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.