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.