Lost in thought

Lost in thought

We tried to refocus for the upcoming case; me by setting up the operating room, Avi by quietly playing a video game on his phone. This was more than any 15 year old should have to face, but was, as we remembered from previous trips, too common a story here. Just before bringing our patient into the room, the power went out. This was a daily occurrence, but the failure of the generator to kick in was poorly timed. Duct tape and headlights were used to fabricate operating room lights, and the non- surgical members of the team were sent for to hold other lights as required…

Fixing the generator

Fixing the generator

The generator was finally fired up, and we proceeded with the case prepared to switch to our homemade lighting setup and modify the anaesthetic as required.

End of a long day...

End of a long day…

It was with physical exhaustion and emotional fatigue that we walked back to the guesthouse and completely collapsed into the beds for the last time on this mission.

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A day in the life

Each half of the team starts and finishes the day the same way.

The first few hours are a little cooler and are savoured. A quick wash, morning coffee rounds with the occupants of our room, then breakfast. The rest of the team starts more slowly (and probably smell better in the morning too!). Eggs, fruit, wonderful toast, sometimes pancakes and very good coffee make up the usual breakfast. Each meal is preceded by prayer then everyone lines up at the serving table. Chris occasionally went for a run in the early hours, with 3 laps of the compound making a kilometre.

The OR team would then walk across the compound, unlock the chain holding the gate closed, and walk across the dusty street, making sure no motorcycles were in the direct path. These bikes are all 125 cc Chinese made street oriented bikes, being driven as enduros. The roads are more like jeep tracks at best and river beds at worst. In town occasional cement bars run across the road to redirect water when the torrential rains burst from the sky; Hesse function as speed bumps as well, and the riders look for the smallest grooves worn into the speed bumps to direct their bikes through, as evidenced by the shiny black rubber left in these areas. Entering the hospital grounds, either through the large sliding metal gate or through the door occasionally monitored by security, was on the first days very exotic feeling, with some vendors selling food for the family’s in hospital, and animals wandering the grounds, but soon became as routine as walking into our 21st century hospital at home. Once inside the ever-present low-grade chaos of the day would begin with the questions: What cases were to be done? Would there be water in the scrub sink? (It only flowed for the first day). Would any crisis from the hospital pull us from the OR? Then after these questions were answered, the day would begin and would, with 100% certainty, deviate from plans, rendering all the original questions useless. Lunch would be late if we were lucky, or missed completely. The afternoon would mimic the morning, perhaps at a slower pace as the heat sapped the energy….

Pre-op exam

Preop exam

For the last few days in the OR, we left the hospital between 7 and 8 pm – the locals preferring an earlier finish as they had their usual daily heavy work load to deal with as well – but the hernias, obstetrical bleeds and abdominal pains kept piling up.

Post op check

Post op check

Some evenings we would form a gaggle and walk around the dirt streets lit by only the occasional light or fire pit, and feel like we were sneaking a furtive peek into the lives of these people; I know we were quite the show for them. Other nights we would struggle to keep our eyes open past 9 pm…

Night scene, Anse-a-Galets

Night scene, Anse-a-Galets

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Haitian Resort?

As the day of rest, Sunday provided a respite from the operating room (and thus rested the mind), but did little in terms of letting the physical body recover.

After the usual early morning coffee run to the dining hall, and the now predictably delicious Haitian cooking, our group splintered once again. I accompanied the four surgeons to the hospital, determining that the post-op patients were doing very well, and discharging home the patient we thought would require surgery. The other team members headed to the church for a very interesting (and hot and long) Sunday sermon. Miss Vero, charge nurse in the OR (and everywhere else in the hospital…) gave an impassioned warning about he dangers of buying drugs off the street, but this being rural Haiti the drugs in question were TB drugs, not crack or meth.

Main Street, Anse-a-Galets

Main Street, Anse-a-Galets

Later in the day the religious theme carried on in a more surreal fashion. We were having a team meeting brainstorming ways to improve medical missions for future teams, when strains of simultaneously upbeat and sad music drifted in through the screened windows from the road outside the compound. We quickly realized this was the funeral of the young man who had died in a motorcycle crash about a week ago. His was the story told by Marc, the young Haitian mentioned in the previous blog post. Peering over the stone wall we were surprised by the sight of Jazz band adorned in black and purple, comforting the men carrying a small coffin with a slightly mournful and distinctly Haitian version of Louisiana jazz. As Katherine pointed out, all that was missing to place us in New Orleans were a few umbrellas.

The daily grind...

The daily grind…

Plans had been made for the traditional boat ride out to a reef to swim and snorkel for a few hours in the afternoon. Foolishly a few of us went for a walk through the Saline (the poorest area of town located on the coastal flood plain) in the very hot early afternoon for an hour before the schedule swim time; this nearly finished us for the day.

About 20 people piled into and onto a creaking old pickup truck for the short ride to the dock area. Rather than piling onto the “Breezy Sea”, we were directed onto the much older deck of the church’s original ferry, an old sailboat called the “Wesleyana”. Having been out to same area 3 years before, I was looking forward to a refreshing swim but had no expectations about memorable snorkelling, but I started to wonder when I noticed the Global partners missionary couple of Lorin and Andrea were strapping diving knives to their calves. They pointed out an area about a 5 minute swim from the boat, where a fantastic collection of coral outcrops was located. Small in size, these outcroppings made up for it with a huge variety of shapes and colours, surrounded by schools of brightly coloured tropical fish. Pretty special.

Ravi was emailed some path reports from biopsies the previous surgical team had taken; these results dictated a change in plans for the upcoming surgical list as we had to book two women in for mastectomies. Aileen tracked down a little boy who had been born at 28 weeks gestation who had been delivered by c-section 3 years ago on our previous trip. Miraculously baby Abraham not only survived, but Aileen was happy to report that he is thriving.

Tomorrow will no doubt bring about more surprises. Haiti seems to be full of them.

Outside the hospital

Outside the hospital

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Fatigue

This is clearly the word of the day. The members of our team are running on empty; emotionally drained from everything around us and physically drained for being on our feet, doing the work and dealing with the heat. The Haitian nurses are drained from working overtime with our visiting team, and with dealing with the differences we bring to the clinics and the OR.

Consult time

Consult time

Today the medical team provided a clinic for members and staff of the compound, and the surgical team worked till 5pm doing a variety of things, including a few very small children. All went well although the work wasn’t without stress…

Nurses station

Nurses station

Tomorrow is traditionally a day off for this Haitian Wesleyan hospital, but Chris may have a case lined up. Not sure what the rest of the team is up to, but Chris will need to head across the dirt track to the hospital in the morning to see how his patient has managed. Colin and I are still looking at motorbikes, but in this part of the world where no one has insurance, and visitors have remarked at how “good the trail riding is” while riding the main roads, the idea of renting bikes needs some thought.

Hallway consultation

Hallway consultation

Tonight we walked through the darkened roads of Anse-a-Galets, passing food stands where chicken was being fried up in the dark, an outdoor public shower was getting use, and large speakers on the road side occasionally duped us into thinking there was a big night club around the corner. We finished the walk at a new restaurant, opened up by a Haitian who had been in Miami. The gate was guarded by two very large Haitian bouncers, and once inside the open patio it did feel like we were on the set of Miami Vice. Apparently the food varied from excellent Haitian seafood, to a much less successful attempt at American food. Earlier in the evening we had run into a young man who had done most of his schooling in Orlando, and who had come to Anse-a-Galets after the earthquake had forced him from Port-au-Prince where his job no longer existed. Marc was now waiting for a green card to join his mother in Florida; it would take another 2 years before this might be possible, and for now he would take odd jobs on the island. His English was excellent and we mentioned he should work as a translator. Ironically he had accidentally been thrown into that role 2 weeks ago, when another young Haitian had crashed his motorcycle late one evening, and he had helped get him to the hospital where the surgeon from the previous team had called for a cordless drill to do a burr hole in the fellow’s skull to relieve pressure from a bleed. Unfortunately the injuries were too severe to survive.

The world is a surreal place, and the contrasts we’ve seen make that unambiguously obvious to anyone who spends a few days here.

After the much-needed down time tomorrow we will be recharged for the rest of the project.

Dr. Ravi Ramsewak and Dr. Garth Christie

Dr. Ravi Ramsewak and Dr. Garth Christie

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Madness?

The concept of madness came to mind a few times today – once a completely spontaneous reaction to what was happening directly around me, and the other a more measured (and significant) response to what others experienced.

The day started for Peter, Garth and me with a prostatectomy in the OR, a case that can be associated with major blood loss in a place with no lab or blood bank (more on the method of transfusions later). Needless to say a little jolt to start the day. The case went very well, in spite of the expected blood loss, but during the case it became apparent that things like extension cords, tape and water for dilution of drugs could not be found anywhere. All the flat surface sin the OR had also been used for storage and I had to creatively make some space to organize myself. Peter found the prostrate quite scarred up, likely from a long term catheter.

Tools of the trade

Tools of the trade

On the way out of the OR I was pulled aside to help put an IV into a baby who was badly dehydrated and lethargic after becoming ill with a GI bug of some sort; after a struggle the poor little guy had an IV in the foot and I looked for something to stabilize the IV and prevent it from being dislodged – there was nothing to be found and we had to scrounge a piece of cardboard from a box in the store room to make a splint. I suggested later the staff find some pieces of wood that better matched the shape of the limb.

Waiting outside the hospital

Waiting outside the hospital

After a lunch there was confusion about the next case, which could have been a hysterectomy, a hernia or a prostatectomy. We eventually started a hernia later in the afternoon. That delay happened because the first patient hadn’t been monitored post operatively and had some sort of “spell”; the nurse watching him had wandered out of the room for a while leaving him alone… Ravi did a nice repair of the hernia and the first patient, after a few small tweaks, also did very well.

Ravi Ramsewak

Ravi Ramsewak

I was told we would resume the following morning, then informed by Peter that his translator told him we would carry on with another prostatectomy. This on an elderly fellow who had had a permanent catheter for the last 9 years and who was also quite anemic. General anaesthesia was the choice here, and though he machine was functional (in contrast to the machine on the previous trip which died a noisy death and was unable to be resuscitated) it was lacking CO2 and gas monitoring. Without those monitors it is difficult to determine the ventilation status or how deeply asleep the patient is. Monitoring vital signs, and blending the right mix of intravenous drugs in addition to using the gas solved the problem. There was no anaesthetic record available, and after the head nurse had disappeared for 30 minutes we managed to find one piece of paper with enough space on the back to take notes. Eventually Miss Vero returned with some forms; apparently none were in the hospital and she had to leave the premises to get some printed up. She also indicated that now we had some blood. This had been obtained after she had gone into the street and tracked down a bystander who was found to have a compatible blood type; a unit of blood was then drawn from the donor after being screened for hepatitis and HIV. We found it staggering that the blood we were transfusing our patient had been walking around in its original owner 20 minutes before! I now understood why when I returned to the hospital earlier in the afternoon I had seen the head nurse going up and down the street shouting like a mad woman. This patient had quite significant blood loss as the long term in-dwelling catheter had caused a lot of scarring, making the surgery difficult, and he benefited tremendously from the blood. He too did very well but only after I was nearly crushed by the transport stretcher which had seized back wheels and failed to make a turn.

Avi Ramsewak helping out

Avi Ramsewak helping out

The entire OR crew was shattered by this point. Avi had been a star, helping me by running chores in the OR and learning everything he could about the procedure and the anaesthesia. Aileen was trying her best to impart proper perioperative technique to the Haitian nursing staff, and Peter and Ravi were drained after the surgery.

Betadine - sterile technique...

Betadine – sterile technique…

I felt the entire day had been cursed with some sort of crazy spell.

But the apparent madness of the OR faded into insignificance when I heard of the day’s events from our clinic team and another missionary team from South Dakota who were on a construction project. Our team returned to same school they were at yesterday and provided from our team funds a lunch of rice, beans and meat to the same children they had seen in clinic the day before. They were obviously hungry, yet they waited patiently, looking at the steaming plate of food they held on their laps, until the last of the 105 children had been served. Then, in unison, they all devoured their meals. Colin says not a single grain of rice or drop of gravy was left…

The South Dakota group had been here multiple times, usually as a medical team, and always visited an orphanage or two. On this trip they took a break from manually crushing rocks for cement to go to a small orphanage, housing 10 children who looked starved and dehydrated. The cistern holding the orphanage’s water had been empty for two days and it was rare for the children to get more than one meal each day. This South Dakota group purchased 1200 gallons of water and enough beans and rice to cover a few meals.

This is the true madness: that our children at home have the lives we rightfully and correctly struggle to give them, yet other, equally human and beautiful babies here, can be lucky if they can drink enough to produce pee and eat more than one meal per day.

"Les Blancs!"

“Les Blancs!”

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Connections

Filling my water bottle before heading off to bed I thought about some of the people we met today and over the last while on our journey here. There are a great many threads connecting an amazing number of people together.

While boarding in Fredericton I ran into Richard Blaquierre, a friend from New Brunswick who is making his 6th trip to Haiti in the last 5 years. A teacher by trade, he decided after the 2010 earthquake to honour his friend Mark Gallagher, (who was a New Brunswick RCMP officer who died in the earthquake 90 minutes after returning to Haiti as part of UN training mission) by building a school. What began as a primary school morphed into the Mark Gallagher Vocational school, and it is nearly complete.

You were introduced to Barry Gould in a previous post. He and his wife Beth are finishing a 4 year stint here and will return to Nova Scotia in the summer. He has been instrumental in helping with various projects on La Gonave, including much needed water production. Beth joined us in the OR as the scrub nurse today!

Dean Stephenson has been taking kids from New Brunswick to La Gonave for years and was the person responsible for getting most of the local medical people in our area to Haiti for the first time after the earthquake.

Even the boat ride across on the “Breezy Sea” invoked this idea of connection. Not only is she a Grand Manan lobster boat from New Brunswick, but the crewing on her voyage here was done by Charles McNair, a New Brunswicker who has since started other projects to bring attention to some of the problems facing Haiti.

The threads described here are the ones that link together some of the people in our very small part of rural Canada, and don’t even come close to describing the full intertwined web of people involved in these various projects – just think of Dr. Colleen O’Connell from Fredericton whose organization Healing Hands for Haiti has helped thousands of people with prosthetic and rehab needs over the past decade.

There are many such webs in many small communities around the world, and places like La Gonave help form tendrils between all these webs.

Pretty inspiring stuff!

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To work at last

Today the team, like the mythical many headed hydra growing two heads from one, split into its surgical and clinic based components.

A school and clinic at the far side of Anse-a-Galets, just past the short dirt airstrip we landed on during a previous trip, is the site of the first of our medical clinics; later the team will travel up into the mountains. There may be malaria, typhoid and other tropical diseases (previously we saw cutaneous anthrax), but less exotic entities like hypertension, vaginal infections and intestinal worms will likely be the biggies.

We wandered over to the OR this morning expecting the surgeons to do clinic work and me to sort out the OR once again, only to find a surgical list had been put together, and a patient for a hysterectomy was being moved into the OR. I soon found out that even after apparently excellent preparation and scouting the day before, there is great deal that happens on a subconscious level at home that becomes strikingly not subconscious when you can’t find the item in question or do the given task in the middle of an operation. Still, after some scrambling and improvising by both anaesthesia and surgery (this improvisational approach is a requirement for work in Haiti), the case went very well and the patient left the OR hopefully to feel much better than she had in a long time. There was a a bit of a déjà Vu in the morning when I went into the little bathroom off the OR and saw the same government of New Brunswick sign insisting on proper hand washing technique we see at home in clinic bathrooms!

Safe hand washing - New Brunswick style

Safe hand washing – New Brunswick style

After a few cases in the morning (which for Ravi and I finished at 2 pm), it was time for the typically well prepared food that the Haitian ladies had kindly kept warm for us two latecomers, washed down with the one bottle of pop included in our daily guest house fee.

Ravi doing what he loves best - plastics

Ravi doing what he loves best – plastics

On their return from a hot and very busy day during which the clinic team saw over 100 children, missing their lunch in the process, we were able to catch up on their day’s events. Problems ranged from cough (possibly TB), to three youngsters who will have their hernias repaired by the surgical team, to traumatic blindness and congenital nerve palsies. Colin said a majority of the children were also given de-worming medication. Angel found her spot as master of logistics…

The surgical slate has now increased to 12 cases, spanning the specialties and the ranges of age. If the pattern of previous trips is repeated the work will just build to the point where we are finishing our last cases just before loading the boat.

Kids at night

Kids at night

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La Gonave

After the best sleep I can remember in Haiti we woke to a resort-like scene outside the window, followed by a repack, breakfast and literally a 30 second cold, refreshing shower.

Haiti coastline

Haiti coastline

The “Breezy Sea” is as reliable as ever, proudly upholding her Bay of Fundy heritage of ferrying objects, whether they are lobster pots, people, or even a Land Rover driven onto large wooden boards laid across bags of food. This working boat was taken from Grand Manan along the Eastern Seaboard’s inside passage then across to Anse-a-Galets. Our crossing today was in typically fine Hatian fashion – bluebird skies, refreshing breeze and building whitecaps. There was surprise for us this time in the form of a playful school of bottle nose dolphins darting from side to side, over and under each and finally leaping and jumping for the sky. This show was followed by tiny flying fish that looked like aquatic offspring of dragonflies and hummingbirds.

Dolphin escorts

Dolphin escorts

The marina in Anse-a-Galets was better kept and more bustling than I remember form the previous trips. Even the walk along the only stretch of paved road on the island, past the Saline and the cemetery up towards the hospital, revealed signs of rebuilding and some degree of wealth. Barry Gould, a missionary from Amherst whom I met in Petit Guave 2010 after the earthquake, says the population here really grew after the disaster as people from “the mainland” came to La Gonave. He is finishing a 4 year term this summer, and says that in spite of the emergence of youth gangs and such, things really are more prosperous and look much promising than when he first arrived.

Haitian fishing boat

Haitian fishing boat

Another surprise waited for us in the compound. I had seen the plans for the new guest house, but hadn’t visualized its final form. It is beautiful (in a practical way), safe (earthquake resistant to California building code standards) and well designed (with passive cooling facilitated by cleverly designed ceiling and wall vents and it’s half buried location). I asked Barry about the earthquake “resistance” of the building. He said they used 5 times the normal amount of rebar in the construction, and up to a Richter 7 earthquake the building would stand up long enough to get everyone out – though it wouldn’t look pretty at the end…

The surgeons started their consults today, the clinic staff were repackaging and labelling drugs, and I spent some time in the OR looking at the anaesthetic machine, the various drugs (many from Cuba and labelled and dosed in interesting ways), and plugging batteries into the things that needed them. Seems on the whole better equipped than previously, and the machine gives me enough faith that we may be doing a 5 year boy with bilateral hernias towards the end of the week.

I am struggling to upload photos now, but for now will continue to document parts of this amazing trip.

Team NB

Team NB

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Haiti bound

We leave shortly for the airport, where rounds of sleepy greetings, repacking and changing into warm weather clothes will take place.

Fredericton airport has become a familiar place to me, and me to it. The fellow screening security teased me about taking too many trips, shrugged off the many vials of ketamine and morphine I placed in the tray, and told me not to bother looking for my boarding pass! The process in Port au Prince will likely be different. Mary Feero recalled attempts by Haitian customs to separate us from each other last time, with the fairly blunt objective of intimidating us into parting with some money in exchange for the exit door. In Montreal I met up with Ravi and a very tall Avi – Ravi unchanged from his past life in Woodstock, but Avi now a man.

In a few hours we’ll step off the plane into the heat and humidity of Haiti (Colin says forecast is for “33 feels like 39…”) and then make our way over to the guest house on the water, where we’ll stay the night and hop on the Grand Manan lobster boat for the 1-2 hour trip over to La Gonave.

Our crew consists of 4 surgeons, one sole anaesthetist, a family doc who will run clinics in the mountains, a pharmacist, 2 OR nurses, a paeds nurse, and a medical secretary, and of course Ravi’s son, Avi. Drs. Chris Adam and Garth Christie are OBGYNs, Peter Feero is urology and Ravi Ramsewak is a general surgeon. Colin Lockhart returns to run medical clinics. Peter’s wife, Mary is a pharmacist and provided excellent documentation for the drugs, which hopefully will meet muster if needed in Port au Prince. Katherine is an OR nurse, Kendra an ER nurse, and Angel works for a family doc in my neck of the woods, essentially a neighbor I’m meeting for the first time. Aileen is leading the motley crew and working in OR with us.

What a change a few years can make. Upon arrival at the airport, the first dramatically obvious impression (other than the soggy wall of heat we stepped into) was the relative order and tranquility of the airport. Still best described as chaotic to the North American observer, there were actually lines forming for passport checks, baggage collection went smoothly, and the parking lot madness wasn’t really even evident. What didn’t change was the old faithful steel caged Mitsubishi truck, where would spend the next few noisy, diesel infused hours bouncing to the guest house.

Tire changing shop

Tire changing shop

A salty swim relieved the heat temporarily, but the sweat returned as quickly as dinner was served. Sleep looks like it too will race to claim us. Day one draws to a close…

Guesthouse at Montrouis

Guesthouse at Montrouis

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Angst

It seems something very different is going on this time around. It is 4 am and if I had an hour sleep last night that would be a generous estimate. Colin also slept poorly, recalling the time he used to do obstetrics and had a lady labouring away next door successfully foiling his sleep. My chest was boiling with tension, and for most of the night I was on the verge of some mild nausea, like the side effects from a typhoid vaccine – which ironically I was never able to source out for this trip. Last night Colin asked if I had a premonition about the trip. Perhaps, but it would be in the form of a fleeting, indistinct and suggestive feeling, rather than any true thought. I don’t know how the 2 am frontal assault of Ransford’s cat forcing its way into my room and launching itself onto my chest fits in…

Probably just the Tim Horton’s from last night.

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