From Whose Perspective?

Never did get the internet issues worked out, and thanks to Rachel for posting what I could get to her. Now with great service 30000 feet over Florida, go figure.

 I've accumulated several, and over the next few days, look forward to sharing them with you

Five hundred years ago, it was common belief that the Earth was the center of the Universe, and all other heavenly bodies revolved around us. Although this was subsequently disproved, we are often reminded of our own tendencies toward egocentricism. And this can become painfully obvious when working in a different culture.


The supply chain challenges here at Sacre Coeur stem from multiple sources, not the least of which is the generosity of individuals and organizations around the world. We were inundated with supplies and donations after the quake, and continue to receive tremendous help from CRUDEM and its network of supporters. In recognition of the need for inventory control, we partnered with Humanitarian Software and BarControl Systems to computerize and inventory our pharmacy and medical consumables. This is a daunting tasks with 1800 SKUs(with multiple subcategories), and 12,000 cartons of inventory. The pharmacy presents additional challenges, as medications, delivered in bulk, are eventually dispensed to individual patients. Bar Code stickers are printed as materials arrive, and there are specific MDC codes on US manufactured drugs that identify dose, form, strength, and quantity.

As supplies arrive, they are bar coded and HSC employees are to scan the item and where it is placed. When a requisition from the hospital comes, the amount dispensed is scanned and subtracted from the inventory. Moving supplies from one location to another should be easily monitored. A running total of supplies on hand, and rate of utilization, will provide a guide to anticipate needs, reduce duplication and prevent shortages.

If it were only that easy…

I spent yesterday in our pharmacy warehouse, which as you may recall, was created by welding shipping containers together. It is well organized, (air conditioned), and has full wireless network access. Since it is the only source of narcotics and other medications for the hospital, you’d think we could monitor utilization, but the reports just didn’t make sense. As I was counting used vials to get a proxy for utilization, I noticed some had bar codes and other didn’t. Remember I said that the US NDC codes served to classify the bar codes? Foreign manufactured meds (probably 50% of our stock) don’t.

Now these were not drugs unavailable in the US. Many were common antibiotics, like Augmentin, with identical strength and form. But they weren’t counted since they couldn’t be labeled. Working with Will Bardos from the bar coding side, we solved that one last night by cross referencing to the codable equivalent, not worrying about specific manufacturer or trade name, rather assuring that the dosage and form were identical.


Challenge 2 was the scanner. They were intuitive to use, but as Will asked a staff member to show us how they dispensed an item, they struggled. As I looked at the scanner, I realized the instructions were in English. Although this system has been employed in other parts of the world, English was more prevalent. The administrators using the system in Milot were bilingual, but other members of the team were not. The egocentric response would be, “If they want a job, they need to learn English.” The pragmatic and practical response is, “This is a major change in how they do business; let’s make it as easy as possible.” We are currently working on translating the instructions into Creole.

For those of you following this blog over the years, these incidents may not seem as dramatic as the stories after the quake. But there is a common theme – as human beings we all have the tendency to deal with our own needs first and view the world from our perspective. The successful among us see multiple other points of view and can adapt their response. We did that in the crisis atmosphere after the quake, and will strive to maintain that attitude.

When I was a Boy Scout, I remember a Native American saying. “Never judge a man until you walk a mile in his moccasins.” Thought that was a little hokey then, finally starting to get it now.

Bonswa!

Incentives Drive Behaviors

On my morning run to Sans Souci, an acrid smoke enveloped the valley. This is not unusual, and occurs when trash that has accumulated is being burned in open pits.

A truck arrived with supplies, and local men, eager to earn some income rapidly unloaded it, even though it was into the incorrect place. They will need to be hired again to move it and will receive additional compensation.

 

A vibrant market has sprung up in front of the hospital, and it has grown larger since my first trips 2 years ago. Just down the street is a freshly renovated building with an office supporting Haitian tourism.

Free market economies are human nature.

The dire economic condition of Haiti, compared to the West, leads many to believe that the country is completely dependent on outside support. It is easy to characterize the population as indifferent. Yet what is clear, is that people will adapt to their environment, and incentives will drive behaviors.

The truck is a classic example. Filled with supplies, it arrived unannounced at the end of the day. The first gate was near a storage facility about 400 yards from the proper site. Supplies shouldn’t be left out for fear of damage, and the truck needed to return to its base. Twenty five men appeared and began to work understanding they would receive a few dollars. The supervisor acknowledged the issue, but said that they could come back again tomorrow and move everything to its proper site. In Western terms, the amount of money is small, and other than convenience issues, there’s no huge downside. Yet for the men, eager to work, the inefficiencies led to additional resources for them and their families.

The market outside the hospital initially sprung up to provide a source of food for patients and staff. Subsequently, with expansion of bed capacity and the paving of the road from Cap, more demand has developed. My favorite fried plantain and empanada place is there, and the owner recognizes me and will cut me a deal, knowing that if the other volunteers see me eating the street food (only fried and no meat) they might try it. There are more motorcycles leading to a brisk business in oil and supplies. Buildings are being completed around the compound and this has brought additional potential customers. Perhaps due to some sense of optimism, tourism is again being encouraged.

So what does free enterprise have to do with burning trash?

There is no organized sanitation system and recycling, other than coke and beer bottles, is unheard off. It’s easy to just toss trash in the gutters or the river. In Los Angeles and other cities, trash (biomass) is a welcome commodity, as it can be burned in a controlled environment to generate electricity. What is we created the same type of demand for trash in Haiti? Those looking for income would gather waste and bring to a central facility where a market based amount is paid. The cleanly generated electricity would reduce the need for coal or diesel powered generators. The electricity would support other areas of economic development. And there were be less need to burn the plastics in open pits.

Perhaps I’ve taken too many courses on entrepreneurship and launching new businesses. Yet by looking at basic human behaviors, and evaluating the environment, great strides can be made that can yield economic, social, and environment benefit in multiple realms.

An Unappreciated Organ

Greetings from Milot.  It’s quite comfortable today and we’ve already begun working on the inventory system and running clinics. Internet access is limited and Rachel will be posting my blogs as I e-mail them.

What is the body’s largest organ?       

Before you start snickering, it’s not inherently obvious. Although the liver can weigh several pounds, and the skeleton has high density by volume, they are not, by cell count or size as large as the skin.

I’m currently on the charter flight from Miami to Cap Haitien, with several other volunteers from around the country, including a dermatologist from St Louis. Earlier last week, I toured the Center of Wound Healing at Georgetown University, where a multidisciplinary team works with patients, who have developed wounds from trauma or disease that won’t heal. Many are diabetic, where the combination of disease of the small vessels, dysfunction of the white blood cells from hyperglycemia, and neuropathy lead to foot ulcers that will not heal, or become infected, leading to sepsis and death. At some point, the disease can progress to where amputation is necessary, creating a new wound, and causing significant disability. The cost to both the patient, and society is dramatic.

In Haiti, we have additional challenges. Given the large number of open flames used for heat, cooking, or other local traditions, burns are common. The use of water that is unclean to cool the injury  can inoculate the area with bacteria. There are great distances that may need to be traveled on foot, to reach medical care, and additional trauma occurs. I have seen burns that area days old, and have begun to fester. Even if they heal, the open burn scar can progress to a Marjolin’s ulcer, a type of skin cancer. I had read about this during my training, and perhaps had seen one in 25 years. They are far more common here. Untreated burns heal by contraction, which, if they occur across a joint can inhibit movement. Sadly this is not uncommon in children.

Highly pigmented skin is protective against most skin cancers; so it’s not surprising that when tumors develop in the local population, they may present at advanced stages. When I went to the OR today, our ENT/Plastics team was excising a large skin cancer in a 20 year old albino woman. It was on her face and had grown into her maxillary bone and the edge of her eye. They were able to get around it and place a skin graft.

We also have the sequelae of tropical diseases, including parasites that block the lymphatic system leading to massive limb swelling, skin breakdown, and disability. One patient had swelling of only one leg, which was unusual. When conventional therapies did not work, a biopsy was obtained and read back in the states – Kaposi’s sarcoma due to undiagnosed, advanced HIV.

Surgeons have been known to say, “Don’t let the skin stand between you and a diagnosis,” acknowledging that we have to violate a protective barrier to repair what has gone awry. We at the same time are dependent on the skin to overcome our insult, and many post-operative complications are related to wound healing and infection.  The process is amazing when you think of it.

Finally, the skin, like all organs, is subject to changes with aging and sun exposure. The amount of resources spent on cosmetics, various spa treatments, and surgery is an economy unto itself.

I’ll be putting on my sunblock and mosquito repellant, but every time I come to Milot, I’m proud to have “skin in the game.”

Two Years and Where Are We

We tend to view anniversaries with mixed emotions. Some celebrate a marker from a difficult event, such as survival from cancer. Others mark a remembrance of the loss of a loved one or the joy of a new child. Wedding anniversaries are referenced to jewels or precious metals, and their significance evolves with the couple. But for Haiti, the anniversary of the quake is a stark reminder of how much needs be done.

There is still hope; if the new government brings some stability, and the court systems deal with the corruption of the past, aid is ready to flow in. Some organizations aren't waiting. I urge you to listen to a wonderful review of a new teaching hospital being built by PIH, recently on NPR.

http://www.npr.org/2012/01/27/145909633/state-of-the-art-hospital-offers-hope-for-haiti


 CRUDEM is also not waiting. We are currently recruiting nurse educators to help with our new nursing school Here's a note from Deb O'Hara.

Many of you know we have been embarking on many exciting expansion projects at both the hospital and the CRUDEM compound in Milot, Haiti. One of those projects is beginning new nursing programs conferring accredited BSN degrees (and later MSN degrees!) We are about to begin pre-requisite courses for all the candidates, along with standardized testing prior to "formal" admission. To this end, we have two very important specific needs:

• Teachers who are qualified to teach English Intensive with a Medical Emphasis (Currently researching Kaplan curriculum–To begin ASAP!)

• Teachers/Faculty who are qualified to teach the following science courses (for pre-requisite to begin May/June timeframe): - Anatomy & Physiology; Pathophysiology; then Microbiology

 Dr. Previl plans on providing the candidates a review for each of the science courses over the next 3 months, hence the reason for the accredited science courses to begin in May/June. Each of these courses can be taught in a condensed version, i.e. Monday through Friday over several weeks instead of an entire semester (HSC will be allowing the prospective students time off with pay to take the courses.) All teachers must be qualified (please submit your CV to CRUDEM) and teach an accredited course (each faculty should have their own course syllabus with course description and objectives to submit.) It has been decided that English is absolutely necessary and that all courses enrolled in UND/CRUDEM nursing school will be taught in English. (French texts to reinforce teaching will be allowed and accessible to all in our library.) Therefore, we need to start this intensive course as soon as possible! Although Sister Maureen has done a great job at beginning some English courses, we are now in need of an intensive English course with emphasis on medical terminology. Sister Maureen can coordinate and oversee teachers, but we need several high level, professional teachers for this effort.

Thank you for your serious consideration to the above requests. Deb O'Hara-Rusckowski, R.N. Nursing School Coordinator debohara1@aol.com

May all your anniversaries mark the beginnings of something new and great, based on the lessons and experiences of the past.

The New Year - Let's Not Waste It

Humans strive to improve themselves and hopefully support those around them. It’s been about 6 months since I’ve had a chance to share with you. As I anticipate another trip to Milot, I am also both reflecting on how my perspectives have evolved after working at Cedars for a year.

Both HSC and CSMC have significant challenges. At the core of their existence, however, is a commitment to patient care and education, support by core beliefs. Cedars Sinai is located in one of the most affluent areas in the world, yet outside our doors are the homeless, and those making tough choices as they have lost jobs. At HSC, we have been fortunate to acquire significant supplies and materials through generosity and the work of CRUDEM, yet at the same time we run short of some essentials, while trying to find a place to store thousands of crutches that arrived after the quake. Cedars provides excellent care at a very high costs: CRUDEM does remarkable things in a very constrained environment. The two institutions can learn from each other.

I am currently returning from a seminar examining reducing waste in health care. Whether it is a catchword like LEAN or Six Sigma, the basic concept is to understand a process, and look at whether we are adding value by each step. In a resource rich environment, we tend to respond by putting more personnel or technology, which can have incremental effect. Yet the greatest improvement comes when you involve those at the front lines. Finding how people “work around” a system gives you a far greater understanding of the constraint, than imposing an external fix with another policy.

In Milot, I saw the value of face to face communication, and learned of ways to use equipment and supplies in innovative ways. People were thrilled to have a job, even at a relatively low wage, and we were able to use human capital to accomplish much. The physical examination could be supplemented with a careful history and focused laboratory studies. The lack of routine CT scanning did not have as much of an effect as one would believe. By the same token, it was often difficult to know when supplies were running low, and the commitment to develop an inventory system will be a key technology with a high ROI. Just as with any new process, however, we learn of other needs, such as a manual determination of our baseline utilization.


Cedars Sinai Medicine is our clinical transformation initiative optimizing our institution and its people to provide the patient with the most appropriate, evidence based care, delivered in an efficient and compassionate manner. We are learning that expectations and reality are often in different places, and much of what our patients want doesn’t cost a lot. We are finding that some of the most valuable conversations are those that occur before an acute illness, and that prevention doesn’t just happen. We are a remarkable institution, with remarkable resources, and like Milot, the greatest resource are our people.

 I did make it through this blog with talking about New Year’s resolutions. I have no excuse for not writing more frequently. Perhaps I’ve been a bit preoccupied. I do enjoy sharing my thoughts and hope that you find my perspectives helpful as you look at your own life. We who are fortunate to be in medicine has much to be grateful for, and many challenges ahead. I’ll look forward to being enlightened by you, my readers.

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.