Healing in the Heart of Texas

US 280 west of Austin winds its way through the rolling foothills of the Texas hills country. The lights of the capitol were fading in my rearview mirror, and I was immersed in thought, appreciating the open spaces and the quickly darkening sky. My cell phone rang – it was my friend, Mike Williams, a classmate at my graduate program in Boston. “You’re about 45 minutes away. Need to let you know that if a deer crosses, don’t swerve, just hit it head on- you’ll have a better chance of surviving. It’s pretty cool tonight, so they should be bedded down. See you soon.”

Probably one of the most practical pieces of advice I’ve gotten from a hospital CEO.

My path to LA took me through Texas, and I was pleased to see that a stop in Fredericksburg would be a perfect place to rest and see how a Parkland trained anesthesiologist, with an MBA from Duke, was building a leadership team that was revitalizing health care delivery in this town of 11,000. And I would again see how preconceived notions can be reframed by real life experiences.

Fredericksburg was known for three things – Lyndon Johnson, Admiral Nimitz, and Mohair goats. Yet it is situated in an ideal tourist area with abundant hunting, fishing, hiking, and biking. There remains a strong agricultural and ranching basis. Mike, who grew up in the Dallas area, wanted to raise his family in this environment. He developed and led an active anesthesia practice, became president of the medical staff, and found a passion in optimizing operations and building teams. At that time, the hospital CEO stepped down, and Mike agreed to come in initially on an interim basis. The hospital was running a significant deficit, employee engagement and staff morale were low, and there was concern that this rural hospital would not be able to meet its mission. Mike recognized that he needed to reestablish focus and build a leadership team. He hired a new CFO and COO.

I met his COO that evening – a Jewish guy who grew up in east Texas, went to West Point, and worked on his MBA at night while in the Army, using night vision glasses to study, so as not to disturb his fellow soldiers. Steve Sosland had no experience in health care – but he knew how to motivate and lead teams. He could listen and was from the school that you win battles by understanding the point of view of all the parties –not ramming excessive force into a foreign culture. His daughter was going to Haiti this January, and they had both read the blog and wanted to discuss my experiences. In addition to his work at the hospital, Steve had begun an outreach program to increase interfaith understanding in Fredericksburg. Those relationships would become an important asset at the time of a local tragedy.



Last fall, Mike seemed a bit distracted one weekend. Over dinner, he told me of a 14 year old local boy, well know in the community, who came to the ED after a football practice with nausea and some vague neurological symptoms. He appropriately evaluated, and all signs suggested a mild concussion. When he didn’t improve, he returned and a CT scan was normal. He was admitted, but suddenly decompensated and was transferred rapidly to a larger hospital where he died of an unusual condition – a vertebral artery dissection. Everyone in the hospital and the community were devastated, and of course, there was always the question of whether something could have been done differently. Mike never mentioned hunkering down and defending standard of care. He wanted to know what they could learn, how they could improve, and most importantly, how could they support the family and the tight knit community.
Similar to well know cases of unexpected and potentially preventable deaths such as Josie King, and the brother of actor James Woods, the leadership team at Hill County Memorial Hospital met with the family, provided support and tried to answer their many questions. They apologized for any shortcomings, and they worked to find ways to reassure the community.

The funeral was held at the Catholic Church downtown. But on the pulpit, next to the priest, was Steve Sosland, wearing a yarmulke and tallit. You see, the father of the young man who died was Catholic, and his mother was Jewish. There was no rabbi and the family wanted a service with both traditions. The outreach that Steve had started months before broke down barriers and helped bring together a community that was hurting. And of course Mike and his family were there, sharing the grief and adding support.

I quietly listened to the story that evening. The next morning I asked to see the hospital and downtown Fredericksburg. Mike took me down, Steve met us in his pickup truck. I took a picture in front of the Mohair warehouse, and then walked by some of the churches. It was a Sunday, and folks were arriving for services. As I looked up, the sun angled through the stained glass, and I recognized a Star of David through the diffused light. Unlikely that was intentional at the time it was built, but I’m starting to believe that very little in life is purely coincidental.


I’ve got another 400 miles, just to get through Texas – and I’m sure there will be more lessons as I roll into California.

New Year's Resolutions

Sometimes I feel like this blog is like Car Talk's "Shameless Commerce" website, but for CRUDEM. Many of you are with friends and family, enjoying the holidays. Others are away, wishing they were home. As we take a moment to be grateful for our gifts, I'd like you to consider a New Year's Resolution that won't cost you much, but will return manyfold - a gift of your time as a volunteer. You don't have to be a doctor or nurse. You don't have to go out of the country. Find a passion, and follow it.

I'm forwarding a letter from Bill Guyol, if you are interested in helping in Haiti. It is safe and an experience that will forever change you. I'm happy to discuss details futher. The effort is far lighter than you think.

Dear Friends,
Up until several days ago Hôpital Sacré Coeur's cholera service had a census or 40 to 50 patients daily. Our Haitian staff physicians and nurses were doing a wonderful job of caring for our patients with little supervision from volunteers. We were hopeful that the number of admissions would remain manageable. It has not.
Things have changed. In the last three days we received 40 to 50 new admissions per day. We assume that this will continue. We now are acutely in need of volunteer personnel to supplement our staff. If at all possible, please consider coming to Hôpital Sacré Coeur's as soon as possible. We need you now. If we can send two physicians and three nurses per week it should be sufficient to care for our current census.
Please be assured of your safety. There have been intermittent demonstrations in Cap Haitian, which at times led to closure of the airport. Things are now back to normal. As always, Milot is quite peaceful and our volunteers are welcomed and well protected by the community.
Please email Deb Motyl at dmotyl@radiusmanagement.com if you can come. Please feel free to contact me as well if you have any questions.
In this season of giving, please consider giving your time and skills to the people of Haiti who once again desperately need it.
Bill
William B. Guyol, Jr., MD
Chair, Medical Committee
CRUDEM Foundation
wbguyol@me.com


Have a safe and fulfilling holiday.. and you don't have to look like Santa to make a difference -

Sister Ann, The Order of Malta, and Other Light Musings

A Midwestern Jewish kid spends his Friday night attending a Mass led by a Haitian Priest and an Irish Nun in a Caribbean styled open air chapel renovated by Canadians… Sounds like the start of a great sitcom, but as you’ve come to expect from these blogs, it’s the reality of Milot, and another experience in the universal nature of philanthropy and spirituality of many religions.

Growing up in the 60’s I still remember the calendars with a fish symbol every Friday, and my knowledge of Catholic education were stories of stern nuns, reminding the girls not to wear patent leather shoes, and the boys of their goal to attend Notre Dame. Similar to my strict Jewish upbringing, I saw Catholicism as a religion of rules and consequences, of following dictums that may not have been relevant to modern life, and using the greatest agent of all, guilt, in an attempt to control behaviors. Needless to say, most of us Jewish guys dated Catholic girls, and our sisters snuck out with the boys from St. Thomas Aquinas. Some actually fell in love and raised great families in both faiths. Others supposedly “got it out of their system” and developed long term relationships within their own communities. As I matured, and saw religion in more supportive and holistic terms, I grew to appreciate the role that religion plays in supporting your core beliefs, regardless of your label.

When I was Chief of Surgery at the Miriam, many of the board members were Jewish, yet in the C suite, all the leaders were Catholic or Protestant. What I saw was an immediate comfort with embracing the multitude of traditions, and the focus on the mission of the care of the sick and injured. So it should be no surprise that CRUDEM is sponsored by the Order of Malta, which has a history dating back over a millennium in the health care. It takes its origins from the Knights Hospitaller, a group founded in Jerusalem about 1050 as an Amalfitan hospital to provide care for poor and sick pilgrims to the Holy Land. After the conquest of Jerusalem in 1099 during the First Crusade, it became a Catholic military order under its own charter. Following the loss of Christian held territories of the Holy Land to Muslims, the Order operated from Rhodes (1310–1523), and later from Malta (1530–1798), over which it was sovereign. (ref Wikipedia) During my stays, a Board member, usually a Knight or Dame of Malta, would be present to help in the operations venue. I also learned that the Order of Malta had some of the earliest Visiting Nurse services, nuns who could travel as unescorted women, and attend to patients.

When Hospital Sacre Coeur was first founded, 25 years ago, it was run by nuns, and a nun’s residence remains in the compound. Although the hospital is now locally led, we always have one or two sisters in residence.

Sr Ann Crawley is one of them.



Sister Ann has a ready laugh, a wonderful Irish brogue, and is completely unflappable. On my last visit, I found her walking through the cholera ward, holding hands with one of the children. Now we had to wear waterproof boots and fluid protection. All of us looked like something dark and rubbery from “Deadliest Catch.” Not Sister Ann – her boot were bright purple with polka dots – exactly what you needed to bring light and hope to a scary place.


My niece had her high school class collect stuffed animals for the children. I took them down, but realized that the conditions of the wards were such that the absorbent material would actually spread disease. Sister Ann, of course had an idea. She was going to an orphanage later that week with kids from the quake – they’ll now have something for Christmas.

So let me get back to the rest of my opening story. We do have a beautiful chapel, that had been neglected. Last September a group of volunteers, many from Canada, cleaned and restained all the pews, put up new fans, and repainted. They finished Thrsday evening were leaving Saturday morning, so they would miss the first Sunday mass. Friday night, Sister Ann arranged with the local priest Fr. Tenjia to hold a celebratory dedication mass for everyone. I sat in the back, watched the candles and listened to the music from the tapedeck. The priest entered and prepared the table. The incense wafted through the cool night air. I had the same feeling to that of my experience in Milot on Palm Sunday – it’s not about a specific set of rules, or a judgemental God. It’s not about killing the heathens and purifying humanity. Religion and all its traditions are to draw us both within and to the outside. To celebrate that even among suffering, there is hope. And to recognize that it is better to motivate behavior by reaching internal goals, than by inhibiting with threats and guilt.

We all stood.
“Peace be with you,” he said
“..and also with you,” those assembled responded.

And so may be for all of us.

Happy Holdays

The Medical Record

In the US, a great deal of emphasis is being placed n the use of an electronic medical record to reduce errors and duplications, as well as increase patient safety. Meaningful use initiatives will create incentives (and penalties) to encourage integration of the EMR into practice. Many of my primary care colleagues have had to reduce the number of patients seen as they integrated the record. Those of us that do not have the keyboarding skills of our children feel inadequate as we hunt and peck. Some have gone as far as hired scribes to enter data for them as they spend more time actually with their patients.

In Milot, we are fortunate if we can even register the flood of cholera patients.




After the quake, the population had swelled, and those acutely ill patients died fairly rapidly. Others were in the hospital for a prolonged period for treatment of open wounds or orthopedic injuries. We were able to keep a rudimentary chart on a clip board, and placed a large cardboard sheet above each bed, listing the patient's name, injuries, operations and dates, and PT needs. We didn't worry about HIPAA and with the rapid turnover of medical personel, essential information was rapidly available.

The treatment of cholera is far more acute. Patients present in various stages of shock, and must be rapidly triaged to those that can drink and be rescucitated with oral solution, those that will need a brief IV, and moribund patients, especially children. Obtaining IV access is crucial, and not easily accomplished. Formulas for IV rate is pretty simple - wide open until fluids in begin to exceed diarrheal output and you can again feel a pulse. Over the last few days, the epidemic has spread to the hills toward the Citadel and 40-50 new patients are making their way to Sacre Coeur. We had three doctors and 2 nurses, as well as our Haititan counterparts. Coverage at night was spotty. By morning light, we would find 10-15 new admissions lined up on stetcher or waiting outside the tents. Some of the docs and nurses became concerned that we couldn't register and document them all. At dinner, the consensus was take care of the patient first, worry about registration and documentation later. Once we made that mental shift, the ability to respond to the increasing volumes increased. In many ways, it was a tremendous relief.

At the same time, a physician from UT San Antonio arrived with Project Hope, and several hundred interossous needles that could be rapidly placed in the bones children and adults who were so dehydrated that we couldn't start ivs. He was to have stopped by earlier, but the violence delayed his trip. Circumstance helped us, as he was there when we most needed the help.

I recognize that in a coplex process such as patient care, good documentation aids in passing on vital information. In my roles in the States, I was responsible for ensuring that processes were documented and billed appropriately. I also saw where multiple repetitive layers of documentation and policies created more fatigue and potentially impacted patient care.

In ATLS we deal with the essential ABC of airway, breathing, and circulation. (and D is not documentation) In Haiti, we use what limited resources, including time, we have to save as many lives as we can.

And it's nice to remember why we became healthcare workers, and document that enlightenment in a blog.

More from Milot

My internet access is a bit better and I'm posting some observations from several days ago. More to follow.

The flight to Cap via Turks was uneventful and I was happy that we could squeeze all the necessary supplies into Ed Constanine’s Baron. Although We didnt what the sunrise, the light playing off the clouds and casting shadows on the Carribean was amazing. After some unusual ATC instructions in French,we broke out over the harbor at Cap, an interesting experience with no radar coverage. The airport was quiet. Immigration d was empty and we actually had to find someone to stamp my visa. The customs agents, however, had the time to open and inspect every box. Ray, the hospital COO, was there, and after some closed door discussions, it appeared that our charitable donations would be allowed into the country.



Despite warnings from the State Department regarding post election violence, the streets were calm and other than some vandalized political billboards, it would be hard to tell that there were any significant issues. The cholera epidemic did not seem to affect the street vendors, and there was the normal buzz of activity around the hospital and the open air market.




Accessing the compound, however, there was a clear change since my last visit. Security was much tighter and fences had been erected to isolate the cholera ward. You could only enter through a decontamination tent, where you put on boots and gloves. Dilute Clorox solution was spread about in open bins, and hand cleansing was mandatory. The former school had been converted to a cholera ward and special beds (with a hole cut in the middle, to allow the diarrhea to drain,) were arranged in three rows. Some children looked better than I expected, although those early in the rescucitation were still quite lethargic. A nurse, who had heard that I was coming, asked, if I knew where there were some Lactated ringers for IVs, - they had been told by staff that there was no more, and patient census was increasing. I found several liters and a fresh case at other sites less than 100 yards away – I guess that confirms why we need the inventory system.

There was a different intensity since my last visits. The volunteers remain as committed as ever, and it was good to see familiar faces. The patients are more acutely ill and get better or die quickly. The treatment of cholera isn’t as dramatic an earthquake victims with crushed extremities, yet diarrheal illnesses remain one of the leading causes of childhood death worldwide. Over the next month we will potentially save more lives than after the earthquake, quietly and competently.

And if we can get this inventory system up and running, we might even find the Lactated Ringers we need, without me raiding my secret stash…

On the Ground in Milot

We have had continuous rain, which makes it tough on our staff trying to treat the cholera victims. In addition, the internet and cell phones have been very intermittent. I'll write more tomorrow.

As expected, the staff is doing an amazing job with an increasing number of patients. The political unrest has died down and in fact, the atmosphere in Cap was quite easygoing.

I need to get off to allow others a chance to check in with their world.

No me bulee

H

Clarity of Thought in the Dark of the Night

As a surgery resident, our schedule required an early arrival at the hospital to check on the patients prior to starting the day’s schedule. The hours from 4-6 am brought us into a quiet world, with virtually deserted streets, and a peacefulness that I certainly appreciated before the hectic day commenced. Although a bit sleepy, there was clarity of thought. There’s something special about “0 Dark 30”

I was actually looking forward to experiencing that again this morning, as Ed Constantine and I were to meet at the Boca Raton airport at 0500, to begin a trip that would take the computer equipment and me to Milot via Turks and Cap; then Ed flying back the same route bringing CRUDEM volunteers to the States to catch evening flights home. In previous posts, I mentioned looking forward to sunrise from the cockpit. The schedule once I got to Milot was also tight, as I needed to work with the local hospital administration on their perspectives to ensure a successful rollout and begin the pharmacy inventory. I also wanted to give the local physicians treating the cholera victims (we have 600), some help.

I spent last evening with my brother in Boca, and slept fitfully. A front was moving through and the wind was picking up. At 4 am I looked out at the palms in the back swaying against the black sky.

Not surprisingly, the phone rang at 0430. It was Ed. He had just finished a briefing that included gusty winds, the possibility of thunderstorms, and an approach into Cap that was doable, but depended on several issues lining up. The flight could be done legally, the question was should it be. There were volunteers that would miss flights home, and my time in country, which was already reduced due to the impending move to California, would be further cut. We were 2 experienced pilots, and prided ourselves on the ability to manage risk and use our aircraft to their fullest capacities. Ed had seldom, if ever, had to cancel a relief flight for CRUDEM. The conversation lasted about three minutes.

We immediately cancelled until tomorrow.

It’s important to have the confidence to move ahead and accomplish a goal, and risks are inherent to any decision. As surgeons, we must have a level of healthy narcissism to open another human being and correct what nature has turned awry. We also must pause to recognize when risks exceed benefits and develop alternative plans. The older I get, I find myself paradoxically more confident and more aware of risks. Perhaps, it’s knowing that you will accomplish your goals, despite setbacks, even if it takes a brief delay to regroup. I didn’t always see that as a younger man. In the blackness that is 0 Dark 30, is the knowledge that the sunlight will be soon be coloring the Eastern sky.

Catch you tomorrow from Haiti.

A Last Run with the Handsome Men

Saturday dawned cold and windy, but the sky was cloudless, and the sunlight's low angle cast long shadows over the homes and gardens of the East Side, creating Dali - like abstractions. As I turned the car down Intervale, the crew were already gathered, exchanging insults over who wasn't tough enough to wear shorts in the 30 degree weather. It seemed like any other Saturday.

But I realized it was my last run with the Handsome Men, before starting the journey to California, via Haiti.

I've described the group before - attorneys, an accountant, an English Professor, businessmen. All have long term connections to Providence, and as they welcomed me to join them 4 years ago, I didn't realize this would be more than just exercise. I would learn about the city, its politics, friendship, and about myself.

It's easy to generalize about men getting together to play or watch sports - that the posturing, the sense of confidence, and irreverance is a way to maintain the right to belong in a competitive environment. But as I would listen during the runs, I recognized that deeply seated relationships developed, even though we may not be emotive in displaying them.

This morning, I chose the route, and decided on "2 bridges" - down Elmgrove to Angell, across the river on the red bridge to East Providence, down to Broadway, then back along the East Bay Bikepath, with views of the water and the city. We would cross back on the I195 bridge, and head up Gano from India point. I wanted to watch the sunlight reflect of the buildings and the Bay, and take in the images.

We started off at an easy pace, our joints beginning to warm up and the discussions centering around the Celtics and politics. I ran past our old house on Hazard - Christmas lights were out and I was happy that the new family was settling in. The guys asked me about the job and LA. They have been a sounding board over the last year as I redirected my professional efforts. They helped me think through options and kept my perspective aligned. And they occaissionally would kick my ass if I got too introspective.

We crossed the bridge outbound and the wind was kicking up - I'm not sure I'll miss that in SoCal. Although at first we would run 5 across in the street, traffic was increasing and we stretched out into pairs. These would rearrange depending on pace and rest stops. We got our water and gels on Warren and headed up the hill on the path. I may have gone out a bit quickly, and started to lag behind. I motioned the others to go ahead, and they finished the hill, then waited. We worked our way back to the East Side, and I admired the city from the bridge. A floating duck blind with a couple of hunters passed underneath.

The unwritten rule is that once we turn back onto Elmgrove, you can pick up the pace heading for home, even if you break away from the group. I was definately slower today and expected that I would finish up well behind them. But on that day, everyone stuck together. It was only in the last quarter mile, mostly downhill, that we sprinted. I finished in the middle of the pack.

We exchanged high fives, and checked our times. "Another one in the books," Alan always says. The goodbyes weren't awkward - I had come into the group, and it was now time to move on. Handshakes, bear hugs, and good luck. We made plans for them to come to California for the 100th Bay-to-Breakers. I'd love to get back for the Blessing.

So why this story in a Blog about Haiti?

As a surgeon I was taught to be self reliant, and not show weakness. I missed out by doing that. I learned in Haiti about faith and interdependence. I learned from my colleagues at Miriam that a common vision of compassionate patient care can help overcome turf issues, and I learned from my running group, that sticking quietly together, even if you can break away on your own, is the greatest sign of acceptance and support. (And now you can kick me for being introspective.)

One more interesting event later that evening. I was with an acquaintance who said he saw me running up Elmgrove with the group on the way back. I mentioned the Handsome Men - turns out he knows a few of them, and is a runner himself. Maybe the numbers will be maintained...

I'll be checking in with you on my way to Milot later this weekend - it should be intersting. Given the current situation, we felt it prudent to fly the inventory computer equipment privately to CAP. I'll be in the right seat and hope to send you some pictures. I'm told that sunrise over the dark Atlantic is spectacular.

Transitions

The recent elections in Haiti were, as expected, wrought with accusations of fraud, outbreaks of violence, and general disarray. However, despite the cholera epidemic and continued refugee issues, the citizen gathered to vote for a new president to replace Previl. His supported candidate Celestin has been seen as both a continuation of the current corruption as well as a pragmatic leader. There are 18 parties involved, and opinion poll leader Mirlande Manigat, has filed protests with 11 others regarding irregularities. American rapper Wyclef Jean, although declared ineligible to run, is in the country and calling for a rapid response to these allegations, citing the risk of violence. And we won’t see preliminary results for another week. Such is the nature of transition.

At Sacre Coeur, we continue to respond to the cholera outbreak. The uprisings in Cap have settled down and in Milot, our volunteers are beginning to return. We still need supplies, and hopefully the relative calm will allow us to bring them in. Tim Traynor, our overall technical and construction wizard is back on site, and we are ramping up the sprung building inventory project. The political climate remains uncertain, however whoever is declared the new President will have unprecedented amounts of support to try to rebuild his country. The transition will be more vocal and chaotic than in the US, but it will occur.

And my own transition also begins. Those of you who have followed my blog know that I have been on a Sabbatical from my academic surgery practice as I returned to school and looked at new options. The times in Haiti, my children growing and leaving home, as well as other experiences have brought me new perspectives on the next phase. This past year, though difficult in many ways, has been a gift. But as I looked at new job opportunities, I was able to relate the lessons learned from the past and this helped me focus on the future.

Beginning January first, I will be heading west and relocating to Los Angeles to join Cedars Sinai Medical Center. I will be involved in the clinical transformation project, Cedars Medicine, as well as serve as administrative Vice Chairman of a large and talented surgery department. I am excited about the opportunity.


Every day we see a transition from the darkness of night to light of day and I will look forward to sunsets over the Pacific. I remain hopeful that a new day will also dawn for Haiti, although if history is any guide, there may be a few storms along the way.

Appreciate the Present

So, many bloggers will reflect on the upcoming Thanksgiving weekend, where families and friends will gather, eat and drink too much, and enjoy the present, even if some of the actions aren't completely healthy long term. It's important to appreciate the now, even as we plan for the future.

Over the last year, I've had more free time than in the previous 30 years combined. At first, I was antsy, that I needed to find something to do, besides school. My previous days as Chief of Surgery had been filled with a constant stream of information, decisions, triumphs. and challenges. Often times, I would forget to eat and by the end of the week, it seemed all seemed like a blur. There were certainly high points - a great conversation with family, friends, or colleagues; a warm Seven Stars roll; a patient that had turned their life around after bariatric surgery. Yet on balance, it was difficult to appreciate the now.



I recently came across the enclosed picture. It reminded me of the gifts I've been given recently with time. Chester and I have had numerous walks through the woods. When I was working, dog walks were fit in to a schedule and the goal was pretty clear. Now they are part of an experience of the day. I appreciate the changes in the sunlight filtering through the leaves as the seasons progess.

Even in Haiti, amid the chaos, we felt the presence of the moment. It is an awareness of the balance of powers and emotions. Trying to project into the future removes the chance to experience the now.

I will be returning to academic medicine in a more formalized role January first. There are several things I want to achieve long term. As I work to those goals, staying present will help me understand the motivations and needs of those around me, and how to work to reach those goals. And during my trip back to Milot in December, I know I will again be energized by those around me by staying in the present.

For those who are traveling - be safe...

Update from Sacre Coeur

I am sure many of you following this blog are increasingly concerned about the situation in Haiti. I have seen pictures of roadblocks and demonstrations in familiar areas of Cap. The state department sends daily updates, and I have also been communicating with Daven, the expat that I wrote about in September. He is working to ensure the safety of his workers against disease and the unrest. I am in awe of his commitment.

This morning, I received the following update from Dr. Peter Kelly, executive director. I am sharing it with you ver batem:

NOVEMBER 17, 2010
It's been a while since my last update about the situation at Hôpital Sacré Coeur. As most of you know we have discharged almost all of our earthquake patients and have approximately 10 waiting for prosthetic limbs.
Just as we were starting to implement some overdue renovations and outline our long term expansion plans we had the cholera outbreak. Immediately our hospital administration developed an emergency plan to handle 1,000 cholera patients and our community health department started teaching prevention in the surrounding areas. Other NGO's also collaborated with the Ministry of Health in implementing an extensive outreach program to contain the cholera. It was an impressive example of collaboration that did not exist before the earthquake. It was containing the cholera outbreak until the hurricane last week.
Once the hurricane hit the outbreak became an epidemic and has now reached Cap Haitïen and Milot. We have received over 100 patients over the past week and are expecting at least 1,000 more patients. Initially we were able to provide the care needed but then another catastrophe struck: FEAR. The people in Cap Haitïen blamed the UN for the cholera outbreak thanks to a news report and the people of Milot wanted to stop Hôpital Sacré Coeur from treating patients outside of Milot because they thought it would bring cholera to their community. Both fears are understandable but not based on fact.
We had 18 volunteers at our hospital and to insure their safety we had confined them to our gated compound for the past 24 hours. Once our administration spoke to the demonstrators it became obvious that the volunteers and staff were not in danger. They have resumed helping in the care of the cholera patients.
In any uncertain situation it is normal to fear for your own safety especially if you have never been to Haiti or Hôpital Sacré Coeur. There was a small group of first time volunteers who became very concerned about their ability to leave Haiti. They left our compound against our advice and thankfully were able to make it to the DR safely. The message we tried to convey to all volunteers was that the safest place in Haiti is Milot. The only danger exists on the roads to Cap Haitïen and in Cap Haitïen.
The reason I am mentioning this problem is that you may hear some negative reports about safety in Milot. Also I want to make other volunteers aware that we cannot always control their ability to leave Haiti. But I want to emphasize that we can control their safety!
At this time we have approximately 50 patients with cholera, 35 severely ill and 26 children. We are running low on supplies because of the road blocks and closed airport. For the same reasons we are now receiving patients that are near death because they couldn't get through the road blocks. We have over 30 volunteers willing to come and help but can't get to Haiti.
Our staff is operating on a skeleton crew because those in Cap Haitïen can't get through the road blocks so we are in desperate need for volunteers to help them and supplies. We are doing everything we can to try and find other ways to get supplies and volunteers
I want to end with a story about determination. Our medical director Harold Previl was at our board meeting in NYC. On his return to Haiti he landed in Port au Prince and heard about the unrest. He left his car in Port au Prince and road a motor bike to Milot because it was easier to get by roadblocks. He had to pass through 18 road blocks to get back to Milot 12 hours later. Another worry he had to deal with was that his daughters who attend school in Cap Haitïen had arrived in Cap Monday morning before the violence but were stranded in Cap Haitïen. Can you imagine what he must have been feeling and fearing? Thank God we have such wonderful and dedicated Haitian staff to guide our hospital. Please keep all of them in your prayers. Peter
Peter J. Kelly, M.D.
President

Please keep everyone in your thoughts. We will prevail.

Harry

Eye on the Future

The timing couldn't have been more symbolic. I was in school this weekend, and reviewing the inventory control project at Sacre Coeur with which I'm involved. We have been making good progress, the building is up, and we were coordinating logistics to get the hardware to Milot and begin installation and roll out. Potential infrastructure roadblock were identified and corrected. Things seemed to be on track. I was planning to head down in December. Twenty minuted before the presentation, I received two concerning emails.

The cholera epidemic reached HSC, and there were now widespread demonstrations in Cap, closing the airport.

The email from CRUDEM,updated the situation and asked for volunteers. The census was again swelling, this time with cholera patients. Fortunately, we had anticipated this scenario, and designated isolation areas in the tents, assured appropriate decontamination (you need dilute bleach, not just alcohol gel), and secured safe water for oral rehydration solution. We once again will respond to meet the needs.

The political unrest is not surprising. There has been no functioning government for almost a year, and frustrations are high. But I also learned that cholera had not been a problem in Haiti before, and the local citizens are blaming outsiders, including the UN, for bringing the disease to their country. They site early European explorers importing smallpox and syphilis to a previously unexposed populations in America.

I contacted several of my colleagues, as well as CRUDEM leadership. The response was what I expected - we have handled these challenges before and we will do it again. The demonstrations will die down, and we will get back to our mission of improving care and enhancing Haitian self reliance.

It's a good lesson for all of us. Crises are part of the everyday ebb and flow of life. By keeping our eye firmly of the long term goal, we will deal with the challenges of the now, keeping them in context.

For those of you who would like to volunteer, please contact Deb Motyl dmotyl@radiusmanagement.com. I would also be happy to speak to anyone about the logistics.

Big Results with Small Investments

As the destructive energy of hurricane Tomas was bearing down on Haiti this past Friday, a confluence of innovative intellectual energy and expertise was converging in Boston to discuss improving surgical care in the global context. I was at the "Role of Surgery in Global Health" program, where I learned more about programs and ideas to increase safe access to surgical services for the world's population. This was not an effort to bring high cost and complex procedures to areas that wouldn't benefit. Rather, it was the recognition that safe, basic, cost effective surgical services are a key component to public health. If you could have just one procedure that would reduce overall mortality in a population, what do you think it would be? Trauma laparotomy? Coronary artery bypass? Appendectomy? Actually, it is the availability of Cesarean section for nonprogressing labor. In addition to reducing maternal and fetal mortality, the incidence of debilitating fistula is reduced. Yet this requires anesthesia and clean operating theaters. We take anesthesia safety for granted in developed country, yet even when I was a child, anesthesia deaths and brain damage were more common due to unrecognized low oxygen saturations. The near universal use of pulse oxygen monitors has increased safety by orders of magnitude. Even though the cost is moderate by US standards ( about $1000), availability is limited in the areas of greatest need. What I learned was of a remarkable group that used business and political savvy to create an organization that would buy monitors in bulk from the manufacturers (who could then provide these at significant discount), and handle worldwide distribution and training. It reinforced my belief that the answer to many of our problems is not by throwing money at it, but by using human capacity for innovation and commitment to reach a goal.


I had more good news yesterday from Milot. The hurricane moved further west and damage was minimal. We are moving forward on our inventory project, the structure is erected, and here again, I've seen how we can bring in technology that will improve care at a moderate and justifiable cost. I'll fill you in on more as I plan another trip to Milot before the end of the year, this time to help with the integration, training, and roll out of the initiative. Thanks also to my classmates and instructors at the School of Public Health, who have provided invaluable insights and perspectives.



All this is in the background of some new directions that I'll be taking. I've appreciated the advice and support from many of you. It's certainly lightened my load and helped me focus on doing good things in the future.

How Much More Can They Take?

Just as things appear to be stabilizing, Haiti is again faced with crisis. The cholera outbreak, and the blunted response from the government again emphasizes the significant challenges in providing even basic needs. Several friends have asked me whether Hospital Sacre Coeur has been affected. From my reports, we have been fortunate that the outbreak is geographically distant. In addition, the proactive work of the local population and CRUDEM has provided improvements in the infrastructure, including water purification and sanitation. If the outbreak reaches us, I have no doubt that we will respond with the same zeal and organization as we always have.

Now we are faced with the prospect of a hurricane, whose track appears to take it over Haiti. I am glad that there will be some advanced warning, and hope that recovery and emergency supplies can be prestaged prior to landfall. As you have heard, the roads are in poor shape, and with extensive deforestation, the risk for mudslides that would limit access is high. Many in Port au Prince still live in tent cities with little protection from the elements. I fear for the outcome, but also realize that this is a country with tremendous resilence.

Susan Cu-Uvin, Professor of OB-Gyn and Medicine, and Director of the Global Health Intiative at Brown, forwarded this recent article, outlining the history of the Haitian government and with some explanation of current challenges. As is common in many struggling countries, the lack of true open elections that would provide a government that has credibility with its people, is a major issue.

http://www.cepr.net/index.php/op-eds-&-columns/op-eds-&-columns/haitis-200-year-economic-earthquake/

All of us have times when we feel overwhelmed, and wonder "How Much More Can We Take?" It is worse when we feel that it is beyond our control. Yet, as the Haitians have shown us, even in dire conditions, the basic human will to survive, and the faith that there is something bigger than us, provides hope and strength. Perhaps it is these types of challenges, as well as our own daily struggles, that teach us how to reach our full potential.

Haiti has been challenged enough. It is time to develop the new paradigm that will allow it to recover and thrive.


...and may it be so for all of us.

Bringing It All Together

They say, “It takes a village to raise a child.” Over the last few weeks I have been fortunate to be part of a worldwide village of committed volunteers that has focused on getting Tania the advanced care she needs to have a chance at a full and rich life. I first told you her story when I was in Milot last month. She is a 23 year old, vibrant woman, who has had multiple recurrences of a benign but locally aggressive chest wall tumor. I knew we were working to get her treatment in the states. Many of the hospitals that had taken the brunt of Haitian patients after the quake were no longer able to provide the levels of care needed. I did an evaluation and medical summary while in Milot and made some calls. So did other volunteers throughout the world. Several weeks ago, she was accepted for treatment at Johns Hopkins. Needless to say, this was very meaningful to me, although I had little to do with the actual application.

The work then truly began. We needed visas and clearance from both the Haitian and the American authorities, transportation, and support when they arrived in Baltimore. Emails and scanned documents traversed the web 24/7. At last count, more than 20 volunteers, many who have never met, were focused on getting her care. The plan was for a private flight from Cap to Fort Lauderdale this past Saturday, followed by a commercial flight today. As of Thursday, the papers had still not been completed in Port au Prince. We were concerned that things would fall apart. But we all had faith, and it worked. Visas were flown from Port au Prince to Cap Haitian. Tania and her mother left yesterday and were flown by Ed and his son to the States. Currently, aboard a Southwest flight to Baltimore, are Tania and her Mom, assisted by the crew who have been briefed and were very happy to help. Tania and her mother will be met by other volunteers and members of the Baltimore Haitian community. She begins her evaluation at JHH Monday morning.


In another confluence of fate, I have just returned from Baltimore, where I have just joined the Hopkins alumni council, as well as continued my work as my medical school class agent. During that time, I saw the commitment of the organization to not only provide world class care and research, but also never forget their mission of increasing access to those in need. Tania’s care will cost Hopkins substantial resources, but it was clearly something they wanted to do. I also had the privilege of meeting many medical students in a career networking symposium, and was able to share perspectives. Not surprisingly, most were committed to volunteer work as part of their careers.



In the lobby of the Dome at Hopkins stands a statue of Jesus. Hopkins is not a faith based institution, and the story of the statue reflects the times of the hospital's opening. Although I am Jewish, I have always felt a sense of spirit when entering the dome. I can only imagine how Tania will feel, 1500 miles away from her home, when she enters this healing place and sees the figure.

I have been doing a lot of self reflection over the last year, as my life and career are taking some new directions. At times I was cynical about peoples’ motivations, but have been refocused by participating in experiences like Tania, and the support of great educational institutions and the next generation.

Not only does it take a village to raise a child, but it takes continued human connection and support to help that child reach full potential at every age.

It's Been a Good Week

It has been a tumultuous and exciting week both on the world scene and within the workings of CRUDEM and Hospital Sacre Coeur. In a previous blogs I spoke of both the trapped Chilean miners as well as a young woman with a recurrent phylloides tumor who I was trying to get transferred to the States for care. Over the last few days, successes have come on both fronts with a combination of teamwork, ingenuity, and self determination.


As I watched the rescue of the miners, I recalled Apollo 13 and the can do attitude that brought those men home from certain death. “Failure is not an option.” And watching a multinational team work together, improvise, and never give up, reinforced my optimism for the future. If there was ever a rebirth, this was it.
At the same time, a smaller miracle was unfolding in Milot. Working with physicians, nurses, the state department, and innumerable volunteers, it appears the Tania will have a chance for a normal life. She isn’t here yet, but a major academic medical center has accepted her for care, Southwest airlines helped coordinate travel for her mother and her, and Ed Constantine, a longtime CRUDEM supporter and pilot will be transporting her out of Haiti after delivering supplies from Florida. Churches, and the local Haitian community will provide support while she is stateside.



As you look on these pictures, see behind the smiles to the joy of new hope and a chance to embrace the future. And hopefully, reenergize yourself to reach your full potential.

Have a great week.

A New Priority

As current reality settles in at HSC, it is clear that the old ways of maintaining inventory and supplies will not jibe with the growing demand and complexity of services provided. I wrote of our difficulties during the immediate post quake period, when truckloads of supplies and equipment would arrive unannounced and a scramble to prioritize and store what we needed ensued. We also found that in many cases, hospitals, despite best intentions, had sent broken, outdated, and inoperative equipment. We also relied on an open barter system with surrounding facilities, without any documentation, but with an eye toward meeting the needs of the patients.



During my most recent visit, I was pleased to see a large concrete slab had been poured next to the mission house. I remember the local men clearing the land by hand and I learned that the pouring itself took place by the wheel barrel well into the night. The results will be the start of a large, computerized and climate controlled warehouse. And as fate would have it, my professional and humanitarian goals would again cross.
As part of my second year at HSPH, I will be working through a practicum - generation a business plan, optimizing an operation, or launching a service line. Given my current career transition, I did not have a home institution, but was welcomed by my colleagues at CRUDEM to join the effort and contribute to the process. Much had been done and a contract developed with Steve Bardos and the Humanitarian Software Foundation, to bring bar coding and inventory control to both the hospital and pharmacy. I am currently coordinating with my advisor an appropriate role in this complex process and will be bringing you new stories of how we will meet the needs of our patients and support the mission of the organization.



So the enclosed pictures may not be as heartwarming as the children I have cared for, but I am thrilled that we will be able to provide an oasis of functioning infrastructure in a country that has so little.

A Taste of Haiti in the City of "Chowdah"

It was grey, 60 degrees and a fine mist was falling over Boston last evening. Not at all like Milot, but Sacre Coeur was on my mind. I had finished my leadership course for the weekend, and stayed in town to support the CRUDEM foundation’s “Taste of Haiti,” being held at the site of “Cheers” on Beacon Street. It would be good to see many others that had volunteered, and perhaps a few familiar faces. Use of the 2nd floor had been donated by the owners, and waiters circulated with plantain appetizers, chicken and coconut, and meatballs, that I was assured were not goat. Corporate donors, many of whom had provided hundreds of thousands of dollars of equipment were acknowledged, and seemed honored to have been given the opportunity to help. I did have a chance to speak with Dr. Peter Kelly, the ophthalmologist who has driven this effort, and had the faith to make me Chief Medical Officer my second day in country. We spoke about the new mission and how to continue the momentum in growth of services. I thanked him again for the experience.

The program was brief and included this video.

http://vimeo.com/14338219

In it, you’ll see many of the patients whose stories I’ve shared with you, including remarkable young people who are regaining their independence thanks to the prosthetics lab. Even though I wasn’t there at the time of filming, every scene reignited emotions, sights, and smells. Around the room were framed paintings from some of the artists that hawked their wares along the street. A photographer who had studied with Ansel Adams had completed hauntingly beautiful black and white prints and a book of the patients, and their families. And we heard that the plans were to continue to support Haitian self sufficiency. The prostheses are now being made by men from Milot, and monthly CME courses have been created for the staff to bring them all up to date on treatment of diabetes, heart disease, and other public health issues. They will be cotaught with local nurses and physicians, and the knowledge base solidified.

As I left into the dark of the Boston night, there were sirens, noise, and restless activity. I got into my car, closed the door and sat for a moment. We are all drawn in different directions, and sometimes fate places you into opportunities that you would not have planned. The last year has been one of new experiences, a recalibration of my priorities, and a great deal of uncertainty. But it has also restored my faith in the inherent goodness of man, that we should lead from the heart, and that each of us has the capacity to transform the world, even as we find ourselves.

Adversity and Leadership

The range of human adaptability to adversity continues to astound me. I have been privileged through my professional life to work with patients who are dealing with debilitating illnesses and lead others by example. My recent trips to Haiti have taught me that one’s attitude to adversity can profoundly affect subsequent recovery. And as I watch the trapped Chilean miners work to ensure their own survival, I am inspired by their pragmatism, optimism, and faith.

This weekend in Boston, we are examining the differences between average and great leadership. Central to great leadership is flexibility, the willingness to challenge the status quo, and the ability to engage others toward a common vision. I can only imagine how the miners have organized themselves and allowed leaders to emerge based on the need at the time. In our own lives, we can lead, or be guided by others; work collaboratively or strike out on our own without guidance. During medical training there is an emphasis on individual accountability and perfection. One of the paradigm shifts that physician leaders find uncomfortable is the ambiguity inherent to the task of leading effectively. We all will make mistakes in our assessment of the situation and deal with adverse outcomes. How we learn to integrate those into our subsequent decisions, and not allow them to undermine our confidence, will be the mark of future success.

I am confident that the miners trapped 2500 feet down will be freed. They will have been active participants in leading each other and determining their future. When you are feeling overwhelmed or helpless in your current situation, look upon the confidence of these men and be reenergized. They will soon see the light of day and be symbolically reborn.

Compassion Fatigue

Katrina…Darfur….Haiti…Tsunamis…Jerry’s Kids…Homeless families…Oppressed women and minorities….

The list is endless and seems to be ever expanding. We are constantly exposed to images and stories of our fellow man who is suffering, and we feel a visceral tug that makes us uncomfortable or sad, energized or determined. As health care providers many of us struggle with the feelings of compassion for the ill and the realities of what we can and should do. With the internet and 24/7 instant global news, how easy is it to become overwhelmed by the suffering, and instead choose to withdraw and shut down.

I heard a new phrase several times this week - “compassion fatigue.” The first was in response to a young woman I saw in Milot with a recurrent fungating, locally invasive phyloides tumor of the breast. It had been excised multiple times, only to recur. She was in the tent, her dressings changed by family and volunteers. At age 23, she was otherwise in perfect health. In the States, she could undergo a wide resection and reconstruction, but the capacity was not available in Haiti. I spoke to several CRUDEM administrators who had arranged transfers of similar patients to several large academic institutions in the US. I filled out a report, took pictures, and made contact. Everyone was sympathetic but the story was the same – we are tired of dealing with the quake victims and others from out of the country that will require a huge outlay of resources, with no ability to pay, even a small amount. Although you could convince administrators and practitioners to give of themselves early in the disaster (and they did), the emotional bank was dry. I had to examine my own motivations as to whether I was doing the right thing even offering the hope of a resection. The jury is still out – I am using some personal connections with other institutions and caregivers that weren’t as involved initially who perhaps still have some emotional reserve.

Compassion fatigue also came up during sermons over the recent Jewish holidays. While we examine our own behaviors and their impact on others, we must also be sensitive to the emotional suffering of our fellow man, even if they have hurt us. Beyond that, in most religions, making amends includes charitable acts as a component of repentance. But with world suffering seemingly enveloping us, how do we feel, and yet not be overwhelmed? And when others are not compassionate toward us, is it because of their unwillingness, or their inability?

I know that as both a surgeon and a parent, I often struggled to let down the clinical barriers when dealing with my family’s illnesses. I remember one of my children showing me a cut and saying, “OK Dad, there’s blood, does it count?” Over the last year, with both my professional transitions and new experiences, I’ve also learned that there are endless opportunities to be compassionate. If you can’t do it all the time, it’s OK, as there are others whose bank is more full than yours. Appreciate the moment, and the satisfaction of relating to another’s suffering and trying to relieve it. Concentrate first on those around you that you love, so that they can be energized and supported. Then do what you can for the world.

And if you feel fatigue, take it as a sign that you’ve truly given of yourself. Rest, recharge, and refill. There’s plenty more to do, and the magnitude and variety of the list gives you endless opportunities.

Milot Managerie

We city dwellers don’t always appreciate the variety of animals that are seen in an agrigarian society. Our meat, eggs, and vegetables come neatly from the store and we seldom see our dinner in the flesh. Not so in Haiti. Animals are ubiquitous, both free ranging and domestic, controlled by a loose understanding of personal property and natural selection.




The chicken population has grown dramatically around the compound and the roosters still don’t understand that they shouldn’t start crowing until dawn. (I quickly adapted, and actually woke up my first night home to car traffic that normally would have been ignored.) My morning run crossed one of the many drainage ditches that also served as dumping grounds; boars rummaged for breakfast. The cows were skinny and grazed freely;
there were multiple donkeys and mules used for portage on the steep slippery slopes. Our local dogs follow us throughout the area, but know enough to stop at the door of the hospital or dining hall. The cats are clueless to boundaries, but seem to keep the mouse population down.


Although Haiti is surrounded by ocean, we had no seafood, and the meat served with dinner was chicken or goat.

Goat! Then I realized that I hadn’t seen our pet, Beeg, who I mentioned in the Passover blog…

Not to worry. As the population in the Mission House drew down, Beeg found a new home over by the machine shop. He has a new lady friend, Mme Bovier, and rumor has it, there’s a little Beeg on the way.




Although sometimes we all have trouble living together as humans, in Milot, the menageries is alive, well, and thriving.

Is There Progress?

The departure lounge at CAP is busy at 7 am. Young men jostle to carry luggage to security (the x ray machine is still not in service) and the bags are searched by hand, slowing the process. There are 5 flights this am – 3 to the States, but unlike in March, there are no other medical volunteers. Although I have picked up a small bit of Creole, I feel like a true foreigner. In some ways, this is comforting – at times, when the relief effort was in full swing, the airport had the feel of an invasion, and I was part of the army. Today, the pace is one of relative normalcy, and the inefficiencies and delays are expected and shrugged off.

The past week has moments that I have felt a great deal of optimism, and other times, frustration. The infrastructure is clearly improving – roads are being paved, there are solar powered streetlights around the hospital and compound, and with potable water, we no longer have piles of empty plastic bottles that were being burned. But at the same time, I saw an unhelmeted motorcyclist hit from behind, thrown from the bike and knocked unconscious. He had an obvious ankle fracture. Peopled emptied out into the street from both the hospital and the compound, and grabbed him by the extremities, without supporting his neck. A stretcher in the back of a pickup arrived, and he was taken to the hospital, but directly to xray. I did what I could to evaluate him, as he had woken up, but there were no vital signs taken, no IVs, and obviously, no way to do a CT. I later learned that numerous ATLS type lectures had been given to the security staff and others, but they clearly had little effect. We took the time to reemphasize stabilizing the neck and running the ABCs before focusing on the obvious fracture. Shortly before that, a young man came in with burns from a homemade still. He was taken outside the ED and numerous buckets of water were poured over him, and he was placed in front of a fan. This is the local standard of care, and we became involved with him, on request, the next day. We debrided and dressed all the wounds. I had rescheduled him for another dressing change in two days. When we called for him, the local nurse told me there were no more dressings, and by the way, he had checked out and returned to Cap.
Once again I was reminded of my role. In Haiti, as well as in the rest of my life, there are things that I can and should change, and others that may be beyond my control. By setting an example that yields good results we can hope that more global improvements may occur.

I was concerned about leaving the patients that I had cared for, as I didn’t know what surgical backup would be available. Then I heard a familiar voice – it was Jerry Bernard, a proud father of a new baby girl, and back to take over the service. He updated me on Rudy, my patient with the pelvic abscess- his ostomy was closed and he is very happy. Several other big cases had made good recoveries, including my little girl with the ovarian tumor. I knew that things, if not perfect, would be OK.



I’m finishing this blog from the Fort Lauderdale crown room. The internet works, there are no mosquitoes, and I’m still smiling from everything, good and bad, that happened last week.

The Jewish New Year and a Haitian Funeral

It is Saturday and the Seattle group returned home this morning. Things were initially quiet, until this evening when a young man was robbed of his motorcycle at “machete-point.” The ensuing disagreement led to quite a few interesting wounds, which were treated by our team in the OR. It is now a little after midnight and I have some time to reflect on the last few days.

Thursday and Friday were Rosh Hashanah, and for a variety of reasons, I am here, as I was on last Pesach. There is one other Jewish volunteer, a woman who came down with the church group from Seattle, but was raised in an Orthodox home, and still tries to be somewhat observant. At our evening meeting, we were asked by the group to share the meaning of the High Holidays and some of the traditions. Several others knew of the apples and honey, but wanted to know of the symbolic writing in the Book of Life. We reflected on the chance to look back on our past year, then forward to the future. The image of God as a stern judge was contrasted with that of a loving and supportive energy giving each of us a chance to reach our full potential. I’ve previously shared with you my own struggles with religion as an entity that tries to control behaviors with both the threat of punishment and the hope of eternal life, after you have died. Although I’ve always felt Catholicism had similar dogma (and the ability to, like Jews, play significantly on guilt), I also have grown to respect the support and striving for personal growth by doing for others. As I gain more perspective in my own life, I appreciate the sense of community as Jews accept responsibility both individually and as a community. “Avenu Malkanu, we have sinned before you…” Some have suggested that instead of striking your heart during the recitation of wrongdoing during “Al Chait,” you are messaging its brokenness and sensing your spirit. For each of us, spirituality comes in different degrees, and different forms – but is the connection to an energy that sustains us.


As I was walking back from the operating room on Friday afternoon, it was 95 with bright sunlight. I noticed several hundred Haitians, dressed in their finest clothes, the men in dark suits with starched white shirts, and the women in beautiful dresses that I last remember on Palm Sunday. Outside the compound was a tall man with a trumpet in a white uniform. There is another, smaller church across from the CRUDEM compound, and people were filling the building and spilling out into the courtyard. I learned that one of the village elders had died and the funeral was beginning. I remained across the street, but could hear gospel style singing, and prayers. The casket was placed into a station wagon and the full band assembled ahead. The drums and brass began a dirge and the procession rolled onto the street. The mourners followed the casket, but I didn’t see a lot of tears – just a community, walking slowly together, accompanying a departed soul to the beginning of the journey. I went back into the compound, but could still here the band. Then a pause, and a familiar tune – Simon and Garfunkle”s “El Condor Pasa.”

I'd rather be a hammer than a nail.
Yes I would.
If I only could,
I surely would.
I'd rather feel the earth beneath my feet,
Yes I would.
If I only could,
I surely would.

Away, I'd rather sail away
Like a swan that's here and gone
A man gets tied up to the ground
He gives the world
Its saddest sound,
Its saddest sound.

Multiple traditions, diffuse beliefs, but at the core a continuous cycle, with moments of self reflection, a commitment to action, and many chances for new beginnings.

The Golden Hour in Milot

I wrote of the “Golden Hour” for photography and painting – just as the sun is rising or setting, casting a golden hue to the surroundings. For me, one of the best ways to get to know a new city is go for a morning run, even get a little lost, and watch the area come alive. We had several ICU nurses join us last night, and some of the Washington group wanted to see the area. We met at 6 am, while there were still shadows in the valley. The rooster had been up since 3 am and was now being answered by his buddies down the road. We turned right out of the compound and headed toward Milot. A few motorcycles were out, with supplies strapped to the back. The smell of charcoal drifted through the air as breakfasts were being prepared. As the dirt turned to cobblestone, we entered the city, with the Church now visible up the hill. Groups of men nodded to acknowledge our presence and went about their morning tasks. As we looked to the mountain range to the south of the city, the sun had illuminated the higher peaks and an outline of the range behind us was cast on the bases. We turned left, cut behind the church and circled up a slippery stone road with a 20% angle. Cows and goats grazed on the grounds around San Souci. As we slowed to a walk, we had climbed about 400 feet and were now standing above the palace, looking over the city, the fog in the valleys, and the ocean beyond. At that moment, the sun rose over the northern range, and we were encompassed by energy and light. Noone spoke.


The run back was down hill. There were areas of new construction, and activity around the hospital was increasing. The local artists were getting set up, ready to offer another “Blue Light Special.” At breakfast, some of the others asked about the run.

“I can’t describe it,” one of the runners said. “You’ll need to experience it for yourself.”

From Generation to Generation

Each generation passes down knowledge to those that follow, and in return learns new things as those teachings are processed, reevaluated, and fed back. Over the last few days, three generations of caretakers are serving at HSC, and the perspectives are melding and creating a stimulating environment.

The pace has clearly slowed and instead of 80-100 volunteers on site, we are fluctuating in the low teens. I am the only doctor this week, given the holidays and return to school. Jerry Bernard, the local Haitian surgeon, had taken a vacation, and cases had been scheduled for me. Arriving at the compound, I was warmly greeted by the CRUDEM volunteers, who heard I was coming. Included were Donna and Sophie. While it is not unusual for parents and children to serve together, this was a grandmother, who attended nursing school in the 50’s and later worked in Ob, and her 26 year old granddaughter, who was a nursing student just starting out. As we had something to eat, each reflected on their own experiences, with Donna remembering dodging flying instruments and starched caps, while Sophie was idealistic, excited, and scared of what she would be asked to do. The rest of the group was primarily from Seattle, with the addition of Phil and Blair a premed and prenursing couple who had met at U Va, and signed on for 10 months, prior to starting school.
Monday afternoon, I did a short case of a soft tissue infection in a diabetic.

There were no translators, and I struggled with my poor French to communicate with the local staff. Although we were able to care for the patient, the process made me concerned about getting through the next day’s schedule. I asked Donna if she would be willing to first assist me, and it turns out that Sophie was fluent in French and was working on her Creole. We did several small cases, then a call came from the emergency ward. A 9 year old was there with an acute abdomen. Concommitantly I looked up, and there was Gilbert Wilkins, a surgery resident from Justinian Hospital in Cap Haitian. It turns out one of the local doctors I met was an attending there and asked in passing, if a surgical resident could observe. I agreed, but didn’t think it would happen. Gilbet had spent time in Canada, and his English and skills were excellent. He saw the child, began the resuscitation, and got her prepped for the OR. I thought it was delayed perforated appendicitis, but when we opened, the appendix was normal, yet there was pus throughout the belly. “Perforated typhoid,” he said quietly, and he located the hole in the ileum, which we fixed. Donna retracted and later admitted she wouldn’t have been able to help me. The Haitian nurse could have, but the language barrier was great.

This morning the child is doing well, and the resident took the bus back from Cap to help with cases today. And is typical for surgery residents, he had a different opinion as to technique and incision placement – and on more than a few occasions, his ideas were better.

In the evening, we meet at 8 pm to review the day. It’s not as structured as when I was here in March, and everyone has a chance to share their feelings and struggles. This was a first time for everyone but me, and they asked how to deal with the degree of suffering and poverty, as well as explaining to others back home what they had seen. I didn’t have any good answers, and tried to share with them some of what I’ve shared with you. But as I looked around, I saw people at various stages of their lives, some with unmitigated enthusiasm and idealism, a few with multiple battle scars, and others who quietly listened and appreciated the moment. What I realized is that each age and each generation has similar goals – self actualization, support of family and friends, and the need to make a difference. And each of us, based on the history of the time, made decisions that reflected those needs. Today 3 generations with disparate histories, experiences, and hopes gathered in a small hospital in the north of Haiti, and synergized each other to do far more than we could alone.

Not quite as good a plot of dysfunction as you see on most of the TV series on Fox…