Shared Experiences

If you were given $10,000 and told it could be used for an object, or an experience, what would you do? Let’s assume basic needs are met, the roof isn’t leaking, and you’re paying your bills. If it were me, I’d choose the experience.

In my last blog, we discussed working toward self actualization, an intangible state. It’s that sense of being fulfilled, by who you are and what you are able to feel. When I reflect on Haiti, my greatest memories are the shared experiences with my colleagues, patients, and the citizens of Milot. I did not bring back many things, and the art that I did is of no practical value, yet ties me to what I felt there. Facebook has remained an active source of continued connection with others who have been to Milot, even those that I haven’t met. We are drawn from many cultures and countries. We have a commonality of what we saw and did, that synergizes the human connection.

For many people, going through difficult times together forms an indelible bond – think about military boot camp, residencies, apprenticeships, challenges in the workplace and in relationships. Afterward, we hopefully can see the positives of those times and look for ways to integrate those into our present and future.

I like to travel, see new sites, and take in new sensations. I now understand why people want to show you pictures from their vacations- it is to both recapture their joy and to try to share it with others. I always seem to appreciate vacation slideshows more if I’ve been to the area, or done something similar.

I am drawn to return to Haiti, but not only for the people of Milot. The sense of purpose, and the feeling of fulfillment by the experience is worth the monetary cost of the time and travel.

What’s remarkable about our minds is that we can take ourselves back to relive pleasant feelings. For me it can be the first sip of a cocktail, the sound of a Pratt radial engine, a song, or pictures of friends, coworkers, and family. We can also catch ourselves focusing the inevitable negatives of other experiences, and let that dominate and control us. I prefer the former, and acknowledge the latter.

Nobody has handed me $10,000 yet, but I'm already working on the itinerary....

Preparedness and Basic Needs

Since the earthquake that devastated Port au Prince, 2 other significant quakes have hit Chile and the Quinghai region of China. In both cases, the magnitudes, at 8.8 and 7.1, were greater than the 7.0 magnitude in Haiti. Yet the destruction and need for international aid was far less. Although a component is population density, the key issue is the preparedness of the countries' governments to respond to these crises. Chile has strict building codes and practices emergency procedures for such a scenario. China, despite its critics, has an extremely well organized military that can respond to events throughout the country. Haiti, with its inherent poverty and ineffective government, was in no position to anticipate the extent of a disaster like this, nor respond. History has taught Haiti the powerful effects of nature. The beautiful Palace San Souci, in Milot, on the way to the Citadel, was severely damaged by an earthquake in 1842 and never rebuilt. Debris was salvaged for other immediate needs. Numerous hurricanes have battered the island and killed many as their poorly constructed homes were consumed by mudslides. Is the situation hopeless, or can Haiti prepare, in some small way, to deal with natural disasters?

When examining a society, one must look at how well individual needs are met. Maslow’s pyramid lays a basis that physiology and safety must exist, before any other personal growth can occur. This can be extended to a country, where as it is able to meet the needs of its people, it can then branch out to the community of nations, gaining esteem, and the respect for and of others. It will also have the time, energy and resources to prepare for emergencies. It will take some time for the infrastructure and economy of Haiti to stabilize and grow. At a basic level, however, the government must find a way, perhaps working with its neighbors, to assure their citizens that they are safe. The UN is clearly playing a role and it is likely that their presence will be required for many years. It is still unclear to me how the response to this disaster will be different, but it must.

In more developed countries, we tend to focus on the higher parts of Maslow’s pyramid that we lack, until we see our fellow man struggling with survival. As a world community, we must figure out the best way to build a solid Maslow base for the Haitian people, or they are destined to repeated tragedy. But they will survive. After all, Palace Sans Souci did not completely crumble; its inherent residual strength is a symbol for Haiti.

Past Performance Doesn't Guarantee Future Results

“So we beat on, boats against the current, borne back ceaselessly into the past.” The closing lines of Fitzgerald’s The Great Gatsby, capture not only Nick’s despair at Daisy’s choice of Tom, but also the central human spirit of the relentless toil to reach a goal, despite multiple obstacles. In the 2 weeks since my return from Milot, I continue to have dreams about what I saw and the sense of unfinished business. At the same time, I have been asked by others what I think about the future of Haiti. And, as I’ve noted in previous blogs, personal experiences seem to reinforce a common theme.
This is a pivotal point in Haiti’s future. The old way of doing business has clearly failed, yet it has not dampened the spirit of the Haitians. The two basics for a successful society are a functioning infrastructure and a government that commits to the support of its people. The quake, and its aftermath have focused the world on Haiti. Aid will pour in, and it must be used to rebuild in a well thought out and controlled manner. Although the US and other countries can provide materials and money, they must not dictate. Other successful Caribbean neighbors, such as the Dominican Republic, the Virgin Islands, even Cuba, have a far better feel for the culture, needs, and local challenges of the region. Health care is in a shambles, not just physically, but functionally. Given the high incidence of AIDS and other infectious diseases, as well as general poor hygiene, the population is often unable to care for itself and each other. The relative success of Sacre Coeur in Milot is that it is privately supported, and not dependent on Port au Prince. As investment in Haiti increases, there will be opportunities to redesign an effective system, assuming governmental buy in and commitment to new paradigms.
Haiti was at one time the queen jewel of the Caribbean. It has great beauty, but its other decisions have kept this asset from being fully realized. The pictures are of the same beach. The top one could be in any travel magazine, the one below is looking 10 feet inland, where all the garbage, tossed into the open sewers of Cap Haitian has washed back ashore. All of our decisions have broad implications.
I went back to Canton, Ohio this past weekend to celebrate my Uncle’s 90 th birthday. Canton was a steel town about an hour south of Cleveland. When I grew up there, I couldn’t wait to leave and never look back. I felt it was conservative (red suit notwithstanding), I wasn’t overly happy, and I was sure that there was something better “out there.” My return trips have primarily been for an occasional class reunion, or a funeral. In the mean time, I’ve lived in Chicago, Baltimore, Cincinnati, Rochester, and now Providence. In each city, I’ve made friends and professional acquaintances, later on raised a family, and tried to figure out what the future would look like. I looked at my past, at missed opportunities, and at my decisions, and felt they would define my future. But what I have realized is that while we are influenced by our past, it is when we are able to let it go and gain energy from the present that we will be empowered to row toward the future. Haiti is at a similar place in its history.

In every prospectus is the warning that past performance does not guarantee future results. Yet, during my courses in Boston, we learned about behavioral interviewing, where, in general, past behaviors predict future actions. But the key in both statements is that nothing is etched in stone. For the people of Haiti to succeed, they must acknowledge the mistakes of the past, but at the same time use this opportunity to commit to a new course of action. And for each of us, especially those that have acquiesced to a future that is less than full, we can live in a past that we can’t change, or use it as the foundation on which to build toward our goals.
Thomas Wolfe wrote “You Can’t Go Home Again.” And he’s right. Because going back to dependency and perceived safety doesn’t allow you to develop your full potential as a person or as a country.

Santayana observed, "Those who cannot remember the past are condemned to repeat it."

I pray that the people of Haiti can both remember and forget.

Self Doubt and Support Groups

No matter how accomplished we are, everyone is plagued with self doubt. It's that nagging voice that makes you wonder if you are really as capable as others perceive you to be.

I was excited about the opportunity to travel to Haiti and aid the people of Port au Prince and Milot. As the time grew closer, I wondered if I could handle the variety of surgical procedures, as well as the need to do amputations on children and be immersed in suffering. Even the note from CRUDEM said to be prepared to work above your comfort zone. I discussed this with friends and family, all of whom assured me I'd be fine. After all, I was a Professor of Surgery and had led a department through some difficult times. I rationally knew they were right, but didn't really get it until I left for Milot and was surrounded by the volunteers who served with me. In the Fort Lauderdale airport, I was traveling alone, but saw a group of nurses clearly on the same charter flight. We spoke on the plane to Cap and shared our hopes and fears. I knew it would be OK when they asked if we could stop for scotch on the way to the compound. There was a silent acknowledgment of the task ahead, and a clear understanding that we would watch out for each other.

Every night around 6 pm, the staff would gather on the porch, have a cool drink, and talk about what they had seen and done that day. As is the case in any medical group, the stories were of great cases and recurring frustrations. We shared how different it was from being at home. At the nightly staff meeting I led, I tried to open up discussion about concerns I had heard and seen earlier. Initially people were hesitant, but as the week wore on, and experiences were shared, the stories and self doubts came out. But by exposing our vulnerabilities out of the shadows, we all grew stronger. Later at night, often when I was composing my blog on the porch, I would watch small groups talking among themselves. The body language showed a sense of trust and openness.

Today was the first Saturday morning that I've been back in time to run with "The Handsome Men." We are a group of professionals, doctors, lawyers, professors, and accountants aged 45-62. We gather year round at 730 and run for 1-2 hours. The topics are typical guy things - sports, politics, jokes, stories of teenage children run amok. But as the run goes on, we tend to break into smaller groups of 2 or 3. The rhythm of the pace and the endorphins lead to different conversations - job challenges, advice about new opportunities, thoughts about the future. We may get together one other time during the week, and don't see each other routinely at work, but there's a sense of trust that pervades.

So you might wonder where the Handsome Men title came from. A while back 5 of us were running on a cold day. There was ice on the sidewalks and we were passing a hardware store when an attractive woman in her forties walked out of the store, slipped and fell on the ice. All 5 stopped and went over to check on her. She was fine, and we helped her to her feet. She looked around and said "This must be my lucky day - rescued by 4 handsome men!"

We began our run again up the hill in silence, each of us reliving years of high school angst. Finally someone spoke up:

"OK guys, who's the one?"

Death and Broken Artwork

Death and suffering are universal experiences. In Haiti, suffering seems to be everywhere, yet the people bear it with grace and hope. Death is seen as a release from suffering, and while not welcomed, is accepted and not blocked. I was told that people should not obsess about death; indeed, when a patient is dying, we are to tell the family, but not the patient.
There is a large and elaborate cemetery next to Sacre Coeur. There is a certain practicality, given the high death rates. As in the States, those with means have more elaborate markers, yet room is made for all to be buried. Many of the locals, especially the men with young children, told me that they have instructed their families to bury them quickly and quietly, and not to waste any money on a funeral that could be used to care for their children. Yet it is not always that simple.

There was a funeral of a fairly well known resident. The procession was winding through the streets when someone spotted a shaman. There were accusations that this person had cast an evil spell on the deceased. The shaman was stoned. Core beliefs and traditions are hard to break.

I’ve just come from the funeral of an acquaintance that died suddenly in his late 50’s. As is traditional in Judaism, the service was a combination of solemn prayers and light hearted retelling of humorous incidents in the deceased’s life. I expect everyone reflects on their own lives during times like this. I looked at his family, wife, and loved ones. They will feel loss, but will rebuild and move on, strengthened by his memory, albeit with some scars.
As I was unpacking, I found that one of the pieces of sculpture that I bought had broken. It was circular and depicted two people. You can’t tell if it is parent and child, or a loving couple. The sense is that there was no beginning and no end. Even after it was fractured and I was able to glue it back together, the fracture lines remain. In our own lives, after loss, we struggle to center ourselves and look to both the past and to the potential for the future. We try to find light in dark times. We accept the fractures as part of the fabric.
So it is with the Haitian people. Many of the dead are buried in mass graves, and others have died away from those they love. The fractures of the Haitian people, both physical and emotional, will eventually heal. Our experience in caring for them will help each of us focus on how we live the rest of our lives.

One of the great concerns after the quake was that the rum distillery had to shut down, cutting off the supply of premium 5 star rum. You see, it is tradition to pour rum on the grave of the recently deceased, so they wouldn’t get thirsty.

Not a bad way to transition to the afterlife.

Reentry

Sometimes I think my parents' generation had it right, when people returned from experiences overseas by boat. It gave them a chance to decompress and process a foreign experience, be it war, missionary work, or even a new culture. In Viet Nam we moved soldiers from battlefield to fireside in a day. It was tough to adjust. Thank God, I haven't had to experience war, but what I saw in Milot, as well as what was I was able to do, has provided me a completely different perspective into humanity, our world, and myself.

The trip to the Cap Haitian airport was in the back of the Hospital ambulance and the ride was over the unimproved roads that I experienced on the back of the motorbike. The bike was definitely smoother. At the airport, you, not just your bags were weighed. The metal detector was turned off. As we walked to the plane, I could see the Citadel in the distance. Local kids were riding their bicylces next to the runway.

Departing to the north we made a left turn and I could see Cap, and the crowding. Just beyond was the dirt road to the beach, and then wide expanses of forested mountains. We needed to stop in Exhuma, Bahamas for fuel. The ramp was lined with business jets and I could see the high end resorts. Landing at Lauderdale, I was overwhelmed by the density of the roads, the large houses with pools and the general high levels of movement and activity. I felt jostled and crowded at Customs.

I made my way to the Southwest checkin which was quiet. After clearing security (there were interesting smiles as the masks and sculptures passed through the machines,) I got something to eat. Still wanted rice. A woman in her early thirties, in scrub pants, was wearing a Haiti bracelet. She was a nurse practitioner, coming from the tent city at Port au Prince, having treated pediatric burns and trauma from the aftermath of the living conditions. As she spoke, she broke into tears, and I hugged her. We talked briefly about the transition from what we had seen to back into America. She nodded, dried her eyes, and got on her plane.

I slept fitfully, had a glass of wine, and tried to read. As the lights of Providence grew bigger and my Blackberry came alive, I reminded myself to follow the advice I gave the staff as they were leaving - go slow, recognize that your friends and family have not experienced what you have, and be easy with them as they will be with you. My family and friends have done that thus far, and I am grateful.

People that know me and followed my blog have commented that they saw a change. I am the same person, just more aware of my abilities, more appreciative of the support and love of friends and family, and more committed to look beyond myself to those around me. Sometimes it takes seeing the darkness of human suffering to get that enlightenment.

I'll be taking a few days off, as I edit photos, and reflect on more stories that I think you'll find interesting. I've truly enjoyed taking you with me on this journey.

The C Suite

My time in Milot has drawn to a close and I am grateful to those of you who followed this journey with me. I will continue this blog for a time, as I have more stories to share, and experiences to process.

I was inspired to come and aid the victims of the earthquake as well as regain perspective on what is important in my own life. Those that came ahead of me did a magnificent job in extremely trying situations. Much of what we did over the last weeks was optimizing the results of their life saving work. We were able to aid in the care of not just the earthquake victims, but also the local community. We will continue to augment the provision of medical care in Haiti, as it existed even before the quake. Unlike many faith based hospitals run by NGOs, CRUDEM has supported a local leadership structure. I want to tell you about a few of them.

Dr Harold Previl (top) is the hospital administrator. He is skillful at balancing the pressures he feels from the volunteers to do everything with the realities of the Haitian culture, his extremely constrained resources, and minimal governmental support. We were talking the other night about administration and were sharing notes on constraints – it turns out he's also doing a graduate program in health care administration in Port au Prince, this one sponsored by the University of Montreal. Harold comes to our staff meetings. He spoke eloquently tonight, his voice cracking, thanking us on behalf of the people of Haiti and in the same breath reminding us of the limitations he faced. I have worked with a lot of talented, smart, hospital CEOs… Harold is right there with them in his ability to read and optimize difficult situations.

J. Raymond Delnatus (middle) is the CFO, and general go to guy. He picked us up at the airport, could find key materials when everyone said there were none, and made sure the volunteers were taken care of. In addition, imagine trying to keep books with a local currency that is floating all over the place, a secondary economy based in US dollars, and a staff that is composed of both paid and unpaid personnel, some with the same job description. He has an apartment on the compound – right across the driveway from where I stayed… and he was always available on his cell. (The ring tone was a frog.)

I enjoyed my work with Dr Jerry Bernard (bottom, right), a young surgeon who just completed his residency in Cap Haitian. He was able to spend several months at Eastern Maine Medical Center and desperately wants to bring surgery in Milot to a higher level. There is no laparoscopy, diseases present at advanced stages, pathology and chemotherapy are not available. He soldiers on alone, draining infections, fixing hernias, and trying to do what he can for his countrymen. He’s also quite a soccer player, and during the afternoon pick up game in the compound, he brings the same level of energy and enthusiasm. His wife, an internist, is expecting their second child and they live next to Raymond. Looking at them, I remember what it was like to be starting a practice with a young family.

So why not pictures of these men in the hospital, looking professional and serious? Because in Haiti, your personal, professional, and societal lives are closely intertwined. You rely on each other, and family is central. All of these men could be making more money and having an easier life outside of Haiti. Yet they stay, nuture their children, improve medical care in fits and starts, and set the example that Haitians can lead their own countrymen.

…and that gives me some hope for the future of Haiti.

A Different Role

It's 3 am and I am sitting on one of the benches outside the main entrance of
Hospital Sacre Coeur. It is actually cool tonight, the skies have cleared
and I can see the stars through the palms. The animals are active. Apparently we have monkeys in the trees just up the hill.

I'm not having trouble sleeping; I'm working tonight as the ICU charge nurse.

Last week, I wrote to you about the transitions that occur on weekends. Our ICU nurses are all leaving early tomorrow. Since I have a bit of flexibility, I assigned myself to work with the Haitian nurses. I learned that with some patience, a calculator, and a volunteer interpreter, you can get a lot done.

Traditionally, wards may not have nursing at night, and if they do, the nurses
there expect to sleep. Medications that are dosed at night often aren't given.
We tried to explain to the Haitians why it was important to give meds on time, they agreed, but it still didn't happen. Tonight I learned that if a patient is prescribed a drug, it is up to the family to buy it and to bring it to the hospital. Often the family will do the dosing, and if they can't afford of full prescription, they will only bring enough for one dose a day.

Its a bit different in the ICU, since many of the meds are donated and are given
IV. Dalie is Mr M's nurse tonight. He is due for 3.375 gm of Zosyn, an antibiotic. Our donated vials contain 4.5 grams of powder. We sat down together and did the calculations. First we dissolved the powder in a set amount of saline. We determined how many ccs would contain the right amount of drug. We wanted to give it in 100 cc of fluid total, and withdrew the dose volume from the bag,then added the Zosyn She labeled it with cloth tape, a marker, and her initials. I helped her hang it and sign off the chart. She smiled.

As part of the transition for the next teams, I prepared a large sign with each
patient's diagnosis, operations, and care plan. (HIPPA is not an issue.) The families asked me to explain what the sign said. Through an interpreter, I was
able to sit with each patient, and take the time to discuss what had happened as well as future plans. They must have been reassured because now,as I step
outside, most of the patients and their families are asleep.

One of the most rewarding parts of this experience has been the chance to get
back to the core of health care - the patient. And by all of us blurring traditional practice boundaries, we are gaining new insights into ourselves and a greater appreciation of the interdependence of those around us.

It Seems Routine

The past two weeks have made me realize how incredibly versatile people are. It also gave me a new appreciation how how each of us, in going about our everyday business, are doing amazing things in the eyes of others.


I've told you snippets of some of the medical issues here. But the success of the compound and the hospital is also dependent on volunteer engineers that troubleshoot, jerry rig, and innovate to give us what we need to care for the patients. They have their own language, and just as with the docs and nurses, and if they put a group together, even if they've never met, they have commonality of experience that builds and synergizes. I've saw them working on respiratory circuits, wearing headlights during our power failures. When I ask how they figured it out, they shrugged. "It's pretty routine."

The Haitians are amazing artists. And although they can be agressive in selling their wares, there is no doubt about their talents. I watched one of them rubbing a piece of wood with a stone to shape it. He wasn't putting on a show for me, he was just doing his job. They have also created an informal wholesaling network to each other, so the merchants have a broad variety of products. Some of them have been our patients, and are extremely grateful for what we do. I wanted to pick up some gifts, and went to Johnny, for "The Blue Light Special." I bought some things, then he looked at my feet. I was wearing my older Nikes. I looked at his worn sandals and offered to give them to him. "No Doc, we trade." A hand carved mask for a pair of old sneakers. It's routine, but remarkable.

No Harry story could be complete with something about flying. Samuel was a C6 quadriplegic from the quake who is normally at a spinal rehab center about 8 miles from here. I managed some wound problems, and got him out of his halo. We can't drive these patients back because the roads are too rough. We have an arrangement with a German helicopter company for transfers. I loaded Sam into the chopper and took the left seat. My pilot, Ben, wasn't much older than my Ben. He flies for the German Army, and is training to do combat insertion and extraction, meaning he has to learn medical techniques. On the way over, he gave me the stick, the controls were very responsive. I managed to keep us relatively straight and level, although I couldn't imagine how much work it would take for me to get good enough for it to be routine. After we dropped off Sam, we toured the rehab site. I found it fascinating, Ben was clearly uncomfortable, but also curious. On the way back to Milot, we had no patient, so we could fly a routine army profile. Heavy on the collective. quick forward stick, and we were heading along a river bed at treetop level, 120 knots, jinking around the hills. His face was utter calm, with a half smile. Buzz the compound, 60 degree climbing 2g bank to scrub off energy, and we hovered to a landing. Every one of my senses was alive. "So Ben, you ever been to the OR?" His entire demeanor changed. "Are you serious?" Sure, and I changed him into scrubs and took him to see a routine case. After all, he had flown hundreds of patients here - now he could see what happened after the drop off. He had a hard time finding the words to describe his feelings. Finally, he lapsed into German, shaking his heading, and smiling like a kid on his birthday.

Daily we fall into a routine, sometimes forgetting what amazing talents we all have. Take a minute and think about how your routine is someone else's remakarble.

Self Determinism

We thought we were doing the right thing.

With the continued medical progress of our earthquake victims, the census has decreased to where we could close a tent and consolidate patients in other tents, as well as the sales, an old schoolhouse. We thought the patients would be thrilled, since it meant that many of them could leave the tents to a more solid structure that had better ventilation. Yesterday, we got all the volunteers, and began to move patients out of tent 1. We shifted the other tents and the sales to balance men and woman as well as ambulatory status, and within 6 hours, had reorganized the care structure.

The problem was we didn’t tell the patients until we started moving them.

Within hours there was an uprising. Young men were yelling at our nurses, getting close to our faces. We had a heavy rain and darkness, and the noise on the tin roof was deafening, I expect it was similar to what they heard and felt as they were trapped inside a concrete building in Port au Prince. Cliques and informal support groups that we didn’t recognize were broken up. One patient begged us to keep him next to his friend, a paraplegic, for whom he was providing superb care.
We met with them and an interpreter, and listened. Clearly there was some anxiety, but what I really pick up on was helplessness. They have been displaced from their homes, they have lost what little autonomy they had, and now we came in and told them what was good for them. It wasn’t intentional on our part, but we fallen back into paternalistic habits.

That night, the staff meeting was open and emotional. There was fear expressed by some of the women volunteers; there was open discussion of the little things we could have done to prepare the patients; there was clear recognition that the anger we witnessed was in response to a reminder of how little autonomy they had.
We all want to determine our own destiny.

In America, perhaps we take this to an extreme, as we seek to fulfill unlimited individual needs, manipulate others, and don’t want our government involved in our lives. That is, until we falter and want to be rescued. The Haitian people have no support system. The government throughout their history has been marked by inefficiency and corruption. They have learned to expect little, but they still want some say in their lives. The New York Times editorial this Sunday discussed the billions of dollars heir marked for Haiti, with the concern that it would not rebuild the country, until the Haitians took charge of their own destiny. And what we did with our actions yesterday reinforced a dependency and colonialism that will inhibit that goal. Even with our Haitian medical colleagues, we will give the meds at night if the local nurses decide not to, or we intervene and show them “how we do it”, without giving them the chance to struggle and perhaps learn by making a mistake.

I will be returning to the States soon. I believe that I have made a small difference in the lives of the patients and those that care for them. All of us that volunteer our time and skills here hope that our efforts will lift the Haitians up to lead themselves, not encourage continued dependency.

Only time will tell.