Haiti: Epilogue

Throughout this week, T.S. Elliot continually came to mind:

Let us go then, you and I,

When the evening is spread out against the sky

Like a patient etherized upon a table;

Let us go, through certain half-deserted streets,

The muttering retreats

Of restless nights in one-night cheap hotels

And sawdust restaurants with oyster-shells:

Streets that follow like a tedious argument

Of insidious intent

To lead you to an overwhelming question…

Oh, do not ask, “what is it?”

Let us go and make our visit.

Before we left, I wondered why I felt so etherized upon the surface of my life.  Perhaps the path of my life and career were as random as Elliots poem.

The people of Haiti do not live etherized lives.  They feel the pain of their plight and the weight of their poverty.  Yet, they continue to move forward with resolve and determination.  They fill their lives with the company of the family and friends.  They share their lives constantly.  They sing. They dance. They live.  Despite an average yearly income of $270, they share an emotional wealth far greater than many of us.

Perhaps our insidious intent to standardize our lives and control our environment has lead to a tedious argument punctuated with questions of whys and whats. But what the people of Haiti shared with me was their warmth and their community.

Our team laughed harder than most college dorm rooms on a Saturday night.  We told midnight ghost stories.  We yelled at each other and cried.  We celebrated and we mourned.  We felt fear.  We applauded and cheered inappropriately in public.  And the rare moments of calm and peace, we felt the lightness of our being.

We have taken away more from Haiti than we have given.  Our initial goals were:

To build

To help

To learn

To share

As I add our fifth goal, I think it may have been the most important lesson for all of us.

To feel

The dust tasted oddly earthy as I sat in the corner of the storage room. Salty sweat dripped from my surgical eyeglasses and headlamp. Surrounded by crushed boxes, overturned medical equipment, and spilled germ cleaning fluids, this hospital room looked as broken as our patients. 

It was Edgard’s idea in the first place. He thought we could take the white marker board from one room and move it here. Maybe we could put information on it. As we talked together, we came up with the idea of putting a table in the room and creating a meeting room for the doctors and nurses to meet every morning.

Just as we spent days fixing broken bones, we began to dissect every broken room in the hospital. The vital entrails were strewn across the open air hallways as the patients watched with an expression I saw during our emergency code 2 days ago. We struggled with the anatomy of what could become an effective field hospital. Homemade shelving with a new homemade operating room table was delivered. Plywood would never receive as much glory as it would on this day. And with the same urgency and panic I’ve had every day, I wondered how I was going to finish this operation by the end of the day.

As Edgard motivated me to get up and continue on the white board project, this disaster as a metaphor became complete. The room would only become complete with the help of my Haitian interpreter. The hospital could only be complete with the cooperation of Haitian doctors and nurses. This disaster will never recover without mutual growth of who we are with who they are.

The simplicity of the white board will be to track every patient that is in the hospital. The medical teams will stare constantly at the board like travelers in a snowbound airport. Patients will never be forgotten and mundane tasks will always get done. This small little idea will save more lives than all our operations this week.

One of my most important lessons this week has been about the elegance of simplicity. We’ve gotten by on a diet of rice and beans, we’ve watched joy and sorrow in each others eyes without the benefit of any electronics, and we’ve communicated as a group without the aid of conference calls or webinars. Last night, we even clutch started a 2 ton truck without the need of a battery.

As we close our work this week, I know Haiti may have healed me more than I have healed her. Though nature has exacted a huge force in the course of our patient’s lives, I hope we have been able to alter their course at least slightly. Their coastline is filled with plenty of jagged reefs but they have equal amount of safe harbors.

“Be safe”… probably the most common statement made to me as I prepared for my trip here. I appreciated the undertones of comfort and security. A nurturing statement that my mom would have said as I walked to preschool.

“Be safe”.  It infects nearly every decision.  Because the water is not drinkable, a slight mistake brushing your teeth can lead to days of diarrhea.  The dirt road separating the hospital from our cabin has large trucks and buses barreling along at 45 mphs.  Besides getting run over, the shower of rocks and pebbles pelt my surgical eyeglasses and headlamp that I wear all the time.  If you forget your bug repellant or your malarial medication, any one of my numerous and growing mosquito bites would be the concern for serious illness.  During one of our surgeries yesterday, safety was never more evident as one of our very own team members sat in the corner with an IV to hydrate as we addressed a child’s perforated intestine.

Safety is a constant process that weighs on every decision.  In surgery, we have to organize our own equipment.  Because there is only one sterilizer, if you forget an instrument, a scissor, a scalpel, or a screw, you will have to wait nearly 30 minutes before that critical tool is available.  Forget twice and it’s an hour. An hour more of anesthesia is also an hour more for the flies to roost on your surgical field and an hour more of danger for your patient.

There is no easily available x-ray.  To x-ray a patient a team member has to transfer the patient on a wobbly wooden stretcher and pull the cart across the gravel road 300 yards to the ancient machine where a near nuclear dose of radiation will produce a gray plastic image to be read like tea leaves.  There is no safety in making orthopedic decision without x-ray.  There is no safety in surgery without proper instruments.  How would we know if our bones are straight or if our screws are too long or too short?  How would we put a screw in without the proper screwdriver? Like Hamlet agonizing over death, we ask, “to be safe or not to be safe”.  I wonder which will lead to more regret.  I know what it means to be safe.  But do I know what it means not to be safe?

There is a patient here with a complex femur fracture.  We were planning an operation to fix it without x-ray or the proper insertion equipment.  If the surgery went smoothly, we could straighten his crooked leg in 30 minutes.  If it went badly, we would struggle for hours and then amputate his leg.  In the aftermath of our recent death, I chose to be safe. Far better, I reasoned, for him to have a crooked leg than no leg at all.  There was no need to be dangerous.

As I unpacked newly arrived crates of equipment today, the insertion tools for his operation hid in the corner of the box.  Then a pick up truck began backing into the dusty entrance with an 1800 lb crate protecting a full size portable x-ray machine.

Goethe said, “be bold and great forces will come to your aid”.  As I looked at the newly arriving aid, I regret the decision I made for my patient.  It is too late in the week to tackle such a large operation. Fortunately, it will be an easier decision for next week’s team.  So I wonder about the words “be safe”.  What is the opposite?  Is it “be dangerous”?

Like a man standing in the middle of the highway, he must decide to jump left or to jump right.  Because to play it safe and stand still will lead to a far worse outcome.

The opposite I think is “be bold”.  By coming to Haiti, I have learned that I may never have enough information or equipment to make a perfect decision and that even an imperfect decision may be better than no decision at all.

We all watched as the little girl sobbed holding her grandmothers hand. The Grandmother’s chest rose and fell agonally for a few moments and then quietly held its peace. We were all there.  We had moved her out of her so called hospital bed a few minutes earlier. The room was the size of a large sauna, sharing its temperature and dimness but not its odor.  It was overfilled with people witnessing an event that would be a story told and retold that night. Perhaps for a week.

As we tried to resuscitate her our medical group continually talked, reviewed, and strategized.  Even if we couldn’t have our modern life saving equipment, at least we’ll act and behave as if we were in the ICU. The only place she really should have been all along.

Her heart was weak. She was anemic. She hadn’t had adequate nutrition in weeks. There were more germs in her bed than my son’s football locker room. Yet, she needed her operation. She was transferred here to specifically get this major operation.  If she didn’t have it, her leg would cease to function, become paralyzed, and the month of constant pain she had already suffered would be permanent. Without the surgery, she would flounder in this bed until she was overcome by the germs of her mucus, urine or feces.

We brought together everyone who was involved in her care that afternoon. I wanted to review her story. Her operation was difficult yet it was quick. It had also been successful. Her pelvic bone returned to normal place. She didn’t have excessive bleeding. After surgery, she was not in excessive pain. Her blood pressure was low but curiously her pulse did not respond to her condition. As if the last month was too much, or perhaps the last 67 years was too much, the heart refused to beat any faster. We did whip the heart with medication, trying to spur a quicker pace. Like the donkey that wakes me every morning, it took a few rapid stumbling steps forward and finally refused to pull any longer.

Oxygen could have helped. So would an EKG machine, a Swan Ganz catheter with a pressor drip and a ventilator. If we had the equipment, we could have done all that. We could have actually improvised many of those things.  But then where would we send her? She and her granddaughter were lying in an open air room behind an iron gate (the closest thing we had to an ICU) for at least 2 hours with an emaciated pregnant dog walking by.

Every day in Haiti, hundreds of people die. Last week, thousands of people died, and the week before tens of thousands of people died. But at least I know it will be less next week. I do not know the stories of all these people. What is important to me is that I know the story behind my patient.  It’s important to our team and all the people who were in her room this morning.

Is the shame that so many people died or that so many stories were never known?

I didn’t hear the familiar pop of the hip joint dislocating as I twisted the leg into a contorted position during the operation. Not that I would have noticed since it had been almost 20 years since I did a posterior dislocation of a hip with an acetabular fracture.

The woman was crushed when her house collapsed on to her back as she crouched for protection. Although initially paralyzed, the function of her legs returned but because of the awkward position of her hip and the pain, she would become permanently crippled unless we did something.

The operation required much of the newly bartered equipment from yesterday. A partial hip replacement turned out to be a critical component of the surgery. Though we finished in under 2 hours, time moved slowly.

But to be out of one’s own routine will slow time down. The way I awake and shower and brush my teeth in the morning is significantly different here than at home. How I eat and what I eat is sporadic, unfamiliar and inconsistent. My routine at this hospital is unlike anything I would do at home.  So it is no wonder that some of the events from even a few days ago feel as if it occurred several weeks ago. My time has been stretched and elongated by the unfamiliar and the change in my environment.

For different reason, my nights are long.  Despite being pretty tired, I’m awoken not only by the noises of the chaos around me but similar noises within me.  Whether it is from the fear of surgery that is unfamiliar and without adequate equipment or the fear of caring for a very sick postoperative child without an ICU, these noises are loud and also stretch my perception of time.  I feel as if I have been here far longer than my 4 days.

But for our patients, it hasn’t been 4 days; it’s been 30 days. They have had their routine disrupted. I’m sure the noises they hear at night are louder and sharper than mine. I’ll be returning home in a few days with these stunning memories of slow motion. For the Haitians though, like a dream of being chased where your legs don’t seem to move, I can’t imagine their endless night.

The drive to Port au Prince is not for the young or old. Sitting on the raw steel plates in the back of an old ice truck, fully enclosed and insulated to swelter in 95 degree weather is not comfortable. Add to it 2 hrs of traveling on unrepaired roads and traffic filled with thousands of other people who have the same sense of urgency as you, and feelings of suffocation and claustrophobia can be strong.

Our goal was to obtain specific supplies we needed for our surgeries. Armed with the only currency that is meaningful here we planned to visit 3 other medical units in Port au Prince for trade and barter.

With the Project Hope Mission we traded anesthesia medication and morphine for 4 femoral rods and a 7.0 mm cannulated screw system. Street value: $30,000. With another outfit, we accepted 4 paralytic unstable spine victims and got 10 Kuntchner rods, 3 blade plates, 1 Austin Moore, and 10 packets of antibiotic cement.  Finally, for agreeing to return Thursday to run an orthopedic clinic for 3 hours we got 30 walkers 4 IV poles and 1 empty dressing cart.

The equipment will help our patients immediately but for those of us who sat around the negotiating table, we walked away with a reinforcement of the reasons why we came here in the first place. These reasons vary for each of us, but as we all walked away from the table satisfied, we were pretty content.  I’m not a 100% what my own reasons are but I’m sure it was a sense I had when I was young that I’m only rediscovering as I’m older.

Footnote: thank you to the surgeons of Project Hope and the Canadian team of surgeons from St. Joe’s Hospital for your incredible support.

It’s far from comfortable here in Haiti. 2 hours north of Port au Prince, Pierre Payen is dry, arid and hot. The dirt roads have been pulverized to a fine dust that permeates everything. The dust is in your clothes, your hair, even your teeth when you talk. It’s also on your bandages and in your operating rooms.

Your daily routine would never work here. With running water or regular electricity, simple things like brushing your teeth or going to the bathroom require extra thought.  Surgery requires even more thought.  Because there is no infrastructure, every aspect of our advanced procedures has to be provided by our team including preparing our instruments and sterilizing our equipment to IV’s, blood tests, anesthesia, transport, and recovery.  Even giving medications, changing dressings, cleaning up diarrhea and showing a patient how to use an inhaler.  As an orthopedic surgery team, we’ve diagnosed and treated pneumonia, congestive heart failure, and probable parasitic infection.

We had been about to start an unstable leg fracture case when we were told about a child just carried to the hospital.  He was clearly sick and listless. Young children can have spontaneous infections in the hip and it appeared that was what he had.  After bumping our trauma cases and positioning him for surgery, we noticed that he was so swollen and infected that his scrotal areas had been obstructing the flow of urine for the last 3 days. In surgery, we couldn’t even place a tube to release the urine.  With nowhere to turn, an emergency circumcision was performed which allowed the placement of the tube and a release of almost a quart of urine.  We could then proceed with the operation to release almost a quart of pus from his hip muscle, which isolated a probable tuberculosis infection.

Although not comfortable here in Haiti, it is rewarding.

Haiti Day 1

An early morning start to meet our jet at 3 am was uneventful. The jet, generously donated by Ariel Corporation, served our needs well. With over 600 lbs of equipment, we needed the cargo space more than direct access to a private landing strip. Even if a commercial flight had been available, we would soon learn about the tight control over air space at Port au Prince and its strong military presence.

First impressions of Port au Prince are numbing. The airport is filled with the chaos and intimidation of military jets and helicopters punctuated with confetti dots of healthcare workers sprawled over the tarmac waiting to leave.  As we unloaded our carefully wrapped surgical equipment the Gulfstream jet next to us unloads their cache of fresh Domino’s Pizza.

The roads, as well as the infrastructure are clearly fractured. Tents and huts made of permanent indestructible plastic garbage line the road.  Limping dogs and goats give glimpses of the lives their owners must live behind these sheets of plastic. Because so much of the plastic is cheerfully orange and blue, it’s an ironic kaleidoscopic ride through town. In a blur, you would be reminded of the disaster only by the ubiquitous smell of burning garbage and diesel.

The hospital is intact and functional. Today, 22 patients are recovering. Still, many are untreated from the initial quake. Dust from the dirt road permeates the operating room with no signs of antisepsis.

Although there seems to be ample supplies there is little organization. Every team has been generous with their supplies but with the urgency to operate, it’s been difficult to manage an effective system. Working on this may be our biggest contribution.

X-ray rounds revealed some major cases that need to be done. Perhaps spine, perhaps pelvis, but definitely femurs, shoulders, and ankles wait for our team to unpack and work.

The Girl Scout Motto and Law states to “be prepared” and to use resources wisely to make the world a better place.  These are words to live by as I write this blog with Girl Scout Troop 591’s banner on my desk next to my 3 bottles of donated propofol, surgical headlamp, and an old general surgical textbook.  With $77 of hard earned money, a group of 10 girl scouts voted to donate their money to our mission to Haiti.  I received it yesterday in a small plain envelope with a message, “Making the World a Better Place”.  Somehow, these 12-year-old girls may understand more about the disaster in Haiti than many of us adults.

Well wishes from Girl Scout troop 591

Over the last two weeks, our team has scrambled to assemble the resources to provide a self sufficient medical unit for a small orphanage 1 hour north of Haiti.  Despite early reports of the futility of providing medical care so close to a natural disaster in a country, our team thought it was worth trying.

Our goals were clear:

1. Help build things.  With an ability to use a private jet and our large network of resources, we could build, improve, and restock an existing operating room to better handle disaster victims.
2. Help people.  A team with surgeons and nurses even with limited supplies could help care for people with life and limb threatening injuries 4 weeks after an earthquake.
3. Learn something.  After spending a week in the foreign environment of a disaster, we hope to learn more about the human condition and about ourselves.
4. Tell a story.  The more other people learn about why we want to respond to Haiti and how they are suffering, the more people may want to help.

Through the use of social networking and real life networking we have succeeded in amassing 600 lbs of medical material.  We found a jet generously donated by the Ariel Corporation in Mt. Vernon, Ohio.  We had people donate an anesthesia machine and an X-ray machine. Individuals from Cardinal Health, Kimberly Clark, Stryker, Wright Medical, DJO, Medline, Clinical Trays, OhioHealth, and OSU East Hospital went out of their way to help find critical equipment. A documentary film team from Malaysia has reached out and offered to help while in Haiti. I have met people daily who volunteered to go. I never realized there were so many people who I knew who had a background in the military or missionary work who were willing to help. ..immediately.

What I’ve learned through this early phase of preparation is that we live in a larger community than we think.  We are far more connected than we give ourselves credit for.  And if you ask for help, the natural tendency of man is to give.  I can see why Goethe’s guidance continues to ring true, “be bold and great forces will come to your aid”.

Our great force is well symbolized by Girl Scout Troop 591.  Thank you for your aid.

Planning for Haiti: week 1

Exactly 1 week ago, I agreed to go to Haiti on a humanitarian mission.  Given a little experience in Vietnam and Afghanistan, I thought I had the skills to help. The difference was that in those missions, a preexisting infrastructure of care and healthcare delivery had already been established.  So the challenge was to build the medical team that could make a difference in Haiti, just 3 weeks after the earthquake.

The response was immediate and complete.  Of course Minh Nguyen, MD, was on board. He started the whole effort in the first place.  His interest started when he rode his bicycle across the country to raise money for charity.  He ran into Project Help Haiti and knew it was a good cause with good infrastructure. As a chief resident at the Ohio State University, he is at the pinnacle of his knowledge of Orthopedics.  Working on a daily basis in a level 1-trauma center, there is little he hasn’t seen or hasn’t done.

David Kasserman MD.  General Surgeon volunteered after only 6 hours of contemplation.  After training in New York City, he has amassed a ton of experience with both rural and urban general surgical emergencies.  Well regarded in at least 4 different hospitals., he’ll bring expertise to abdominal trauma and injuries.

Amy Bush RN serves currently as the VP of Operations at Dublin Methodist Hospital.  A former critical care nurse with experience in mission work in the Caribbean and well as travel experience through China, travel into inhospitable environments are not foreign to her.   In addition, she has an MBA!

Regina Chen, RN is probably one of our best PeriOperative nurses.  She knows the ins and outs of getting patients ready for surgery and getting them through surgery. With little equipment in Haiti, she’ll be able to put her resourcefulness to the test.

And finally, Ed Chen, MD.  Chief of Anesthesia at Dublin Methodist Hospital.  I’ve known Ed since he was a resident at Ohio State University.  Even then he was an agile clinician who found physiology more interesting than the mundane world of surgery.  He got even better as he got specialized training at the Cleveland Clinic.  With a recent trip from Africa under his belt, he’ll be our best asset on the trip.

Logistical planning into a disaster zone is difficult.  There are no commercial flights to Haiti currently.  Landing slots are tightly controlled.  We were able to get clearance for our mission dates of February 13 to 20 through Project CARE.  With a lot of pleading through Facebook and Twitter we were able to acquire a jet.  But with every victory, there is a little loss, and we found out the pilots who have been shuttling teams nonstop have reached their monthly quota of flight time.  We may have a jet, but we don’t have a pilot.  Our search continues.

In addition, the xray machine, which was marginally operational, finally broke.  Again with more pleading and begging on Facebook and Twitter, we found a mini-C arm. With a weight of almost 900 lbs, we face the challenge of shipping it down to Haiti.

Interest from the orthopedic community remains high despite negative reports from some of the earlier missions.  Ruth Thomas MD from Little Rock, head of the Humanitarian Committee of the American Orthopedic Foot and Ankle Society is beginning to plan her own mission 3 weeks following ours.  Rob Veith, MD, my teammate from a Vietnam mission is flying to the Dominican Republican and plans to get to Haiti overland!  Mark Slovenkai, MD, another surgeon with Vietnam background is considering a mission shortly. Joao De Carvalho Neto, MD

But the greatest interest comes from our friends, families, and neighbors.  I get daily volunteers willing to join.  Regardless of skills, there is a great sense of desire to come into a dangerous region and just help.  Pretty inspiring.

We’ll be evaluating all of our donated medical supplies this week.  Hopefully finalize flight plans.  With continued contact with teams 1,2, and now 3 (leaving today), we’ll try to define our medical goals in the coming days. We’ll keep you up to date through Twitter, Facebook, and this blog. I anticipate the chaos to only get worse with time.

Immunizations now up to date.

My thoughts after a week revolves around the many offers to help.  Volunteerism seems to be a root element of our culture.  It is yet another aspect of our community that we can be proud of.