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.