In Search of Normal

I'm not sure I know what normal is anymore. Sure, I've done statistics and know that in a poulation, you define the mean and standard deviation. 2 SD on either side is abnormal, even though many of these people in the 5% are not really different. In my practice back home, I've spent time, money, and created anxiety persuing "abnormal" results in normal patients. Sometimes we hurt them in the process. Since I've been here, my understanding of normal has been expanded. Healthy functional people have blood counts half of what we see in the western world. They respond to pain and other interventions differently. And it made me appreciate the extremely broad limits of human physiology and experience.

On my second day here, I operated on Mr. M, who had a bowel obstruction. I found a sigmoid cancer, a common condition in the states. The OR was filled by Haitian physicians and nurses who had never seen one. Normally, we would do an ostomy, but there are limited supplies, and patients with ostomies are ostracized. On the basis of advice from other surgeon who had worked here, I did a segmental resection and put the ends together. Mr. M stayed in our ICU (the equivalent of a medical floor elsewhere). Over time, he began to eat, have bowel movements, and was off antibiotics. His abdomen remained distended, but not tender. I obtained an X ray, which showed what appeared to be a massively dilated loop of bowel, suggestive of partial intermittent obstruction. His white blood count was normal, and yesterday morning, when I saw him, he was standing up, his wife bathing him. I was still uncomfortable and after consultation with another surgeon from Duke, felt we should reexplore him. It was a good thing we did. He had a massive pelvic abscess, and a leak. We washed him out, put in drains, and gave him a colostomy, recognizing he would stay in the hospital 8 weeks until it was closed.

Normally, you would give this type of patient large amounts of fluids, and keep him on a ventilator for several days. We had just found a ventilator when we worked through the supplies. Oxygen tanks were limited, but we all agreed to ventilate him overnight for the best chance of breathing normally. Fluids were restricted as long as he was making some urine. Oxygen was conserved to keep his saturations at 90%, rather than 100%. I was called at 230 am. The ventilator had failed. I went over, saw that he was awake, and realized we had little choice. I extubated him. In the States, after 10 liters of fluid, the patient would have not be able to breathe and would have died. Mr. M sailed. This morning he is up in a chair, asking for food. He's not out of the woods, but clearly has plans to stay around for a while.

In the compound, they are building a house for the hospital director. There are no backhoes, power equipment, or prefab trusses. Using axes, hand saws, wedges, and simple tools, they cleared the lot, dug out the stump, and cut the lumber on site. Unlike the situation we would be used to, there weren't 3 supervisors for every worker. Men helped each other out, and from what I could tell, took great pride in their work. This is normal for Milot.

Garrison Keillor, speaks wistfully of Lake Woebegone, where "all the children are above average." In my own life, despite many achievements, I have often wondered if how I felt or the decisions I made were normal. We ostracize others as abnormal and cast our own values to try to define societies and groups without a full appreciation of their experiences. By not trying to categorize things into normal or abnormal, I have become more open to basing decisions on what I realize is right or wrong, taking into account those around me. After Haiti,I will never look at outliers in the same way.

And remember the little girl with the large tumor? She was discharged yesterday. The postoperative course was normal.

Passover in a Land of Freed Slaves

Tonight, Jews around the world gather for Sedar. They eat, drink, laugh and retell the story of our escape from slavery in Egypt to freedom. It is one of my favorite holidays. Leslie, Rachel, and I would drive from Providence to Hartford to be with David, who had hosted ecclectic Sedars since we were all together in Rochester. When Ben and Adam were still on the East Coast, they would join us with Janine and Sarah. I would look around the room and feel a connection with the past, and seeing our children, the future.

Tonight, they are scattered around the country, and I am contemplating the meaning of freedom as I sit in a country founded by slaves who cast off French rule, and tried to live and prosper. Unfortunately, Haiti continues to struggle with poverty, class divisions, and tragedy. I tried to understand differences with the relative success of the Jewish people. Some is our time in history, some is the climate, and others may be intangible. Economics certainly played a part. Although the Haitians drove out the French, they agreed to a large repayment which crippled them for years. The ruling class was not the African blacks, but the Mullatos - and as I've noted before, the class divisions are obvious. Then again, since it was several thousand years before the Jews could have a successful homeland, Haiti still has time.

This is clearly not about belief. The Haitians are sustained by their faith in God. CRUDEM is a Catholic foundation associated with the order of Malta. Although it is clearly a spiritual place, noone asks your beliefs. Those who wish to go to mass, can do so. We are here for the patients, and for each other.

I was sitting outside on the porch this morning having coffee with the Board representative, talking about our experiences and beliefs. I mentioned I was Jewish, and we talked about the meaning of Passover and Easter.

It was a busy day, and when I got home, I took out the Matzoh we bought before I left. The warm sunlight was just fading, signaling the start of Passover. There was no wine, so rum and orange juice would have to do. We have spicy dressing with onions, peanut butter would be the charosetz, and I had a salad for greens. I couldn't bring myself to go after our pet goat for the rest.... As I sat in my room, said kiddush and made a peanut butter, onion, and matzoh sandwich, I felt incredibly lucky to have this experience.

The Board Member grabbed me before the nightly meeting that I lead. He asked if I'd be comfortable sharing my feelings about Passover with the group. I agreed.

We went through our usual routine of introductions, housekeeping, and logistics. At the end of the meeting I run an open forum of what went wrong, congratulatory shout outs, and what went right. We always try to finish on a positive note. When every was done, I took a breath and began speaking to the 60 people, many of whom I had known only a few days.

" I'd like to take off my CMO hat for a moment and talk to you about some reflections today..." I spoke of the meaning of Passover in the Judao-Christian context. The fact that I had agreed to come, before realizing it was Passover, and that my family nonetheless supported me. My voice cracked a bit as I described Sedar with friends...and as I spoke of the analogies between the Jews and the people of Haiti. I desribed the dietary restrictions, indicating that my normal happy hour beers on the porch would need to be replaced by rum and coke. I thanked the group for what they are doing and for creating an environment where we all felt safe. I closed with the meaning of "L'sahana habaha b' Yersushayim"

At that point, I swallowed hard and dried my eyes, and wished everyone a good night.

I walked back up to the porch, to compose this blog. Pat, a big, loquacious Viet Nam vet walked up to me. "Hey Doc, you'll need this."

It was a bottle of rum.

Sitting at David's last year, I never imagined when I said "Next Year in Jerusalem," that I would be in Milot, Haiti. Alot is going on, and I don't know where I'll be next year. But for the rest of my life, when I mutter those words, I will remember the taste of peanut butter and onion on a Matzoh, and the sound of the crickets on a humid night in a land founded by freed slaves.

Going Home, Moving On

There was a clear sense of increased energy around the compound this morning. Not only was it Palm Sunday, but 23 earthquake victims were going home, and some degree of normalcy was slowly returning to Hospital Sacre Coeur.

The hospital was originally conceived to serve the population of Milot and the surrounding towns toward Cap Haitian. Care is on a fee for service basis, and families are responsible for daily care, including feeding their loved ones. They stay in the main hospital, and vendors position themselves at the entrance, selling drinks and meals. The hospital rates are $5 /day, but that is still difficult for many Haitians. You cannot have elective surgery or be discharged until you pay. Across the street, in the tents, by law the patients cannot be charged, and since many are without family, food is provided. There is running water for washing in the central courtyard. Needless to say, there is some quiet tension between the local population and the quake victims. The victims themselves are anxious to return to Port au Prince, and the local hospital staff, though wishing to help their countrymen, tended to be more responsive to their neighbors.

So there was mutual relief and a celebration when the brightly colored buses pulled up to the gate. All the patients were given a letter stating that their care was free and they were medically stable. Not all of them were fully ambulatory, and some would ideally have some revisions – but that could be figured out closer to home. The equivalent of the Red Cross provided basic hygiene packs, extra suitcases from Crudem volunteers were donated to pack, and the process began. We needed 3 buses for 23 patients, because many had family, walkers, and crutches. It took a couple of hours, but they eventually rumbled down the road to return to familiar surroundings, and try to rebuild.

Last night, I met with the hospital director, and we went through the census, both of the tents and the main hospital. “It is time to put the quake behind us, and get back to work.” He had completed renovation of a bright pediatrics ward, complete with a separate NICU, in anticipation of CRUDEM volunteers coming in a month to train the Haitian staff on neonatology. We would be able to get some of the children out of the tents and into the hospital. The remaining quake victims will have more room, and resources, such as bottled water, would be less strained. Consolidation of services, proximity of production to consumption, payor mix - all the issues I’ve been studying this year in Boston, were here in Milot.

Part of getting back to work, meant seeing the pent up demand by the local community for surgical services. So this morning we had clinic. By 830, over 130 patients were milling around the courtyard. We had three new surgeons arrive, and everybody took an exam room. The majority of the cases were straightforward - hydroceoles, hernias, breast masses, and the occasional gallstone. The younger surgeons asked if I could help them on that one, since it would have to be done the “old” way – open. The Haitians also want every lump and bump removed – not because of fear of cancer, but rather due to cultural mores I don’t completely understand. Evaluation and booking took 3-5 minutes. By the end of clinic, we had scheduled 6 cases in each of 2 rooms for each day. We still have the 3rd room for ortho and other quake related surgery. I’ll be playing traffic cop as well as surgeon this week.

I did have a chance to walk to Milot and experience my first Palm Sunday mass. People were dressed in their best and a few came into the church early to get a good seat. I only took one picture before the service to give you a sense of the naturally lit sanctuary. The band backing up the choir had drums, electric guitars, and a sole trumpeter who was warming up. I didn’t expect to recognize anything as the tunes had a definite island flavor. Then I heard the notes of “Amazing Grace.” It was only the first few bars, and I found myself again reflecting on the universality of the human experience. The noise outside increased, the bells began to ring, and suddenly the church was overwhelmed by families from the procession, carrying palms, and rapidly filling the pews. After a moment of quiet, the doors reopened and the priests and alter boys entered. I watched as the incense was lighted and placed around the alter. Words that were clearly Latin were uttered, and the congregation broke into Creole song. Here I was, a white Jewish kid from Ohio, being filled with a sense of hope and energy, just by being with my fellow man in their moment of community and prayer
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I started back shortly thereafter. It was cloudy and cooler today. As I was walking down the shaded cobblestone streets of Milot, my radio crackled. “Dr. Sax, Dr. Barnard (the local Haitian surgeon) is starting his incarcerated hernia in room 2. He’d like your help.”

I smiled at the thought of a straightforward general surgery case. It is time to get back to work, and for the people of Haiti, to some degree of a normal life.

Somehow it Works

"Hire for attitude, train for aptitude" Southwest Airlines is a study a corporate culture. I've been here 10 days, and have watched at least 100 people come and go at various points during the week. Fortunately, we usually have overlap, but Saturday and Sunday have major turnover.

Yet somehow it all works. People arrive here and their first words are "What can I do to help?" I watched a nurse who has been traveling for 12 hours, take night call in the ICU after an hour nap. Surgeons and anesthesiologists have strong personalities. In all my time here, I have yet to hear a raised voiced, and delays are taken with a shrug - "It's Haiti." Now I acknowledge that people who volunteer for this type of mission self select. I also realize that a culture has been created here that allows easy transitions, even for a first timer like me. At my nightly staff meetings I try to reinforce the culture through my words, and during the day, my actions. In my previous leadership roles, I found myself sometimes frustrated that I couldn't get people to do what I needed them to. I tried to manipulate them. What I'm realizing is that a leader must support and create the culture. Social mores then should drive the rest, as well as identify outliers.

I am in a transition phase in my life and my career. I teach patient safety, citing the airlines and the culture of safety. I couldn't put my finger on what it takes to create that environment. I'm still not sure, but I'm going to be watching carefully how they do it here, over the next week.

I'm going to have alot of things to do and decisions to make when I get home. And having been enlightened by lessons of Milot, I think I can do them better.

Three Stories One Theme

I didn't post yesterday - I was given a day off and went with a group to the beach. Didn't know what to expect, but I was open to a new experience.

We needed to get from Milot to Cap Haitian, then from Cap over the coastal range to the beach. You don't just grab a cab or car service. We took the "tap tap" (a bus named because you bang on the side when you want to get out.) The ride was bone jarring, but gave us a chance to see the world from a local point of view. The bus wound to a stop along a narrow street at the cab stand. There were 20 young men on 125 cc motorcycles. No helmets, no meter, just a negotiation for the ride, $6. This would never happen in America, but what was my alternative? The bus is gone, and I've seen these guys all over the place, balancing boards of lumber, food, even their families on the bike. They must know what they were doing... I hopped on back and we fired up a dirt road through town. As I relaxed, I began to feel sensations that previously would have been blocked by fear. I smelled the crops, food cooking and the road beneath us. I instinctively leaned with the driver into the turns, and as we crested the hill, the ocean laid out 400 feet below us. He cut the engine, and we coasted down the hill, the the sun angling through the trees. When we arrived, I could still feel the vibrations. There was no sense of relief, I couldn't wait for the trip back.



Joseph lost his entire family in the quake. He was with us for a while, and then was taken in by one of the vendors on the street. He supposedly had family in the States, but no way to leave the country, as he had just turned 18 - the age at which you can get a passport. Several of our longer term physical therapists knew Joseph when he was an inpatient, and maintained contact with him. He was also friends with Patrick, our guide and interpreter for the beach trip. We asked him to come along. He was quiet and introverted when we got there. The other therapists convinced him to swim in the ocean, but he only had his underwear. He went in anyway and seemed embarrassed around the women. I gave him a spare set of shorts. He wouldn't eat when we had lunch. The bike ride back was every bit as exhilarating and it appeared we would ride all the way back to Milot, as the bus was nowhere to be found. We didn't take the normal route, but stopped at a small office- passport photos. His paperwork had just come through, thanks in part to our therapists, and all he needed was a picture. We watched as he posed, the first real smile I saw all day. His expression leaving the office and on the ride home says it all.



When I returned, they were looking for me. A 4 year old had been admitted with an enlarging abdomenal mass. Our imaging is limited to ultrasound and simple xrays. She was beautiful, with a massively distended abdomen. I felt a large mass with both solid and cystic components. The differentials ran through my mind. Our only choice was to explore her, at least for diagnosis, with hopes of cure. I spoke to the mother through an interpreter. I told her I wasn't sure I knew what it was. She looked at me for a moment. "Jesus knows," she said. This morning we gathered in OR 1. I was fortunate that an Ob/Gyn team was here and scrubbed with me. I hadn't done pediatric surgery in years, but the basic concepts of any procedure are the same. I made a small incision, high in the abdomen, in the only clear space I could find. We entered and gradually worked inferiorly. I slipped in my hand and the mass, was smooth and mobile. Clearly benign. Over the next hour, we did a right oophorectomy and appendectomy. Her other ovary is fine. I won't post the pictures, but the curious of you can ask to see the teratoma, complete with teeth and hair. I just returned from the unit. She is awake and playing with one of the nurse's I phone.

What do these three incidents have in common? I realized that I experienced faith. Growing up, I always felt that organized religion was a series of rules that were designed and meted out by a paternalistic deity. You must have faith in this power or bad things would happen. What I am growing to realize is that faith is what takes care of the things for which you have no control. Once I relaxed and handed control to my driver, I experienced a remarkable ride. Joseph must have had faith to keep going after the quake and to believe that one day he would get the passport and the chance to move to a new life. My patient's mother had faith in God, and at least acknowledged that I would do my best. And I had faith that by working with my colleagues, doing what I could, and recognizing that other things were beyond my control, I could live with whatever I found or did.

I was raised in an observant Jewish household, but I didn’t have faith. I tried to follow the rules, and things still didn’t seem to work out. As a surgeon, it is hard not to feel you should control everything and everybody around you (for the patient, of course) – you can’t. And in our own lives, we sometimes try to juggle multiple story lines because we don’t have faith in the present or the future. What I learned is that faith is universal and you don’t need a religious leader to tell you how to get it.

Motorcycles, passport pictures, and teratomas – in every experience is a lesson, even on your day off.

The Citadel

Twenty thousand people died building a fort from which a shot has never been fired in anger.

It rained heavily again last night, but the sky was clearing by dawn. Fog shrouded the tops of the mountain range that borders the southern edge of Milot. Atop that mountain, 3000 feet above the surrounding valleys, and with a view of the ocean 20 miles distant, stands the Citadel. We left at 7 am for the 7 mile drive up a winding road. A few of the more hardy souls among us, including Jackie and Jono, felt it would be a nice brisk walk and left earlier. As we bounced out of town, we passed the remains of the royal palace, which was destroyed by an earthquake in 1847. Several miles up, large numbers of school children in uniform were walking toward us. I didn’t recall seeing a school nearby, and was told that they were walking to Milot, a trip of an hour each way. People were bathing and doing laundry at public fountains, primarily served by cisterns that catch the rainwater from higher in the mountain. Our guide, Michel, was born in the village below the Citadel, where the road ended in a dirt lot. We were immediately surrounded by locals, offering to be our guides, sell us artwork, or give us horse rides the rest of the way. We could see the fort another 1000 feet up and three quarters of a mile away.

As we climbed, Michel told us the story of the Citadel. The Haitians drove the French out of the country in slightly over 2 years, ending around 1805. King Christophe from Grenada was to lead the people. The palace was built in Milot, but it was not defendable from an attack, should the French wish to reoccupy. The king chose to build a fortress on the highest point possible and began work. Over the next 15 years, a human chain of workers brought bricks, captured cannons, ammunition, metal bars, and other materials up the mountain. A caldron was built to render animal carcasses for a gelatin like material that served as mortar. The Citadel was finally completed, and cannon shots rang out across the valleys both to celebrate and as a warning.

The scale of the fortress cannot be captured by pictures. A system for water, multiple cannon batteries, toilets that empty to the valley 1500 feet below, and royal bedroom designed to be ventilated by the prevailing winds were all there. Yet they were never used. King Christophe suffered a stroke after an argument with a priest (some say he was struck down by God), and subsequently committed suicide. His body was brought to the grounds and secretly buried. Subsequent rulers chose to be closer to the population.

Yet there was something more concerning as I toured. Much of the compound was dedicated to prisons – not for combatants, but for slave workers who were deemed to be lazy. So a country founded by freed slaves, enslavened some of its own people, forcing them to work and to die for the perceived good of a larger society.

Whenever humans live together, hierarchies form. In many cases it is important to have a leadership structure, to provide the most good to largest number of people. But I couldn’t help but wonder how these form. Is it the random chance of your birth parents? Is it truly your abilities? Even today, at Sacre Coeur, there is the clear understanding that certain groups will get paid jobs, and others won’t. Although we in America claim that “All men are created equal,” our actions have not lived up to that ideal. In moments of fatigue and frustration, I catch myself in stereotyping. Being surrounded by Haitians asking for money or trying to sell me “local” products made in China made me uncomfortable. Then I saw their living conditions, and recognized how they were viewed by the more connected of their countrymen. And I realized that they were fathers and mothers, brothers and sisters, children and friends finding whatever way they could to survive and pass on something to the next generation. So I bargained for some artwork, and took a chance by buying 2 freshly fried empanadas. They were delicious.

And as we got into the truck for the trip down the mountain, the fog lifted and sunlight reflected off the puddles from the rain.

The Supply Chain

Be careful what you wish for.

The outpouring of donations to the Haitian people after the quake was tremendous. Add to that ongoing support of existing humanitarian programs, and the volume can overwhelm even a reasonably sophisticated infrastructure. So it is here in Milot at the CRUDEM compound.
Over the last three months, we have received supplies at an unprecedented rate. Our staff works tirelessly to store it out of the rain, in makeshift tents, and existing buildings. Because the supplies are medical in nature, you need someone with a surgical background to aid in sorting and prioritizing the inventory.

As the CMO, the task fell to me.

Because the facility also holds the stockroom for the hospital pharmacy, access is limited and the only key is in the possession of a hospital pharmacist. After a bit of negotiation, we gained access. The pictures tell the story. Our volunteers took hundreds of boxes outside into the bright sunlight and tried to organize them in some reasonable fashion. As the boxes came out, thousands of dollars of equipment came into view. The ICU has no built in oxygen. Loose tanks are available, but limited and we had several patients in need of oxygen. We found three oxygen generators under the boxes of drapes.
I actually did find several neatly labeled pallets with 40 large boxes, taking up about 250 square feet of floor space (the picture shows just three to give you an idea of the size). I was excited to think what must be inside – it was Prozac. Now I’m all for pharmacological support of those suffering from trauma and depression. But based on our local population, we could dose everyone for several decades.
The experience made me reflect on my own response to seeing suffering in distant lands. You want to do something, and sending money is easy, but seems hollow. Gathering supplies at your hospital, labeling, packing, and shipping is tangible, and done properly, is important. The key is to make sure that what you are sending is truly needed. Easier said, then done.
So today’s blog isn’t about patients, but about what it takes to have the means to care for them. Sometimes in the midst of plenty, you don’t have what you need – but every once in a while, when you’re doing something else, you’re wishes are answered.

Dance Fever

You’ve survived one of the most devastating earthquakes in human history. After being buried in the rubble, you are rescued, placed in a helicopter, and flown 100 miles from home to a city you’ve never seen. Due to the extent of your injuries, you undergo multiple surgeries, eventually require an amputation, and live in a tent with temperatures exceeding 90 degrees. It’s now two months later, your home in Port au Prince is destroyed, you don’t yet have prosthesis, it hurts to move….and you’re 7 years old. What would you do?
If you’re a patient in the earthquake ward at the Sacre Coeur Hospital in Milot, and it’s 3pm, you have a dance party.
I’ve sent you pictures of the tents set up across the road from the main hospital. Each holds 30-40 patients, and some family members. Tent 2 is dedicated to pediatrics. Additional patients are in the pediatric nutrition center next door.
A company has donated an interlocking plastic floor to place over the rocks and mud. They have fashioned a patio, complete with lounge chairs, outside of tent 5. A covered DJ booth sits at the entrance. Patients and their families congregate, and enjoy the breeze that will filter through the compound. Around 2:30, the music starts, complete with Milot’s own version of Tupac. Rap, creole music, and the occasional American tune fill the air. Benches are set up, and adults in wheelchairs jockey for position. Because it’s Haiti, the party never starts right at three. But the children begin their parade – those on crutches, a few on stretchers, a good number that can move on their own. They gather to dance. Nurses and physicians join in, family members clap, and for a brief and wonderful moment, there is no pain, no concerns about the future, just the universal experience of being caught up in the music. Kids who grimaced during physical therapy, moved their extremities.
What I saw today was the human spirit. It would easy to say that as Americans, we are spoiled, and expect life to be fair and easy. We all experience adversity differently. I recognized that the human condition transcends color, money, status, or even life expectancy. To find the joy in the face of sorrow, to dance when it hurts to move, to smile when you should be crying; that is what we call resilience. And in my eyes, if you looked up resilience in the dictionary, you would see a picture of the Haitian people.

The New Millenials

Part of this experience is the people I meet. Their energy brings light to what could be a dark time. It helps me focus on my life and the future.

I’ve been involved in medical education my whole career; I’m also a boomer whose own children are now coming of age. We hear a lot about the “Millennial Generation” – young adults, raised by overindulgent boomers, who need constant reinforcement, and are unwilling to make long term commitments. My fellow attendings bemoan how training has changed to adapt to these students, and that this generation can’t see beyond their own sphere.

And then I met Jackie and Jono, Jen and Nick.

Jackie and Jono (left) are third year students at Mount Sinai and NYU respectively. They met during college at Middlebury; Jackie had always planned to go straight to med school and Jono,after reflection, also found that it resonated with him. Although Jackie’s dad was a neurosurgeon, she never felt pressured. Jono learned of CRUDEM through a surgery attending who was involved in international health, although he had no experience in overseas medical work. Without a second thought, they committed to two weeks. When they arrived last week, we were short on physicians to cover the 30-40 patients in each tent. The two of them stepped up to the plate, and within two days, had organized tent 5, coordinated with the Haitian medical staff, and appropriately consulted for specialty needs. This was the first time they had worked this closely together and when asked, admitted that their mutually strong personalities provided a few challenges. In the next breath, they also smiled at each other and said it was good for the relationship.
Jen and Nick are residents at Washington University in St Louis. They met at medical school when he was the medical student on Peds and she was a 4th year JI. He wouldn’t ask her out, thinking she was a resident. She asked him. “Sometimes you have to take charge.” He clearly got the message and when he was given the opportunity to make this trip, made sure to ask her to come. It may have helped that she was in a lab year, having switched from surgery to peds. I met them Friday, assigned Jen to the OR and Nick to lead a tent. Over the weekend, they each took a tent. When one was done, they sought out the other to help with dressings or medications. This was their first vacation as an engaged couple. Instead of a week in a beachside cabana, they were in a 4 person room, with only a fan, sleeping on cots, sharing a bathroom with 10 other people… and they were having a great time.
So what does this have to do with the future?
Humans, and the societies they form, cycle from times of plenty to times of challenges, from moments of dependency to increased self reliance, from seeking external recognition to finding the joy in the human experience. The stereotypes of the millennials likely reflect our own discomfort with how we raised them. We talked about all the trophies given at events, as this generation grew up. Jackie stopped me and swept her arm around the room. “This is my trophy.”
As I grow older and transition from being a healthcare provider to a healthcare consumer, I admit that I had concerns about the future of medicine…

And then I met Jackie and Jono, Jen and Nick.

Why we're here

We've had rain the last 2 days. Electricity and internet were down. We were lucky that a volunteer arrived from the University of Arkansas who was an engineer. He go us back up and is the most popular man in the compound.

It’s about a 200 yard walk from the compound to the hospital along the main road to Milot. The bus stop for the school is just outside our gate. I was walking over this morning, and my mind was preoccupied with the cases ahead of me and other thoughts. There was a fair amount of sunlight, and I noticed I had a shadow. “Bon jour monsieur doctor” he said. Andre walked with me on his way to school. In my poor French, I tried to learn more about him. He was from the area and wanted to go to school and learn so he could one day support his family. I said little and just walked beside him. As I turned into the hospital he shook my hand. “Au revior monsieur.”
The hardest part of this work is recognizing, that we cannot, nor should we do everything for those we meet. The Haitian people are strong and proud. They have asset of beliefs that are both pragmatic and spiritual. I watched as my colleagues resuscitated a premature infant with respiratory distress and likely anoxic brain damage after meconium aspiration. There are no ventilators, and even if there were, there was no aftercare. The child was extubated and died after being held by her father. The Haitians seem to accept this with grace and faith.
They are among the most stoic patients I have met. Ibuprophen is used for most postoperative pain. Morphine is given for major fractures or laparotomies, however the dosages are small. They are always grateful for whatever we do, yet they also want to learn to do things for themselves. We are in the difficult position of not swooping down to the rescue, as it would not allow the local medical teams to care for their countrymen.
My hope is that the people of Haiti continue to rise from their adversity and face the future with strength and independence. If we can help them, without creating dependency, then we have done what we can.

Day 2 The magnitude is sinking in

I had a restless night. Lots of roosters as well as noise from the tent city. Did manage to get a run into the city - some beautiful old castle ruins and areas of building.

The hospital has set up a tent city for the earthquake overflows, as well as general surgical cases that have backed up from after the earthquake.

I'm enclosing some pictures from outside the hospital as well as our OR and the ICU.

I've done 3 cases already this am with 4 more therafter. Intersting way to verify site and side. Reexamine the patient prior to the or.

Best to everyone in the states.

In country

Have hit the ground running. Met a team from Union Memorial in Baltimore at the airport and flew in with them The airport has a single runway, no instrument approach and small operations building. We saw several traffic accident on route as there are many scooters and nobady follows any rules. The poverty is everywhere, yet it is interspersed with great beauty.

When I got here, I ran into three surgeons I knew from Rochester, and did a case. Lots of advanced cancers, and old fractures.

My current housing is a tent - hope to move into the doctors quarters on Saturday. I've been asked to serve as the medical director for the hospital, once they found out about my management experience. Not sure wat that entails.

We only have ine compute her on the deck, and others want to get on. We have about 60 volunteers - all wonderful folks.

Time for dinner and evening rounds...

Thanks for the support

Heading out

The trip down will take 2 days. The hospital is served by the Northern airport of Cap Haiten. Service is 4/week in the morning. I'll go to Fort Lauderdale today and stay with my brother, Drew. Should be in country by 1230 tomorrow.
Packing is unusual - we wear scrubs 24/7 and there is no personal laundry, so the main items are socks and underwear. My backpack and suitcase look like something from Fear and Loathing - stuffed with donated drugs and medical paraphernalia. Should be interesting going through security.