Capturing the Moment

I just received a CD of pictures taken by Patti Gabriel (www.pattygabriel.com) who was with us during our recent trip. Her work has also been published in the most recent Crudem magazine.
On looking at pictures, I always wonder how the photographer captures the soul of the subject. It doesn't have to be by perfect color tone. Some of the most striking photos I've seen are in black and white (think about Karsch or Ansel Adams). Haiti, for all its poverty, is a land of vibrant color. Even run down homes are painted shades of green, pink, or blue. The hospital clinic is accented in an aquamarine shade. Clothes are bright, if worn.

The faces of the children are unforgetable. I am reposting a picture from over a year ago, of a young girl who had lost her leg above the knee. This was at the weekly Tuesday night dance party. If you think her smile was great then, you should have seen her when our prosthetics lab gave her a new limb.


Are we better when our professional pictures are airbrushed, tones adjusted, and lighting controlled - perhaps in some situations that is appropriate to cast one in their best light. Some of us like to pose, whether from narcissism or to capture the joy of a moment with others.

When I looked at Patty's pictures of Jerry Bernard and I, I don't remember her taking them, yet the intensity of our deliberations is captured. I can feel that even now, weeks later and thousands of miles away.
So next time you sense a photographer about to take your picture, try to ignore it. Don't take off your glasses, don't force a smaile. The light will be natural and the image real.

And We Teach

It's been two weeks since returning from HSC. As seems to be the case, I'm fine when I'm there, and come down with some respiratory crud on returning to the States and flying 10 hours. One of the high points in between spasms of coughing was the arrival of the latest CRUDEM magazine. It was great to see pictures of former patients doing well, and the continued growth and development of the staff. It was easy to get bogged down when dealing with the crises of providing basic care after the quake; now, with a more measured pace, we are able to carry out our second mission - teaching and learning

A key component that I've picked up in my work with CRUDEM is a commitment to helping our Haitian colleagues to achieve self sufficiency. On the second floor of the administration building is a conference room (thankfully air conditioned) Throughout the day, nurses, pharmacists, and physicians participate in continuing medical education such as Advanced Trauma Life Support, medication dispensing safety, and ventilator management. During the cholera epidemic, a group came in at night to learn how to put interosseus needles into the legs of children who were dehydrated and couldn't have an IV started. We got eggs and chicken bones from the kitchen to practice.

I've told you briefly of the remarkable Tufts students who were here during my last visit. Not only was I able to discuss some of my perspectives of care, but I learned from them about water sampling, maternal education in rural villages, and interntional programs in childhood development.



One afternoon, I heard laughter on the porch - the students had organized Creole and English lessons. We were able to get some nurses as well as COO Ray Delnatus' wife to teach us basic medical Creole and us to teach English. Ray's daughter was there -the students taught her to ask for a car for her 16th birthday in Creole.

My education in many cases had nothing to do with medicine. Tim Traynor arrived around sundown on Friday, and two hour later we were on the roof of the Convent, wearing headlamps, and testing the continuity of the satellite hookup to try to restore internet. I also wondered why he was constantly smoking cigars - then I noticed he was never bitten by mosqutios.




Did you know you can climb 40 feet on top of the sprung storage building with only a rope and by screwing bolts into the framework. There is no OSHA in Haiti.

On my return, I brought some of Haiti back in the form of a lymph node from the patient with suspected GI TB. Before you call the CDC, it was in formalin and triple sealed. Our pathologists here at Cedars had a great time figuring out the diagnosis, and have made copies of the slides to teach others.

Throughout my career, some of the most memorable moment have been with students and residents, trying to pass on my experiences, and gaining new perspectives from theirs. I also think of those who have taught me, some formally, some by example, some by a kick in the butt. I realize that for continuous growth, learning never stops, and that teaching is truly a privilege.

The first annual Pediatric CME week is coming up at HSC. Not quite a ski conference in Aspen, but I bet for those teaching and learning, just as much fun.

Belated Greetings from Milot

Have been at the hospital for 4 days. There is a single internet access, and I have been spending some time working on repairs, as well as helping our surgical team from Hartford and the MD/MPH students from Tufts. Rachel has jumped right in and is out in the community with the MPH students, completing a survey on maternal health choices. She's worked with one of the MPH students on a early childhood stimulation program in the nutrition center, and has travel to Cap to go to the orphanage with Sister Ann. It's hard not to feel exceedingly proud of her.



I've already been humbled again by the interesting diagnoses. A young man presented with clear cut appendicitis. As the students were coming over to examine him, we ran through the differential - don't forget typhoid I said, remembering a previous case. I was working with a Haitian surgeon, educated in Cuba. Communicating in French and Spanish, we explored the patient and found a mass in his cecum and very large lymph nodes. It didn't look like cancer, and I was pondering what to do next. "GI Tuberculosis" I heard over my shoulder.

It was my friend Jerry Bernard, who had stuck his head in at just the right time.



There's always more to learn...

I'm keeping notes and will update you as access permits.

Thanks for your support.

British Sensibilities

Long flight and significant time change from LAX through ATL on the redeye and on to the small airport at Turks. The last time, I was flying into Provo with Ed Constantine in the Baron, and the strip seemed adequate - on a Delta 757, it took full reverse thrust and left us with about 500 fet of runway. Interesting that there's no external power units, so we had to lower the window shades to keep the heat out - and the air stairs were attached to a truck.

I'd forgotten that we were in a British colony, until we pulled out and started driving on the left. Many traffic circles, and perhaps the best measure of being genteel - instaed of "Yield" the signs say "Please give way."

And of course there was a gin and tonic waiting - the quinine reduces the risk of malaria.

No wonder the Brits have survived so long...

Catch you tomorrow from Haiti.

The Night Before

We will be departing for Milot late Friday night. Last minute running around for supplies that seem mundane for us (printer cartridges, crayons for the kids) I've also been impressed by how willing my colleagues have been to help. Although I've only been here a few months, I sent out one email with a small list of basic supplies (ostomy kits and some scrubs.) Within a week, I'm at my desk, and someone who I've never met before rolls up with boxes and bags far in excess of what I asked for. Turns out she knows some folks at other local hospitals that chipped in. So my CRUDEM colleagues in Milot will have labeled scrubs donated from from Cedars Sinai, Santa Monica Hospital, The University Hospital, and St. Johns, among others. And patients requiring ostomies won't have to jury rig IV bags.

I was pleased to learn that we will be working with a group of medical and public health students from Tufts, as well as a surgical and pediatrics team. Tim Traynor and I will overlap toward the end of the week, and we've briefed what needs be done in the Sprung building. His engineering mind and my surgical outlooks aren't that far apart.

The one downside is that internet access is degraded in Milot for a variety of reasons. It sounds like I may be climbing in the rafters to trace the cables and install a router. Fortunately, between the X gens that will be in Milot, and some cell phone briefing from Ben back In LA, I should figure it out.

I found out that my expat friend Daven will be in CAP. You may remember my blog last September about his experience being buried after the quake, but returning to try and keep the company running and employ as many of the local populous as possible. We hope to visit each others compound.

We'll be posting from Turks on Saturday.

Thank you all for your support.

Tradition

In “Fiddler on the Roof” Tevye struggles with the blurring of traditional roles and choices for his children. Why must we keep doing what was done by previous generations? Tevye answers in song ,”Tradition!”

This past weekend I participated in a ceremony that is hundreds of years old – commencement. The end of a period of academic study, it is seen as not only the conclusion of one phase in the student’s life, but the beginning of another. So why would a 54 year old surgeon fly back to Boston from Los Angeles, to dress in medieval academic garb, and stand in the sun with 4000 others for several hours.

Tradition!

The commencement ceremonies at Harvard Yard predate the founding of this country. And from the initial class of 9, certain consistencies have been passed from generation to generation. Bagpipers escort the classes through the various gates surrounding the central yard, undergraduates congregate to the left, graduate students to the right, with the oldest schools situated closer to the stage. The President and Fellows arrive, wearing the traditional garb of their home doctoral institutions. To begin the ceremony, the Sherriff of Middlesex County, as he has for over 3 centuries, approaches the lectern and bangs a silver tipped cane three times, calling the meeting to order. Three speeches are given, from memory, by two undergraduates and a graduate student. The first was in perfect Latin (a variation of “Wheel of Fortune.”) With specific scripting, each school is asked to rise, and the President bestows the degree en masse. Symbols are waved by each class – gavels for the lawyers, angel wings for theology, stethoscopes for the med school. We in Public Health were given plastic fruit.

The awarding of the honorary degrees was a bit more light hearted, the provost introducing each honoree as if it were a game show. The high point was when Placido Dominigo, after receiving his degree, sang the citation to Justice Ruth Ginsberg, herself an avid opera fan.
The Sherriff, still regal in a top hat and tails, again banged three times, and dismissed the meeting.

On the streets of Cambridge, several of my classmates and I were stopped by a group of Japanese tourists, who wanted their pictures taken with us in full dress. I must admit it was a little strange.

In the afternoon, we did the walk across the stage to receive our copy of the Declaration of Human rights. All of the School of Public Health was present, and after another set of addresses, the 480 names were dispensed with fairly efficiently.

In the crowds afterwards, my classmates all dispersed to meet family and friends. No real chance for a formal goodbye. I turned in my gown (kept the tassel, I guess for the rearview mirror), and picked up my diploma. More than 25 years since I last graduated from a formal program. The same sense of accomplishment, perhaps a bit more pragmatism, and a bit less uncertainty. And I wondered what to do next.

When my middle child, Adam, graduated from Hamphshire College, there were no caps and gowns, the diplomas were a circle and you were identified by the year that you entered, not graduated, signifying the beginning of lifelong learning. A tradition reflecting the nature and values of this innovative institution. At Wesleyan, my oldest son, Ben, walked with his classmates down the hill between rows of faculty who formed the entrance to the field and applauded the graduates. I will feel intense emotions next year when Rachel graduates from Hopkins.

Traditions may not make great sense in a modern world. In reality, our transcripts are all electronic, and the diploma could be sent as a pdf file. Yet we as humans do things that aren’t always rational, but give us a sense of continuity. Perhaps it is our own way to assure a degree of immortality – continue the traditions of those who raised us and are no longer here, hope that our children and grandchildren will remember us through traditions after we are gone.


It’s been a while since my last post – finishing school and some new work projects have kept me busy. But I look forward to sharing with you more perspectives on Haiti and Hospital Sacre Coeur – Rachel and I will be travel there in mid June for a week.

Now there’s a tradition I hope will endure…

A World View

Last Sunday evening, I was returning from dinner with several of my classmates in Boston. Entering the hotel, we saw the television with a somber Wolf Blitzer building up to President Obama’s remark about “an issue of national security.” As we sat in the lobby, I looked around and realized that half the people I was with were from other countries. How would they react? Is this as big a deal to them as it is to Americans?

Earlier that weekend, we presented our year long practicum projects, a extensive planning and execution program. Those that have been following this blog know I worked on our ambitious inventory control project for Hospital Sacre Coeur. As I detailed what we have and haven’t been able to complete, I found myself discussing civil unrest, cholera outbreaks, and electricity that goes out twice a day during the switch from the generator to inverters. I also showed pictures of the volunteer electricians from the San Francisco bay area, Ed Constantine and his airplane, and the Haitian workers, digging out stumps and pouring concrete by hand to cultivate the sprung building. It was a remarkable examination of what can be done when committed to a cause.

At the same time, I listened to presentations as diverse as improving the experience of complex cardiac surgery patients in the Netherlands, to the challenges of attracting a new chief to a struggling academic department, and how to get specialists to cover an emergency room at night, when the patients had no insurance. Other international projects began an ophthalmology residency in Cambodia, examined the cultures and motivations of the staff in an inner city federally funded health care center, or presented the business plan for merging several multimillion dollar cardiology practices to maintain viability given massive cuts in reimbursement. The key theme was that by understanding what motivates people, aligning the incentives to meet those motivations, and realizing that all of life is shades of grey, problems can be addressed and the human condition improved.

What does this have to do with the killing of Osama bin Laden? My colleagues from other countries were happy for America that it had achieved a goal and found some degree of justice. But they were also saddened at the amount of resources and lives that we expended in fighting these wars. A recent NPR broadcast discussed the “the economic death of a thousand cuts” as one of the methods used by terrorists. There is no question that every country must defend its people, and in societies, certain segments need to take on the role of policeman. We in America have chosen that role, and also have had it has been thrust upon us.




I’ve definitely developed a broader view of the world and human needs over these past two years, both by listening to others perspectives, and experiencing it myself. I don’t have even a small number of the answers, but based on what I’ve seen from Cohort 11 of the Heath Care Management Program at the Harvard School of Public Health, I have great hope that the answers are out there, and we have talented, commited people willing to find them.

Passover in the Land of Stars

It’s about 3 miles from my office at Cedars-Sinai to where I’m currently living in Beverlywood. I’ve been walking a fair amount lately, and the route is quite interesting. We border Beverly Hills and West Hollywood. As I walk south, I cross very familiar streets- Wilshire Boulevard, Rodeo Drive, Beverly Boulevard. The Four Seasons Hotel, with a statue of Marilyn Monroe, is on Doheny and I always check to see if the paparazzi are out. As I head through “The Flats” the homes are classic California Spanish, on very small lots. Garages are almost always converted to living space, so upscale cars are parked outside, along the street or on short driveways. I ‘m wearing my suit, and nod to the occasional dogwalkers or retirees out for a stroll in their jogging suits.

Crossing Olympic, the scenery changes – there are more apartments, and small businesses. The lawns, though neat, are not as groomed. Turning on Pico, I now see more men in suits and women pushing baby strollers. It is the first night of Passover and the observant community near my home are heading for Sedars. A similar scene occurs every Saturday, as families stroll to services, stopping to talk and coo over babies. The youngsters later play ball in their driveways, wearing yarmulkes that match their tennis shoes.

Last year, I celebrated Passover in a poor country, founded by slaves, one of the few Jews within 50 miles. Today I am immersed in my historic community and culture. And the economy responds to demands. It is easy to keep Kosher and live within walking distance of Temples and other activities. There was even a brisk business of portable car cleaners, who vacuumed every last bit of breadcrumbs from your interior.


We had a small Sedar. Ben and Janine invited some Wesleyan friends, and the realtor that found us the rental joined us. (Her first husband was Jewish.) We did have some Mogen David wine, but immediately deferred to a Napa Cabernet. The story of the Exodus was retold, we had some laughs, and a great meal.

Later, I was walking Chester through the neighborhood; I could glance into homes, and see families still surrounding the dining room table, with multiple generations. In some cases, the doors were open and one could hear the conversation and singing. I felt a strange sense of both connection and discomfort.

Returning home, the others were gathered around the fireplace and I sat and listened for awhile. It was the optimistic, energetic thoughts of the next generation – I remember being in their place. And I remember a promise I made to myself.

There was some Matzah left over. I found the peanut butter and cut up a scallion. The 5 star rum was still in the freezer, and I squeezed some orange juice. On the back patio it was dark, and many of the stars were obscured by the haze and lights of the city. I could still hear the crickets, as I had in Milot. In the distance, the sounds of I 10 and planes on approach to LAX. What an amazing contrast and at the same time confluence. Whether you a Christian, Jewish, Catholic, Muslim, or an agnostic, you are part of something greater. Looking both within and out, we experience the world through our communities. They may change as we gain more insight, and align with those with whom we resonate.

Two years ago, in Hartford, I never thought I’d spend Passover in Haiti, one year ago, in Milot, Los Angeles was nowhere on the radar, and next year?

As Sedar concludes we say L’shana habaha b’Yerushaliyim – next year in Jerusalem. But in reality – it is not a physical place – it is the reminder that we must all continue to evolve and strive for our goals, whether they be personal professional or spiritual.

And so for each of you, may you find your own Jerusalem and have the drive, support, and good fortune to reach it.

Forward to the Past?

“He who knows syphilis, knows medicine”
-Sir William Osler, First Physician-in-Chief, Johns Hopkins Hospital

It’s been an interesting week for me in my various healthcare roles. I’m currently en route to Dallas, where I will participate in a summit on using a balanced scorecard to assess and compare individual physician performance, as a preface to public reporting. The long awaited Accountable Care Organization guidelines (429 pages) were released. At the same time, Hospital Sacre Coeur and CRUDEM are working to expand interventional cardiology services to include treatment of rheumatic heart disease. Finally, I have been involved in the recruitment of an individual involved in public health. When I asked how he would measure his success, he said that one key would be the elimination of syphilis in urban areas. (and this was in the US!)

It is easy to forget, that a century ago infectious diseases and their complications were the leading cause of death and disability. Syphillis caused more than genital lesions. The spirochetes would house in the walls of the aorta, especially exiting the heart, causing weakening, dilation, and death from rupture. In other forms, it manifest as neurosyphilis , causing confusion and delusions. Some have hypothesized the former Ugandan dictator Idi Amin’s bazaar behavior was due to neurosyphillis. One of our most shameful legacies in human subjects research was the Tuskegee experiment, where minority individuals with syphilis were not treated to follow the natural history of the disease. The concept of “bad blood” reflected the explanation given for the progressive illness. Many died of the one of the multitudes of complications.

Rheumatic heart disease is the sequelae of untreated streptococcal infections of childhood, such as recurrent tonsillitis, and strep throat. Although these are easily treated now with antibiotics, this is not the case in Haiti. The antibodies to strep can form vegetations on the heart valves, especially the mitral valve between the left atrium and left ventricle. This cause stiffening and narrowing of the valve, reducing blood flow from the lungs to the rest of the body. Patient develp a classic murmur, then progressive pulmonary edema and eventually heart failure. This is especially tragic in Haiti, when young woman die during pregnancy as their hearts cannot increase output in responses to the demands of pregnancy. Medications can only do so much. Autopsies confirm this is a mechanical problem. As surgeons, we seek mechanical solutions. How can you mend a broken heart? (Sorry Barry Gibb)


Before the development of cardiopulmonary bypass in the 1950’s and 60’s, and cardiac procedures were done with the heat still beating. Normal output from the heart is about a gallon a minute, and the mitral valve was accessible only by opening the heart muscle. As early as 1925, Souttar reported an elegant, if somewhat simple solution. There is a small outpouching from the left atrium, the appendage. If a purse string suture is placed around the appendage at its base, the tip can be cut off and a finger placed into the left atrium, until it reached the mitral valve. The opening was restored by fracturing the vegetations with the finger, hopefully not completely destroying the valve. The finger was removed and the purse string tied down, closing the hole. Subsequently, devices for mitral commisurotomy were developed to replace the finger and provide a more controlled dilation. With the sophistication of cardiopulmonary bypass, we now arrest the heart, and physically replace the valve. But what about countries like Haiti, where there just isn’t the infrastructure yet to carry a patient safely through cardiac surgery, let alone long term followup?

It may be time to look back to guide how we go forward.

Several years ago, the cardiac surgery team at my previous place, the Miriam, travelled to Africa and did open mitral commisurotomies without bypass, as I described. The patients overall did well. Since then, intervention techniques that can access the heart via an artery may be able to obviate the need for a surgical incision. Mitral commisurotomy can now be accomplished with a specialized balloon, under fluoroscopic guidance, in a cath lab environment.



We are examining how to accomplish this in Milot. We do have some fluoroscopy equipment and improving ICU capabilities. Teams of cardiologists can come for a week at a time to do the actual procedure, but we must involve our Haitian colleagues in the preoperative identification and postoperative care of these patients, eventually training them in cath procedures. This starts with using echocardiograms to assess degree of stenosis and heart function. When I was in Milot in September, Dr William Battles, an echocardiographer was training the first group. As he was doing it, I watched. He smiled and said, “so simple a surgeon could do it.” (Later that night, a man came in with multiple deep facial and arm lacerations from a machete. Bill was the only other doc around. I took him to the OR, reassuring him that “even an echocardiologist can do this…”, but that’s for another blog.)

While reflecting on the high yield from treating basic infectious disease and public health problems I am concommitantly overwhelmed with the amount of data we collect and policies we propagate trying to make American medicine affordable, effective, and appropriate. We need to help physicians understand how they practice and how we can learn from each other to optimize care. We can legislate to align incentives, with both a carrot and a stick. I’m still not sure how it will drive behavior.

But I do know that I never again want to watch a 23 year old Haitian girl die of progressive heart failure from untreatable rheumatic heart disease. I look forward to when we can bring the balloons to Milot, and if not, there’s always your index finger and a 2-0 Prolene suture for the left atrium.

…and I’m not sure how that will fit into the ACO paradigm.

Evidence Based Decisions and the Art of Medicine

“The evidence clearly shows……”

How often have we heard that argument made, trying to influence our choices or behaviors. Experts provide data that support their point of view, often in the face of conflicting information. We would like to believe that we always make rational decisions based on facts. But human nature proves otherwise. We will base our most recent decision on how the last situation played out. Negative outcomes, even if infrequent, have a greater influence on future behavior than their true weight. And as clinicians we are often told, “Judgment comes from experience, and experience comes from poor judgment.”

So it has been very interesting for me in my new position to work with clinicians and systems on best practices for various patient conditions. Unlike the “hard” sciences like physics, mathematics, and chemistry, soft sciences like medicine and pathophysiology have shades of grey. Even the best designed studies are inherently ambiguous, and the literature tends to further this bias by publishing studies where a beneficial difference is found, as opposed to equivalence or detriment. How do we sort through the data and try to come to a rational conclusion?

By analyzing how to analyze data.



Health service researchers have developed an elaborate grid that attempts to balance the potential benefit of an intervention with the strength of the data supporting that intervention. These decisions subsequently form the basis for clinical guidelines, and in many cases, whether the service will be paid for. The strongest recommendations, IA , are the most stringent , and should be generally accepted. III A findings strogly support more harm than good. You can see where the ambiguity comes in. A IC may well be good, but there’s not strong randomized data. By the same token, a IIIC recommendation not to do something is less of an indictment than a IIIA. As a surgeon, who has spent the last 30 years trying to do the best for my patients, often with limited available data, this is clearly a shift in thinking. We were trained to listen and examine the patient and then determine if they were sick and needed an operation. Subsequently, the specifics of the diagnosis would often be revealed in the operating room.

So why is this new paradigm important? Increasingly, with limited resources, we may be steered to provide or defer therapies based on into what evidence category the question falls. Could “Watson,” when he’s not winning at Jeopardy, calmly crunch all the potential permutations and risks to come to a definitive plan? I suppose he could, but I hope we don’t come to that alone.

When I was still a medical student, Arnie Rosenbaum, an internist in my hometown of Canton, took me on rounds. In each patient’s room, he would sit at the bedside, and take their blood pressure, while gently feeling their pulse. Afterwards, I asked why he would do this when the data were already on the clipboard. “Because I always touch my patients and look them in the eye. It really tells me how they’re doing. And when the time comes for me to be a patient, I hope my doctor makes the same human connection.”

My n=1 in this nonrandomized study of internists in Canton Ohio in 1979. But based on my experiences since then, that’s Level IA data in my eyes.

Making the Tough Choices

Two massive earthquakes – 2 very different patterns of death and destruction
I knew this one would be different than a year ago, when people asked- “So are you going to Japan to help?” The answer was quickly “No, they really don’t need me.” By the same token, my colleague Glenn Braunstein, Chair of Medicine at Cedars and a superb endocrinologist, has been bombarded with requests for interviews and advice regarding potassium iodide to reduce the risks of radiation exposure.

The drama unfolding in Japan is no less riveting than what happened in Haiti, but for different reasons. The patterns of death and injury were not from collapsing buildings or lack of infrastructure – it was rapid and massive related to the Tsunami. The Japanese government is well organized to deal with earthquakes and has teams and supplies available. Building codes are strict. But no one could anticipate the difficult decisions related to the Fukushima Dai-ichi nuclear plant. The risks of additional injury and death are significant, and resources are being poured into the area to minimize harm. Although rescue and recovery operations continue, they seem to have taken a lower priority to preventing additional catastrophes.

What we see in action in Japan is similar to other disaster scenarios - the use of triage. Triage actually originated during the Napoleonic wars with Dominque Larrey, a French battlefield surgeon. He designed some of the first ambulances used on the battlefield, would treat enemy soldiers along with his own countrymen. He recognized that you needed to make a best guess at how to get the most good for the most patients, which may mean not treating those who were likely to die, or would consume disproportionate resources. It is a form of utilitarianism where one tries to maximize benefit for the greatest number, even if the decisions may not be best for an individual.

We saw triage in Haiti, when we were truly resource constrained. Patients that would have survived in the States, were allowed to die comfortably. Others might have quality of life worse than death. Throughout my surgical career, I have been faced with the decisions – they don’t get easier, but after some time, you gain perspective.

Like it or not, we will be performing some type of high level triage if health care in America is to survive. For now, we seem to have unlimited resources, but just because we CAN do something, doesn’t me we SHOULD. Resources spent in futile care, are resources that could immunize a child, provide safe water, or help educate a generation. This isn’t about Death Panels - it’s about having an honest dialogue about where priorities are placed to stabilize the present and build to the future.

There may be a few setbacks along the way for the Japanese. But a year from now, unlike Haiti, they will be back on their feet and stronger with the knowledge of what they learned.

Freedom of Choice

“All around the world, it’s so easy to see. People everywhere just want to be free..."




I am currently over Ontario enroute from Boston. I look down on the landscape of farms, interspersed towns, and the city of Toronto in the distance. It is a route I have traveled often, especially when I was based in Rochester. I fondly remember trips to Canada, and the palpable sense of a difference in tolerance and priorities as I crossed the border. The newspaper in my seat pocket recounts the unrest in the Middle East, and concerns that oil prices rising above $100/ barrel will inhibit Americas own economic recovery. Gas is $4 a gallon in LA, yet, I don’t see any fewer cars on the road.(Driving, in California, is freedom.) There are protests in countries that we normally don’t recognize as foci of discontent – Tunisia and Liberia for example. We wonder what drives people to risk their lives to overthrow a government, when they know that whatever follows could be as equally oppressive. In a commentary, WSJ columnist Michael Novak notes that the desire for liberty is universal and rooted in basic Judeo – Christian beliefs. We talk of free choice, and consequences – whether to eat the apple, whether to accept a deity or idols, how we choose to do business with one another. What I am realizing is that even the replacement of one corrupt government with another, is an expression of the peoples freedom to choose their destiny. Whether extremists can recognize this basic human value or will continue to oppress women and the less well to do remains to be seen.

I am returning from one of my final weekends in the healthcare management course at the Harvard School of Public Health. As we looked at payment systems, it was not surprising that the US high cost for moderate quality paradigm was again examined. Classmates from Israel, the Netherlands, Australia, Canada, and Dubai discussed their own countries; how resources for health care were collected, how they were pooled, and how they were distributed. We fervently debated market pressures, the malpractice environment, and free market competition. Trying to place any of their systems in the US, despite the fact that there was “more bang for the buck,” seemed untenable.

Then we reframed the discussion, and the light went on – it’s all about choice.
Americans are fiercely independent, and pride themselves on being able to guide their own destitny. There is some sense of social responsibility for the less fortunate, but the disparities between the haves and the have nots are extreme. Americans want free choice in whether they drink or smoke, or want to be able to take a medication in lieu of exercise - and they don’t like to wait. This impatient spirit helped us accomplish great things in the past, but may be blinding us to the realities of the present.

There is no question that the American health system is expensive and inefficient. It is focused on technological repair of disease as opposed to a societal understanding of health, responsibility, and support. We realized that by dealing with the economic disparities, many of the health disparities would be ameliorated.

“My God,” you say, “He’s moved to California and is eating too much granola.”

Not so. I believe in technological advances in medicine to reduce suffering. Surgery is one of the most cost effective ways to return someone to health and being again productive. My classmate, who is Chief of Cardiac Surgery at the Hague, does 8-12 case /week – as part of a well organized integrated system in a relatively small country. It has nothing to do with socialized medicine.



Looking at the other countries we discussed, the populations are fairly homogeneous, resources can be concentrated near population centers, and from the time you are a child, there is an understanding that you may need to wait to have your needs met, but they will be. America is vast, we have huge variances in population density and medical resources. There is a safety net available, in public hospitals and emergency rooms but it is not the best way to provide continuity of care.
So how do we tie the unrest in many of the middle eastern countries to public health. And how do we help Americans realize that there must be a change in their perceptions and responsibilities?

It is by understanding that as humans, we want some control of our destiny. Depending on how well our basic needs are met,(remember Maslow’s pyramid?) we are willing to trade some free choice. But when oppression is coupled with poverty, an uprising is inevitable. In a similar manner, American health care is impoverished in the midst of plenty, and the shift must come at the center – with the patient.

Being proactive in your health, making good choices, and partnering with your provider isn’t limiting – it’s the ultimate source of freedom and self actualization.

Henri Ford - Professor of Surgery, Son of Haiti

Sunset Boulevard is worlds away from the spine jarring road between Cap Haitian and Milot. Yet, as I moved slowly toward Children’s Hospital of LA, I recognized that those two worlds would coalesce soon.

Parking in the garage, I took the brightly painted Giraffe elevators to the 8th floor and the department of Pediatric Surgery. There were many familiar names of colleagues with whom I’ve shared lab results and meals at various academic surgical meetings. The Chief of Surgery is one such colleague, Dr. Henri Ford.


I’ve known Henri for more than a decade, as our paths crossed at meetings and other groups. He was the President of a major surgical society and always projected a calm confidence and humility. I knew he was from the Caribbean, but it wasn’t until after the earthquake, that I realized his roots were in Port au Prince. I asked him if I could stop over, not to talk about recruitments and academic politics, but rather about Haiti. He readily agreed.

Henri’s father was both an AME minister and director of immigration in the government. His spiritual core, compelled him to speak out on occasion and this led to a visit from the Tonton Macoutes. Realizing that future opportunities for his family would be limited, he moved them to Brooklyn, where there were some relatives. Henri was 14, and spoke no English. His parents made it clear that English was to become his first language, and he spent many nights struggling through standard high school English texts. During summer school, he met a tutor who was a junior at Princeton. Seeing Henri’s determination and drive she encourage him to apply.

He was admitted with a full scholarship.

Rather than rest on this accomplishment, he continued to accel and fulfill the expectations for himself and his family. Harvard Medical School, residencies in General and then Pediatric Surgery, followed by a stellar academic career in Pittsburgh and now Los Angeles. But he never forgot his roots.


Henri travels back to Port several times a year. He led a group immediately after the quake and you may have seen him with Dr. Sanjay Gupta of CNN, working in primitive conditions. As Haiti moves beyond the one year anniversary, Henri continues to be involved in organizing medical care and working for stability.

We talked of our various experiences and the frustration of not being able to provide even basic levels of care. He shook his head telling me of finishing somewhat advanced neonatal surgery, only to have the child die when he left. We talked of the “Haitian Diaspora” where well intentioned and committed practitioners become frustrated and leave for other countries. I’ve spoken of Jerry Bernard, who learned laparoscopy in the states, but does not have the equipment in Milot. He is staying, as is his internist wife, but I’m afraid they are the exception.

Aid will not flow to Haiti until the government stabilizes and faith is restored. In an ideal situation, 9 regional hospitals will be built, one in each district, and residency programs will train the next generation of providers. Haiti can learn from its successful island neighbor, the Dominican Republic.

But after all the theoretical talk, and the hopes, we both concluded that it will be a long haul. Why do we keep pouring our souls into what seems like an endless hole? Henri was quiet for a moment, then softly said, “Until I returned to Haiti, I didn’t know my raison d’être” I nodded.

In that small office overlooking the Hollywood Hills, two middle aged academic surgeons, successful by many external measures, shared a moment of what they both knew was truly important. And despite the challenges, they will return to Haiti, do what they can, and carry on with faith for the future.

Beauty in a Time of Chaos

On the way to work today, I was listening to NPR discussing the current unrest in Egypt. Apparently, some of the intensity has died down, but there has sprung up a large tent city in the middle of downtown. Protests continue, but people are also finding other ways to channel their energy.

They are making art from the trash that has been discarded by the thousands of people that gathered.

I couldn’t find pictures on line, but the descriptions are pretty uplifting. One young man fashioned a plane from plastic cups and rags. Asked what it represented, he said it was the way that Mubarak would be leaving the country. Others created Egyptian flags from scraps. They expressed their energy through creative development.
Even in the aftermath of the quake, the street leading to Hospital Sacre Coeur was awash with color. Although the vendors could be a bit aggressive at times, the art was remarkable. It celebrated the past, and the bright colors reflected the light with hope for the future. Even the brick wall, where the water supply faucet was mounted, was transformed into a street scene.
You express yourself where you can.

I was returning, and wanted to keep a small reminder with me of the people of Milot. One of the artists gave me this simple woven bracelet. The markings have faded with wear. Some of the pieces were local stones that otherwise sat on the roadside. It’s just string and stones, yet it is more. We all can look at an object, but feel the emotion that goes with it.

Trash is in the eyes of the beholder. Find inherent beauty and hope wherever you can.

In the Public Eye

The mobile TV vans and Kleig lights began to clog the streets around the hospital. In a well practiced protocol, security kept them at a distance, to assure appropriate privacy for patients and staff. Given our location it is not uncommon for high profile individuals to be treated here. Maintaining a professional level of confidentiality is foremost, and is pushed by those sighting the public’s yearning to know.

Such is the conundrum of being in the public eye.

The media has a powerful influence on society. Governments use the ability to control information as a tool to control their citizens. In the US, we discuss the rights of a free press and numerous Supreme Court rulings have sided with this right. In the past, significant events could be withheld from the public, if it was felt that knowledge would be disruptive. President Grover Cleveland discovered a tumor in his jaw several months after inauguration. Given his cigar smoking history, it was no doubt malignant, and the doctors of the day recommended excision. Cleveland was concerned that knowledge of his illness would be disruptive to upcoming legislation dealing with a financial crisis. After a delay, he arranged to be treated aboard a friend’s yacht as it sailed up the East River. Nitrous oxide anesthesia was delivered, and historical accounts suggest concern on the part of the physicians, as the patient was a set up for what we now know was sleep apnea. The surgery was successful as was a prosthesis placed to reconstruct his jaw and allow him to speak normally. All this was kept secret from the press, and reportedly, even the vice president.

Could you imagine that today?

We are struggling with finding a balance of full disclosure of every known fact or supposition and the requirement that some things need to kept within a limited group to allow free and open discussion, leading to well thought out recommendations. The Watergate affair profoundly changed our trust of government and placed the press in the position of both reporter and influence agent. In all of my leadership courses, I am learning how to interact with media and others in the public eye. It is a different set of skills.

Those that are at risk of being subjected to the glare of the media are also able to turn that harsh light in a more positive direction. I spoke of the Thalians and their work in mental health. Celebrities and politicians have been able to turn attention to significant issues like Rowanda, US illiteracy, “Jerry’s Kids”, and Haiti.

In the year since the quake, we haven’t seen as many of the positive stories as we have the riots, corruption and tire burning. So let me take a minute to use this public eye to pass on some excerpts from an uplifting note from CRUEM president Dr. Peter Kelly who just returned from Sacre Coeur.

PHYSICAL PLANT

Our physical plant has expanded to include a new maintenance building/warehouse on the land by the nutrition center. This will house the maintenance department and housekeeping department as well as be a storage place for their supplies. Next to it is the prosthetic lab and solar powered water purification system. There is a garage and service pit for our vehicles as well. Our new laundry building is on the rear of this property and the oxygen generating equipment is in a building next to the generator building. There are 2 new generators outside the building waiting to be installed.
When I arrived there was a team of 20 volunteer electricians from California who were completing rewiring of our hospital. All of the supplies needed to do this were donated. These volunteers worked 16 hour days to complete this job without disrupting patient care.
A team from CRS arrived to discuss the addition to our lab. They feel that this can be completed by the end of February. Their opinion was that our lab was the best they had seen in Haiti and with our addition we will be able to perform testing that is not available elsewhere in Haiti.
CRS is also coordinating a network of Catholic hospitals in Haiti and we are part of that network. They are instituting a post graduate training program for nurses and physicians and will fund the renovation of our auditorium and provide the equipment to allow us to participate in this program. They will also fund the conversion of a room on our housing compound into a library with computers and internet access so the students have a place to study. Finally they will fund the conversion of our existing depot into a 2 story housing compound with rooms, bathrooms and common areas for 52 volunteers and students.
The reason we are able to convert our existing depot into housing is that we now have a large storage building called a sprung building that was donated and constructed behind mission house. This building is 60X100 feet and 30 feet high. We have shelving that extends to the ceiling and a forklift to enable us to move supplies. We have contracted with a bar coding company( thanks to a generous donation) to bar code all of our supplies. This will enable us to track our usage and needs. Representatives from the bar code company were at HSC this week beginning the training and implementation of this system. There were also volunteers helping with moving and organizing the supplies. We will be able to access this system by the internet so we can coordinate our donations and also volunteers can see what medications are available and what are needed for their trips.

EDUCATION

We held our first week long symposium in January. The topic was Diabetes Mellitus and we invited physicians and nurses from other hospitals to attend. We had speakers from the US and Haiti who were experts in Diabetes Mellitus. It was standing room only for every lecture and at the end of the week over 300 people were screened for Diabetes and Hypertension. It was a tremendous success thanks to the efforts of our education committee. We have 3 more symposia scheduled for this year. Emergency medicine/ ICU in March, neonatal care in May and pediatrics in June.
During the earthquake relief efforts it became apparent that their was a need for a nursing school and post graduate nurse practitioner program. We have been in discussion with Northeastern University, CRS, Malteser International and the Minister of Health to determine the feasibility of beginning these programs. We are hopeful that we will be able to work with the Catholic healthcare network in Haiti to begin construction sometime in the next year. Our goal is to ensure that these programs are sustainable before we begin construction. Until we are able to begin we have started a scholarship program to send 10 students a year to nursing school in Port au Prince. They will do their clinical training at HSC and will commit to returning to HSC when they complete their training. We had a testing and screening program in the fall to choose the 10 candidates from the town of Milot. They began their training in November with much excitement from the students as well as the town.
Finally we purchased land to the east of the hospital which can be used to expand the hospital and build new clinic areas and cafeteria for the staff. We are developing the plans for this expansion with the assistance of an architecture firm from Indianapolis who are donating their services. We will be beginning in March the public phase of a capital campaign to finance this expansion.

PATIENT CARE

The cholera outbreak seems to be decreasing. When I arrived there were 14 cholera patients. During the week it increased to 25 but had again decreased to the teens by the end of the week. The patients are arriving earlier so they can be controlled quicker and discharged sooner. Our public health teaching seems to be having an effect. The bulk of the care is being provided by our Haitian staff with volunteers working side by side. We try and adjust our staffing needs based on our volunteer numbers.
At the present we have 119 part time Haitian staff in addition to our 250 full time staff. Most of the part time staff are nurses and housekeeping. We currently have the following Haitian physician staff: 3 Internists, 1 General surgeon, 2 full time Family Physicians and 1 part time, 3 Pediatricians, 3 OB/Gyn, 2 General Practitioners, 3 Social residents, 1 part time Ophthalmologist. Another General surgeon will be starting in March and an Internist in February.

Perhaps this won’t raise network ratings as much as the latest riot or celebrity breakup, but in my book, it has a whole lot more impact on what we strive to be as people and a society.

Have a great week, and try to keep your mug shot off the front page.

Mental Illness from A Societal Perspective and a True Walk of Fame

He is a fixture outside the gates of Hospital Sacre Couer. A tall disheveled man, in his 50’s, he paces along the sidewalk, yelling obscenities, and gesturing wildly. The locals keep an eye on him, and by evening, he has disappeared, only to return the next day. I never felt concerned, and it appears that he has struck a peaceful coexistence with his fellow citizens.

A vivacious, eloquent English teacher, she began to forget names and addresses in her early 50’s, and rapidly developed early onset Alzheimer’s disease. Given her otherwise good health, she required nursing home care for 15 years until her death.

Another young man is introspective and well groomed. He sometimes laughs inappropriately, seems to have problems with impulse control, and understanding social norms. He has been diagnosed with Asperger’s syndrome, and his parents are at a loss of what to do.

A brilliant surgeon at the peak of his career suffers a bicycle accident. Despite a helmet, his brain is injured enough that it leads to a significant personality change. His ability to support and enjoy his 5 children is altered forever.

…and then there the Tuscon shooter, whose unclear need for recognition and driven by as yet unknown demons, killed and maimed many. How can he be included with the others?

Such is the broad spectrum of brain and mental illness. And along that continuum is how society chooses to deal with the victims.


In medical school we learned of French physician Philippe Pinel who supervised the unchaining of mentally ill patients in 1794 at La Salpêtrière, a large hospital in Paris. Pinel believed in treating mentally ill people with compassion and patience, rather than with cruelty and violence. Prior to that, the mentally ill were subjected to restraint and torture. In museums, I’ve examined trephines, used to drill holes in the skulls of the insane, in hopes of releasing the spirits. In some cases, the fortuitous draining of a traumatic subdural hematoma led to clinical improvement and reinforced this therapy.

The age of modern psychoanalysis began to bridge the gap between spiritual dogma and an appreciation of the complex responses of the human brain to outside stimuli, including trauma and abandonment. As we have gained the ability to watch the brain function in realtime, using functional MRI, addictions, schizophrenia, and depression are being redefined at a molecular level. New and more effective therapies will be developed.

Yet we all have twinges of discomfort when we see the homeless on the streets and wonder if they are just looking for their next drink. We debate gun control after shootings, without understanding that increasing social isolation may be the driving factor in these senseless events. We have no problem donating money for kids with cancer, but sometimes it is difficult to get behind calls to increase funding for mental health. As a society, we all suffer, yet it still remains in the shadows.

I park my car behind The Thalians building here at Cedars. The sidewalk out front has stars in it just like Hollywood Boulevard. Yet I didn’t recognize any of the names. When I went to the website, I learned that The Thalians was founded in 1955 by a group of young actors and allied professionals from the film industry who wanted to give back some of their blessings to the community. They met at actress Jayne Mansfield’s home to discuss how they could use their time, talent and energy to help children with mental health problems. Taking the name from Thalia, the Muse of Comedy and the Shepherdess of straying and lost lambs, the first Hollywood “celebrity” charity was born, and just four short years later, The Thalians Clinic for Emotionally Disturbed Children at Mt. Sinai Hospital was established. When Mt. Sinai and Cedars of Lebanon merged, The Thalians pledged $1 million toward the construction of the first building on the new campus, which was named in their honor: The Thalians Mental Health Center.

Each star represents a significant donor and from what I understand, the annual Thalians Ball is not to be missed, even if it wasn’t at The Playboy Mansion.



The way to eliminate darkness is to expose it to light. As you may have surmised, other than the Arizona vignette, all the people I mentioned, I know. Some are family members. Treating mental illness may not be as quick or dramatic as resecting a pancreatic tumor that encases the portal vein, but the long term return on investment for the patient, those they love, and society, can’t be underestimated.

In Haiti, there are few handguns, and the mentally ill would have a hard time wreaking large scale havoc with a machete. The US is different. Means for destruction are easily available. We can only hope that young men like the Columbine shooters and Loughner are recognized and helped before they explode again in violence.

Dr. King and "Baby Doc" 25 years later

“Wanted – charismatic leader for an oppressed population. Highly challenging position with success uncertain. Must understand a strongly ingrained culture of fear distrust, and intimidation. Unlikely to remain in position long enough to complete duties as assigned.”

Today we celebrate the 25th anniversary of Martin Luther King Day and pause to realize that Dr King’s dream continues in its struggle to reach full potential. In the more than 30 years, since his murder in Memphis, we have an opportunity and achievement gap, and it is not just the black population that suffers. Our country has become more divisive than in my memory, and it seems that we can only be drawn together by tragedies like the Tucson shootings, 9/11, or the occasional miracle like the USAir successful ditching in the Hudson. Dr. King spread energy and belief across all sectors of society and encouraged us to reach within ourselves to find the common core of our existence as one people. I am in awe of what he was able to do, and wonder where we would be now, had it not been for the bullets that ended his life, as well as that of RFK in 1968.

Another leader is back in the spotlight after 25 years – Jean-Claude “Baby Doc” Duvalier made a surprise return to Haiti, after his forced ouster an exile in France. Only 19 when he assumed the Presidency from his father, “Papa Doc,” he continued the oppressive style and corruption. Opponents routinely disappeared, and the sunglass wearing “Tonton Macoute” symbolized unrestrained power and terror. By the time he left, many believe he embezzled as much as $500 million. Arrest was threatened, if he returned.



Yet, last night, at the Port au Prince airport, he was met with cheering crowds and provided a police escort to his high end hotel.

Haiti remains essentially rudderless. Its elections have been seen as fraudulent, and it is unlikely that the runoff will be completed and certified before the current President Rene Preval’s term expires. It is likely Haiti will be without a president. Just as nature fills a vacuum, Duvalier’s exultant return is too coincidental to be happenstance. Why would the average Haitian support a dictator? Just as in Iraq, under Sadaam Hussein, things seemed to run better, even if there was rampant corruption. We will turn the other way, if it means that our children will have food, and the schools are safe. What is most sad about the Haitian situation, is that these descendents of freed slaves are oppressing their own breathren.. Dr King fought an open racism, the Haitian people have a far more insidious enemy.

My biggest fear is that the lack of a stable government will further thwart the influx of needed resources to rebuild Haiti as a nation. The work of organizations like CRUDEM will bring the occasional beam of light to the gloom, and their commitment will not waver. However, large scale involvement by the outside world will wait, until those committing their blood, sweat, and tears know that the help will reach those that need it.

I have spent time in Selma, Alabama, starting point of Dr King’s march to Montgomery. Mornings, I would run across the Edmond Pettus bridge. In the cool light of dawn, I could imagine the mounted police waiting on the east side to drive the marchers back. And in the wind, the sound of the people, black and white, of all religions, inspired to look beyond themselves.

“We shall overcome. We’ll walk hand in hand. We shall all be free. We are not afraid. We are not alone. The whole wide world around. We shall overcome, someday.”

Baby Doc, the world is watching, are you listening?

An Anniversary that I Wish We Didn't Have

One year ago, the long suffering Haitians were subjected to a disaster of unprecedented magnitude. Rather than wax philosophical, I thought it best to forward this note I received as a CRUDEM volunteer, from our President, Dr. Peter Kelly:


January 12, 2011
Dear Friends,
A year ago on January 12, 2010, Haiti endured the worst natural disaster ever to strike our hemisphere. The massive earthquake killed an estimated 230,000 people, injured over 300,000 and left over 1,600,000 homeless.

It got worse. A hurricane, floods and a devastating cholera outbreak ravaged this struggling and impoverished nation.
Over the past year, your generous support enabled CRUDEM/Hôpital Sacré Coeur to:
Treat over 1,000 earthquake victims and their families and perform over 800 surgeries to repair serious earthquake injuries
Install one of the first prosthetic labs in Haiti and fit 41 and counting prostheses
Treat over 1,100 cholera victims, almost a third of them children
Host over 1,600 medical and non-medical volunteers
Send almost $20 million in donated supplies for disaster relief.
All the while, CRUDEM/Hôpital Sacré Coeur continued to provide first class, tertiary care hospital services to the North region’s 225,000 residents.
In keeping with our commitment to put our our Haitian sisters and brothers first in line:

100 % of funds and supplies raised for Disaster Relief were sent to Hôpital Sacré Coeur.
CRUDEM/Hôpital Sacré Coeur has been in Haiti for 25 years, and that’s just the beginning. We are in it for the long haul. No matter the number of disasters or their daunting challenges, we will keep our vow to create a healthier Haiti, one dignified life at a time.
On behalf of the people of Haiti, thank you for your continued support! YOU have moved mountains and put countless men, women and children on firm footing.

May God bless you and your loved ones!
Sincerely,

Peter J. Kelly, M.D.
President
CRUDEM/Hôpital Sacré Coeur

Thank you all for your thoughts and support. May the light of a new and better year shine on the people of Haiti.

Harry

Planes, Trains, and Automobiles

“Get your kicks on Route 66”

Over the last four weeks I’ve traveled about 20,000 miles and experienced multiple Americas. From commercial aircraft flying from East to West and back, the driver’ s seat of an SUV cruising along the Arizona /Mexico border through border patrol checkpoints, or the Amtrak Acela, returning to Providence for dinner with a colleague, I appreciated the diversity of our country, and developed a greater understanding of the things that both divide and unite us.

I started my new position in LA January 1, and we had already packed the apartment in Providence in early December. There was the trip to Haiti, then a flight from Milot to Port au Prince to Kennedy, and then on LA so I could be fingerprinted for my license, find a rental property, and finalize the job details. Cars and Chester still needed to get from East to West, so a long drive was in order to arrive by December 28th. Finally, I was to come back to Boston, January 6th for my health care management course. I had made arrangements to catch up with Rich Goldberg, Chief of Psych at Rhode Island Hospital and the Miriam, and now SVP for Lifespan Network Development, who is a friend and fellow graduate of the Boston program.

You truly don’t realize the grandeur of this country until you drive from one end to the other. I’ve flown enough to have recognized landmarks and cities, appreciated the circular irrigation pattern in the high plains, and reveled in watching a thunderstorm from 36,000 feet, the cloud to cloud sparks lighting the night sky. But as Rhode Island faded in the mirror, I was looking forward to the trip down 95 and across Virginia, Tennessee and the South. Finding dog friendly hotels was easier than I thought and appreciating the rise in the terrain, the change in vegetation, and the new accents and voices on the radio made for a surrogate marker of the trip’s progress. Transitioning from bumper to bumper around New York to seeing no one else for miles around in the Bayous of Louisiana, I realized that we adapt to our environment, and develop attitudes and mores that work for that region. We bemoan the dissent in Congress and the narrow mindedness of those who live in other regions than ours, yet it became perfectly apparent why those differences occur. And I can only imagine what early settlers felt as they gazed across an endless dessert, and worried about survival.

Airplanes are efficient ways to travel, but the time warp doesn’t always give you a chance to appreciate how far you’ve gone. Most airports look the same, although a few have nice amenities (the rocking chairs in Charlotte.) On a trip from JFK to LAX, a former cast member of Saturday Night live, sat down in front of me, he was clearly fatigued and appreciated that his fellow travelers left him alone. From what I could tell, this New York – LA trip was repeated on a frequency similar to many of us traveling on a regular basis from Providence to New York. In five hours, we had crossed 2500 miles and 3 time zones. It was dark when we left, and dark when we landed. Quick and yet sterile. In some ways we’ve made flying so easy that it’s lost its adventure – but that’s for another blog.



Before moving to the East Coast, my experience with trains was going from Chicago to Canton, Ohio on the Broadway Limited, when I was in college – a completely different way to experience America. I would have flashbacks to “The Sting” and met quite a few unique personalities, who had plenty of time to talk in the bar. The Grand Stations built in the 30’s always make me think of my parents traveling, or young men in uniform, returning to their base. You would get snapshots of America, and I always remember the smell of jelly as we rolled through Orville Ohio, home of Smucker’s. Even today, the Acela is my preferred way to go to New York, although the food is a bit more like the airlines. I took Amtrak Sunday night from Boston to meet Rich. Walking up the steps at the Providence Station, I immediately thought about finding the car and heading back to the East Side. Took a minute to reorient, and I had a great dinner and chance to reflect on the past and the future. Train back that night, a plane to Baltimore yesterday to see Rachel, who just got back from France, and I’m currently following the sun back west on Delta. Hop in the car and will still get into the office.

BTW, the picture is of the Salton Sea from the car heading to LA. The light was perfect, and I stopped to capture the moment. Flown over it multiple times as the LAX departure corridor is right there, but I felt it in a different way, having driven over multiple days and thousands of miles. There are new opportunities in California – there are friends and family back East – and in between is an amazing collection of geography, cultures, and experiences that we call America.

Route 66 was the road to dreams from Chicago to California. On your bucket list should be a Coast to Coast drive. And let me know what new perspectives you find.

CRUDEM Volunteer Goes Above and Beyond

Ed Constantine paused for a moment as he taxied the Beech Baron into position on Runway 5 at Boca Raton Airport. “At this point, I always pray.” I nodded and bowed my head as he quietly crossed himself. He looked up, advanced the throttles and we rolled toward the light of the rising sun. I made the call outs- “Airspeed alive; rotate; positive rate; gear up.” There was nothing wrong with the airplane that required prayer to urge it skyward. While most people would be a bit shaken by a pilot praying immediately before takeoff, I wasn’t surprised.

Ed Constantine feels blessed and reminds himself of that daily. Today’s flight is his way of giving back for his successes, and fulfilling a calling.

The morning of the flight was the first time we had met face to face. Introduced initially through emails and CRUDEM, we shared stories of flying and he brought Tania and her mother from Cap Haitian to the States for her subsequent treatment at Hopkins. We discussed the medical issues related to bringing her in a nonpressurized aircraft and calculated weights and balance so that a fuel stop would not be needed in another foreign country. He safely delivered her to Florida last fall. I later found out he would do even more.

Before we met, my image of Ed was that of a retired business man, likely in his 60’s, flying a 25 year old plane that he used for pleasure and occasional philanthropy. That morning at the FBO was a young athletic man, and his airplane was a recent model G58. As we loaded the computer equipment, he mentioned falling off a ladder several years ago and breaking his back. There were recommendations for multiple surgeries that would have significantly reduced mobility. He was fortunate the night of the injury that an orthopedic resident doing a spine fellowship was moonlighting and immediately placed him in a brace that stabilized the bones. His spinal cord was intact. There was a period of time before he would have to undergo surgery. He spent those weeks thinking about his life and realizing not everything was in his control. Over time, the bones realigned and the fragment in his canal reduced. He admitted that he felt the power of faith.

Subsequently, he and his wife devoted themselves to family and his church. He is an engineer and had started a consulting business looking at operational improvements in process. Through hard work and some luck, the business was bought, giving him a moderate windfall. What did they do with the money? They set up a charitable foundation, and were able to purchase the plane, to be used for trips like today.

We leveled off at 11,000 feet and the broken cloud deck below cast shadows on the water that looked like islands. I realized we were in the Bermuda triangle and could see how early sailors and pilots could easily be confused. The conversations flowed easily and we discussed the differences and similarities in our religions. There were clearly some significant differences in beliefs around certain subjects – they were mentioned and tucked away. At one point I could only see water and subconsciously checked the fuel flows and cylinder head temperatures. We pilots think that engines know when you’re away from land and purposely run a little rough, just so you know who really in charge…



Miami lost radar contact and we were back to giving position reports like the pilots of the 30’s and 40’s. Soon we picked up the beacon for Provo, in Turks where we’d refuel and head for Cap. The Haitian ATC system is quite rudimentary. We broke out of the clouds for the runway 23, only to see a plane ahead on us back taxiing where we were land. A quick 360 degree turn to the right bought us some time, and the landing was safe, given the runway condition and potholes. He dropped me off, and picked up some volunteers heading back to the States. I stood outside to watch him disappear back into the mist.



We exchanged a couple of emails and Holiday greetings. Then I got a note sent to the team of volunteers who helped with Tania.

Tania made it to Hopkins and received wonderful care. Her father and relatives were able to see her in Baltimore, and her mother and cousins stayed across the street. Unfortunately the disease progressed rapidly, despite therapy. She died just before Christmas at age 24.

Her family was too poor to return her body to Haiti, and we were trying to work out the logistics. However, she was cremated in Baltimore and her mother went back to New Jersey with family. They asked Hopkins to dispose of the remains. Ed had met Tania and her mother for only a few hours, but felt that she needed a final resting place. This Monday a funeral mass will be held at St Joan of Arc church in Boca Raton Florida, followed by interment at the cemetery. All arrangements were carried out by Ed and his family. Tania’s parents will be there.

And the next time I see sunlight reflecting off a Baron, I will pause and be grateful that the world has people like Ed. And now that I think about it maybe it's better as a pilot to say your own private prayers, than to look over at your passengers and see them fervently praying for their survival.

Moving In

Many of us awake New Year’s morning with a headache, and the resolution not to overindulge the next time. We avoid the sunlight breaking through the windows. And we wonder how the next year could be any different from the previous slog. I’m not feeling any of that. At this time last year, I had no idea I would be going to Haiti, moving to the West Coast, and finding new meanings and opportunities. Or enjoy moving a house.

It’s quiet in the rental, the kind of quiet that you experience after front row seats at a concert. The continuous hustle and activity of the movers ended at 10pm last night. Gentle Giant had packed the old house and did the move here. Alfonso and Ish were both from Providence, and you would never put the two of them together. It was good to share stories of kids, RI drivers, and how they liked this lifestyle where they could chose when to be on the road, work intensely, then be able to stay in Providence to coach football for their kids. These two guys unloaded the whole truck, smiled the entire time, and kept asking how I was doing trying to keep up. Over deli sandwiches and Mountain Dews, we laughed at stories of heated political debates at truckstops. We shook our heads at their experiences in the South, where they couldn’t find a place to get a beer together. (Alfonso is African American, Ish is from Eastern Europe with an accent.) And when the move was all done, they were under budget. It’s a good sign for 2011.

What the last year brought me, which was reinforced yesterday, was that when you are open to the experience of the moment and to new opportunities as they present themselves, you may be surprised what you can learn about yourself. I never enjoyed moving before. Perhaps because I am looking to the future with a new perspective, and with the spirit I in learned about in Milot, even the simple act of unpacking brings both memories of the past, and excitement for the future. Ben and Janine helped set up the bar. It’s about 5 feet from the sliding door, looking over a small pool. We found the martini shakers, tall juice glasses and the nice wine carafes. This morning, I’m seeing ripples of light against the water, and visualizing friends and family enjoying a beverage and each other’s company. And I’m excited about the challenges and potential in my new job.

Given the housing market here, another move locally will be likely, if I ever want to own anything. Another goal for the future, while enjoying the now.

Happy New Year. Hope to see you in 2011.

And in the words of Jed Clampett and Granny, from “The Beverly Hillbillies,” “Ya’ll come back now, y’hear!”