Saturday, December 25, 2010

Team Sinai - Operation Rainbow Plans Haiti Return

From the day we returned this past June from Port au Prince, we have been planning our return. Our experience at Adventiste Hospital was for all of our team members, uniformly, life changing. It didn’t matter if we were veterans of many international relief missions, or if we were first timers. None of us will ever forget the children and adults that we treated that week.  Scott Nelson put it aptly, “Haiti messes with your head.” Well it is certainly a point in fact that Haiti messed with Scott’s head. He was back earlier this month for a two week volunteer stint at Adventiste. (Read more about Scott and Marni Nelson at http://www.caribbeanortho.com/caribbeanortho/Nelson.html). As you may recall, Scott had been in Haiti for a full 6 months after the January 12 earthquake, and did amazing work organizing what has become the top rated orthopedic facility in Haiti.  He left shortly after our June mission, to start his new life and career at Loma Linda University in California. Scott returned in early December to help orient Terry, and provide his inimitable expertise and enthusiastic, boundless reserves of energy to serve the Haitian underserved population. In his place, Dr. Terry Dietrich, from Appleton, Wisconsin has now arrived, as of November, along with his wife Jeannie Dietrich, R.N. for a year-long commitment. (Read more about the Dietrichs at http://www.caribbeanortho.com/caribbeanortho/Dietrich.html).

Team Sinai / Operation Rainbow all packed and ready to go. 
Our plans were to return for a week of service on December 26, at which time we would be the only expatriate medical team present, with the long term volunteers being scheduled out for the Christmas/New Year holidays. We were ready to welcome some new team members, including Drs. Ron Delanois, Dr. Rishi Thakral, Dr. Julia Ramberg, and Dr. Jossie Abraham. Unfortunately, fate intervened, and we have had to cancel our trip.  Here’s the story…

Over the past 6 weeks, the political situation in Haiti began heating up considerably. Nationwide elections took place on November 28, plagued by controversy, with accusations of ballot rigging, and other irregularities. Haitian electoral law requires that the winning candidate capture at least 50% of the casted ballots. With over 20 candidates to choose from, no single candidate took a majority, which leads by Haitian law to a run-off election (scheduled for January 16th, 2011) between the top two candidates. The third place candidate, who by the official count, trailed by a mere few thousand votes, cried foul, along with many other candidates. This lead to mobilization of various supporters in the form of street demonstrations that turned violent, and essentially shut down the city for the better part of a week. HAH was on lock-down, and all volunteers present were forbidden to leave the hospital compound. Things got so bad that American Airlines stopped flying to Port au Prince for about a week.  New reports showed street barricades, gunshot victims, and burning tires. Tap-taps stopped running, and the general populace hunkered down, waiting for the political game to play itself out. Unfortunately, things are at an uneasy stalemate, with many of the stake holders still negotiating and posturing. Even today, no one knows if there will be a recount (unlikely), a re-election (more unlikely), or a continuation of the current government as a provisional government (who knows?). The US and Canadian embassy shut down, and forbade their staff to go to downtown PAP.
Street riots and barricades in downtown PAP

The enthusiasm of the rabble to create mayhem has died down over the past two weeks, given the paralysis of the government and the electoral board.  This past Monday, the final election tallies were to have been announced, and everyone feared that this would provoke yet another round of unrest. Fortunately, the government decided to postpone any further election announcements until the entire mess can be worked out by a combination of the government, the Organization of American States, Bill Clinton, the candidates, and the UN. Don’t expect anything to be decided too soon. Once there is a decision, it is feared that the losing party/parties will be unhappy, to say the least.  According to Haitian law, the run-off elections should take place on January 16th and the new government installed on February 7th.  It is doubtful that this time line can be maintained, given the current impasse that has become, in effect, a political Gordian knot. Rumors of renewed civil strife, unrest, and even civil war are floated. Given the volatile nature of Haitian political history, with numerous past coups, military takeovers, and dictatorships, these possibilities are not far fetched.  For an insiders view of Haitian politics, see the Haitian news site www.haitilibre.com  which has an English version as well as a French version.

On top of the political strife, Haiti is enduring a nationwide epidemic of cholera, that has now infected, by official count, at least 120,000 people and killed 2,500.  See an epidemiologic analysis at http://www.reliefweb.int/rw/fullmaps_am.nsf/luFullMap/2D9992968E894422852577F2007C2B3E/$File/map.pdf?OpenElement . It should be noted that these figures are widely believed to be underestimates. See this recent posting from Haitilibre….  http://www.haitilibre.com/en/news-1972-haiti-cholera-epidemic-the-mspp-hides-the-truth-to-the-people.html .  In yet another twist, the Nepalese soldiers from the MINUSTAH (United Nations Mission for Stabilization in Haiti), have been accused of being the source of the outbreak of cholera, though in the boiling cauldron of Haitian culture, at least 45 voodoo practitoners have been lynched by street mobs who are convinced that the cholera epidemic is being promulgated by the voodoo priest casting spells on the unfortunate victims. For details of this bizarre aspect of the epidemic, see http://www.haitilibre.com/en/news-1975-haiti-social-lynchings-at-least-45-dead-cholera-or-religious-war.html

Given this volatile mix of civil, political, and electoral unrest, with a dollop of a deadly cholera epidemic thrown in, and intermittent cessation of airline flights, the Adventist Health International (AHI) has decided to suspend the short tern volunteer program at HAH. Two weeks ago, with only a few days notice, they officially evacuated the short term volunteers who happened to be at HAH at the time, plus the five long term volunteers, which included the Dietrich’s, the Russell’s (assistant administrators), and nurse Lynn Byers. Scott Nelson, and his Dominicana nurse Lucilla and anesthesiologist Dra Adrian were also there when the order came to evacuate. Predictably, he and his crew placed patient safety above the orders from the AHI home office, and chose to stay a few extra days beyond the AHI ordered evacuation deadline to make sure that the recent post-operative patients were stable. Scott even managed to squeeze in an emergency open reduction of an unstable pelvic fracture that had been told by MSF  doctors to stay in bed for three months. For a description of the last few hectic days of the evacuation, read accounts from Terry Dietrich and Scott Nelson from December 16,17,18 on the www.haitibones.org  website.

Rishi, Ella Joy, Amy and Merrill packing duffles.
The current situation over the holidays is that all expatriates are now gone from HAH, and the hospital continues functioning with a Haitian only staff. Obviously, the orthopedic capacity has been reduced dramatically. On a hopeful note, AHI is considering giving the permanent expats (Terry and Nathan) a tentative go-ahead to return in January. The fate of the short term volunteer program (that’s us) remains in limbo.

Up until two weeks ago, when we were notified of the evacuation order, we were busily preparing for a December 26 departure. Dr. Rishi Thakral, orthopedic fellow at Sinai Hospital, and Nurses Amy Monitillano and Ella Joy Napoles Brown came to our house to prepare more than a dozen duffle bags stuffed with hospital supplies that had been requested by HAH, including sterile OR drapes, gowns, and towels, bandages, as well as ex-fix components and various and other assorted sundries that have been donated for this mission. Amy and Ella Joy worked with Sinai surgical techs Hassan Hooper and Jenel Slonaker to collect discarded but otherwise unused drapes and gowns from surgical packs that would have been sent to trash. Instead, they reprocessed/resterilized them for our mission.  Another packing party had been planned for the following week, but we cancelled once we had the official word from our sponsoring agency, AHI, that we were no longer allowed to volunteer at HAH until such time, indeterminate, that AHI declares the situation safe.

Palisades, NJ Rotarians donate to our mission after hearing my PowerPoint.
All of us were sorely disappointed, but we have regrouped, and are planning to use our American Airlines tickets (minus a change fee…) to reschedule our trip for later in 2011. We will be in close contact with AHI and the permanent volunteers at HAH to determine the safest and earliest date.  When we went to Haiti last June, we were representing Sinai Hospital. This time, we are proud to be co-sponsored by Operation Rainbow.

John and I have been long associated with Operation Rainbow, going on yearly trips to Nicaragua or Ecuador. Thanks to the vision and generosity of Laura Escobosa, executive director of Operation Rainbow (www.operationrainbow.com), we have the additional logistic support that promises to make this mission (when it actually happens…) even bigger and better than our previous trip. We've been fundraising to help buy medicines and Medika Mamba (Plumpy Nut) for our patients. Special thanks to the Palisades, New Jersey Rotarians for enduring my Power Point of our June mission, and for their kind donation. Additional thanks to the Rubin Institute for Advanced Orthopedics (RIAO) at Sinai Hospital for their Save-a-Limb Fund which helps support our mission plans. Each year, Sinai has an annual Save-a-Limb Bike Ride http://savealimbride.org, and this year's October 2010 ride brought over 600 participants. 

Save-a-Limb Ride and Team RIAO
One thing for certain, Haiti is still suffering from the destabilizing effects of the January 12 earthquake, the agonizingly slow rebuilding phase, and the confounding factors of political unrest and a cholera epidemic. Clearly, there is a continued need for volunteer groups such as Team Sinai / Operation Rainbow to provide orthopedic care for the masses of Haitian adults and children that cannot afford to pay for what might be considered even the basic necessities of life. The overall theme that AHI has planned for HAH is to increase the Haitian national medical presence, with a goal towards sustainability. For the foreseeable future, however, volunteers are still desperately needed.
--Merrill Chaus, RN

Saturday, August 28, 2010

Team Sinai - Mission Report JUNE 2010

Mission Report: Team Sinai at Hopital Adventiste d’Haiti (HAH)

Prepared by John Herzenberg, MD

Introduction

Team Sinai spent one week at HAH (June 10-17, 2010). We were an 18 person team, primarily from Sinai Hospital of Baltimore. This report is based on our experience there. During that week, our team included one orthopaedic surgeon, two orthopaedic fellows, one podiatry resident, one anesthesiologist, one family practitioner, one physical therapist, six nurses, one prosthetist, one central strerile tech, and three helpers. We worked closely with Dr. Scott Nelson, Orthopaedic Director of HAH. We also “drafted” several volunteers from other teams to work with us (Loma Linda residents, medical students, and nurses from an Oregon team that overlapped our stay). We performed 54 surgeries, and operated past midnight on four out of seven nights.  Thirty-one cases had anesthesia by our team anesthesiologist, the remaining twenty-three had anesthesia administered by three Haitian anesthesiologists. We worked hard to accommodate both the elective cases that had been prepared for us, as well as the emergency and urgent cases that were brought in. Examples of cases we performed: hemiarthroplasties for hip fractures, pinning of hip fractures, osteotomies for femoral neck non-unions, SIGN nailing for tibial and femoral fractures, SIGN nailing for nonunions, posterolateral bone grafting for tibial nonunion, plating of femur fractures, ORIF ankle fracture, 8-plates for tibia vara, release of knee/ankle contractures, many clubfoot surgeries, CP tendon lengthening, Fassier Duval nailing for Osteogenesis Imperfecta saber shins, I&D of abscesses, VAC changes, amputations, bone transport for tibial defect (Ilizarov), open reduction of neglected shoulder and hip dislocations (from the January 12 earthquake) and iliac crest bone grafting for various nonunions. In addition, we staffed an orthopaedic clinic on three days, and a Ponseti clubfoot clinic on one day. Average orthopaedic in-patient census was 45. About 50% of patients we operated were below age 21. One third of our cases were earthquake related.

HAH was a 70-bed hospital where not much orthopedic surgery was done before the January 12, 2010 earthquake. It is one of the only hospitals in PAP that survived intact after the earthquake. There is only one thin crack in the structure, and it has been certified by the Army Corps of Engineers as safe and in no need of repair. We were told that the original architect/engineer who designed and built HAH was from California, and that he built it to withstand earthquakes. Immediately after the earthquake, nobody wanted to enter any building in PAP, fearing the aftershocks would cause more damage. Thus, for a short period of time after January 12, 2010, operations at HAH were being performed in tents in the parking lot.  Dr. Scott Nelson came to HAH shortly after the earthquake, and stayed for 5 months until June 20, 2010. During those five months, he and others did a tremendous amount of organizational work, and developed one of the most active and advanced orthopedic services in PAP. During the week that we were there, many patients were transferred from other medical facilities (such as MSF and Medishare) to HAH with complex orthopedic injuries, including hip fractures and spinal fractures. Drs. Richard Schwende and Kaye Wilkins were commissioned by the Pediatric Orthopaedic Society of North America to survey potential sites in Haiti for POSNA members to staff, and wrote that based on their survey in late March 2010 that “HAH was the best-equipped and administratively managed hospital among those visited”.   http://www.posna.org/news/Haiti_Apr8Update.pdf

Physical plant

HAH is in the Carrefour district of PAP, and is about ¼ mile from the Adventist University.  It is about one hour’s drive from the PAP airport, in a mixed residential/commercial neighborhood. There are nearby markets and stores within a few blocks from the hospital. The entire hospital compound is protected by a wall, and has a guarded gate entrance. HAH is a two story concrete hospital, with attached chapel. There is no elevator to the second floor, but there is a covered circular ramp, so that patients could be wheeled on gurneys to the second floor. The first floor contains the ER, OR, pre and post-op wards, radiology department, pharmacy, cast room, clinic, and administrative offices. The second floor has numerous private rooms (one patient per room), numbering about 24, and more administrative offices, and a volunteer’s break room. Air conditioning is present in the three OR’s, break room, cast room, and clinic room. There is a separate, adjacent pediatric ward and OBGYN ward in front of the hospital, about 50 feet away. There are several donated large military style tents on the hospital grounds that are used as step-down units, and there are also numerous small tents on the hospital grounds where many ex-patients and Haitian staff (translators, for example) are staying.

HAH has its own water supply piped directly from a nearby spring. This reliable water supply was actually developed after the earthquake. There is also an onsite purification unit for drinking water. Two generators on site provide back up power if the city grid goes down (almost a daily occurrence). There is good cell phone reception and the hospital has free Wi-Fi available.  Due to generator issues, we did have to operate several times in the evenings briefly by lantern/head lamps. In the basement, there is a hospital kitchen that provides one meal daily to patients and volunteers.

The majority of the ex-pat volunteers sleep in a breezy, covered veranda on army cots and under mosquito nets. A few intrepid volunteers pitched tents on the roof of the hospital. Some volunteers stay in the unused private rooms. There is a sufficient number of flush toilets and cold showers available for the volunteers to be comfortable. One meal per day (lunch) is provided by the hospital for patients and volunteers. In keeping with Adventist tradition, the kitchen is strictly vegetarian. Volunteers also bring their own food, which can be prepared in the adjacent air-conditioned volunteer break room, which is equipped with dining tables and a microwave oven. Hospital housekeeping provides dishwashing service. The volunteer sleeping area and break room are guarded 24 hours/day to discourage theft. We never encountered any problems in this area.

Staff

There is a full time Medial Director, Dr. Lesly Archer, who is a Haitian OBGYN. He trained in Montreal, and maintains residences in both Canada and Haiti, but has been continuously present in Haiti since the earthquake. He is charming, trilingual (English, French, and Creole) and was very helpful. They have about three obstetric deliveries per day at HAH, which take place in a separate, adjacent OR facility that I did not see. Dr. Archer does elective OBGYN cases in the main OR facility.

Until recently, Dr. Scott Nelson was the Orthopedic Director, but he left on June 20. Dr. Terry Dietrich of Appleton, Wisconsin tj.dietrich99@gmail.com, is his replacement, but is not due to arrive until November 2010. Dr. Dietrich has served as a volunteer with Dr. Nelson at HAH previously, so he is familiar with the system. For the four month interval until Dr. Dietrich arrives, HAH is relying on part time and short term orthopaedic volunteers, including Dr. Mark Perlmutter, an orthopedic hand surgeon from Pennsylvania, Dr. Barbara Minkowitz, a pediatric orthopedist from New York, and Dr. Karl Rathjens, pediatric orthopedist from Dallas, Texas. A team from New York Columbia Presbyterian is also scheduled to arrive in November. Dr. Lars Hansen, president of the Haitian Orthopaedic and Trauma Association, visited us but we did not see Haitian orthopaedic surgeons operating at HAH.

There are three Haitian anesthesiologists, but their schedules require coordination, and they are generally not available after hours.

The wards are staffed by Haitian nurses, but due to the large volume of patients, dressing changes, and complex problems, it is highly recommended to have a full cadre of volunteer nurses.  There is an ex-pat nurse, Brooke Beck brooke.bbeck@gmail.com who has been working for the past four months. She coordinates many patient care aspects as well as coordinates the volunteers.  She is scheduled to rotate out of HAH in September, and work with another NGO in Haiti. A new expatriate nurse, Jessica Scott has arrived, and will be staying for the foreseeable future. There is also a Haitian American floor nurse coming this fall, which should be a great help in keeping the hospital running efficiently.

The OR has Haitian orderlies, and central sterile personnel for decontamination and instrument sterilization. There are Haitian radiology technologists in the x-ray department.

Haitian doctors staff the ER and peds ward. Many volunteer groups have augmented the Haitians with US family practice or ER docs.

Numerous volunteer translators are ever present to help the teams. While French is spoken widely by the educated class, including nurses and doctors, most of the patients speak only Creole. It is customary for the international volunteers to provide a gratuity to the Haitian translators before departing. Such tips are greatly appreciated by the translators, and other local personnel, many of whom are working for free, and truly depend on the generosity of the international volunteers.

Early on after the earthquake, there was a full time ex-pat relief administrator, Dr. Andrew Haglund, who helped coordinate the reconstruction efforts at HAH. He left about two months ago, and is sorely missed.  Recently (late June), a full time ex-pat assistant administrative director has arrived, Nathan Lindsey nlindsey@llu.edu   mobile +509-3491-6539  along with his wife, Amy, a nurse. They will be staying for an extended tour of duty. This should be a great help to further develop the long term viability and growth of the HAH. The challenge for volunteers, both long term and short term, is to scrupiously respect the feelings and sensibilities of the Haitian indigenous personnel, encourage them to become invested in the workings of the hospital, and ultimately become sustainable rather than dependent on expatriates.

Affiliation with Loma Linda University (California)

HAH is affiliated with the worldwide network of Adventist Hospitals. HAH has a special relationship with Loma Linda University’s Global Health Initiative. They are also partnering with CURE.
Coordination of volunteers since the earthquake has been through LLU. The contact person at LLU is Alex Sokolov asokolov@llu.edu
At any given time, there are 25-35 volunteers working at HAH. Some groups also have ventured out to staff clinics in the refugee camps and tent cities.
The hospital is affiliated with the Seventh Day Adventist church, so the Sabbath is celebrated on Saturday not Sunday. The OR’s and clinic are closed on Saturday, except for emergencies. Sunday is a regular OR day. Scott Nelson started each day with a 6:30 inspirational meeting on the steps of the hospital. This time was used to read some inspirational passages from sources such as Mother Teresa, to relate stories about what it was like after the earthquake, and to discuss organizational issues. It was conducted in a culturally sensitive, non-denominational fashion, which was important for our team, which included many orthodox Jews.

OR facilities

The OR suite at HAH comprises two large OR’s and one small one. There is a changing room, toilet, large well-organized storage room for orthopaedic sets, a small storage room for sterilized sets, refrigerator (used for blood, drugs that require refrigeration, and drinks), and large central sterile room with two large sterilizer units that can handle any large tray. Between the two large OR’s, there is a small pharmacy storage area. There is not a specific room in the OR that would handle the volume of equipment that Rainbow brings, but there are one or two rooms just outside the OR suite doors that could potentially be used for this. The large OR’s can accommodate any big case, including use of the c-arm. The small room is appropriate for simple cases.

There is a modern c-arm (OEC 9600) with a double monitor and printer. This can be wheeled from room to room. There is a plethora of orthopaedic gear including the following: Synthes large and small fragment sets, cannulated screw sets, Synthes battery powered drills, external fixator sets (Orthofix, Synthes, Hoffman, and Taylor Spatial Frame), hemiarthroplasty set and implants, SIGN nail set and a pedicle screw set for posterior spinal fusion.  There are also many surgical instrumentation trays available that are appropriate for orthopaedic cases. There are many wound VAC machines, and a modest supply of consumables for the VAC’s. Suction and Bovie electrocautery were available in each room. For tourniquets, we used Esmarch bandages, and also brought a supply of Hemaclear disposable tourniquets.

Anesthesia facilities

The anesthesia machines and monitoring machines in the OR were old, and only partly reliable. Oxygen was readily available in the OR from tanks, and these could be transferred to the floor if needed. This is similar to what we have encountered on previous missions to Nicaragua and Ecuador.  The Haitian anesthesiologists favored spinals over general, and used Ketamine liberally. It is highly advisable to bring a Propack and i-stat. Laboratory facilities at HAH are rudimentary. It was possible to obtain a CBC quickly. We had an i-stat which allowed us to get nearly instant blood work. Microbiology and Blood Bank services are available only off-site. Obtaining blood for transfusion is an ordeal, with the patient’s family having to bring a sample and request to the central Red Cross facility in downtown PAP. Two days is a routine time frame for obtaining blood.

Hospital supplies

There are three fairly cavernous (think last scene of “Raiders of the Lost Ark”) storage rooms which have been well organized and labeled to store the enormous amounts of equipment that was donated after the earthquake. Still, maintaining the supply chain is a challenge, particularly for sterile drapes, gowns, and other OR consumables. We brought a moderate amount of sterile gowns, drapes, towels, lap sponges, and gloves, which came in handy. The hospital routinely washes bloody lap sponges, dries them, and then resterilizes them for re-use.

Orthopaedic Clinic

There is one clinic room and a cast room. Both are air-conditioned. Additional rooms could be made available if needed in the nearby ER suite. There is a digital radiography machine, which stores hundreds of images in its memory. Efforts are being made to obtain hardware that would allow transfer of these images to a PACS.  There is also a film radiography machine in the x-ray department, but this was rarely used due to the need to pay for consumables (film and chemicals).  Orthopaedic clinic was held three days per week, including one morning of Ponseti clubfoot casting (20 babies). Patients hand-carry their own prior medical records and hard copy radiographs, and are very reliable about bringing them. Most patients have cell phones, so reaching them is not a huge challenge.

Security and Safety

Prior to our mission, there was concern about security and safety issues, based on reports of violence in PAP and kidnapping of MSF workers. Happily, we encountered no problems whatsoever.  We felt safe and secure within the HAH compound. We did not experience any episodes of theft or pilfering. The patients and staff at HAH were welcoming and appreciative. Some of our team members ventured on foot a few blocks outside the hospital to purchase soft drinks and fruit at the local market. They reported that the chief safety concern was from road traffic, not people. On two occasions, members of the group went on a supervised walking tour outside the HAH compound to the nearby (1/2 mile) Adventist University site, which has become a tent city. The locals were warm, friendly, and were happy to engage in conversation. Our team included three younger volunteers (age 16-19), and they all had a very positive experience.

No member of Team Sinai became ill during the trip. All were taking malarial prophylaxis. Two members had needle stick exposures, and started taking anti-retrovirals until the HIV test from the involved patients came back negative (24-48 hours later).

Summary

HAH is a very viable site for North American volunteers to consider. It is currently perhaps the most advanced orthopaedic facility in Haiti. The facility is comparable and in some ways superior to other sites in Nicaragua and Equador and Colombia that I have worked at over the past 12 years.  There is a generous amount of  existing orthopaedic surgery sets and instrumentation, but restocking is a challenge. Teams coming should communicate with the hospital well ahead of time to determine what supplies should be brought down.

Until Dr. Dietrich arrives in November, it will be challenging for teams to get as much accomplished in a short time as we did under the supervision of Dr. Scott Nelson. Nonetheless, the needs are great, and the potential impact that volunteer teams have is tremendous. The local needs are for both pediatric and adult types of cases. Orthopaedic surgeons, nurses and anesthesiologists who go to HAH should be comfortable treating both children and adults. There is much earthquake related trauma sequelae, as well as fresh trauma, and elective pediatric orthopaedics.

Volunteer groups need to partner with Loma Linda University for coordination purposes. LLU is well organized, and even provides malpractice insurance and health insurance to the volunteers. They keep track of various volunteer groups and individuals to insure that there will not be excessive overlap of manpower. Loma Linda does charge each volunteer $15/day to cover the cost of food (one meal/day) and airport transfers.

The Sinai Hospital team had a remarkable and positive experience, and to a man, expressed interest in someday returning. In fact, we are currently making tentative plans to return in December 2010.

Friday, July 9, 2010

Team Sinai in the Baltimore Jewish Times


Sinai Team Back From Haiti

Sinai team returns from earthquake-ravaged Haiti.

July 9, 2010

Alyssa Jeffers
Editorial Intern

Sinai Team Back From Haiti
“We take for granted what we have here — food, clean drinking water, state-of-the-art medical equipment, even oxygen,” says Dr. Aaron Zuckerberg. “They don’t have any of that, and yet they don’t complain.”
Last January, a magnitude 7.0 earthquake rocked Haiti, a poor Caribbean country the size of Massachusetts. Approximately 230,000 people died, and there was widespread damage, particularly in the capital of Port-au-Prince.
Since then, relief has poured in to Haiti from all over the world, including a recent volunteer group from Sinai Hospital of Baltimore.
Dr. Zuckerberg and Dr. John E. Herzenberg, along with 16 other Sinai-affiliated doctors and health care workers and volunteers, as well as some of their family members, traveled to Port-au-Prince to help take care of injuries sustained in the quake. They were there from June 11 to 17.
Getting to Haiti was not easy because of airline restrictions, according to participants. Not allowed to transport crates, extra bags and narcotics, they said the team worked around the clock to pack three bags per person — for food, clothing, and necessary gear and supplies.
Upon arrival in Port-au-Prince, they said they immediately saw tents lining the streets and roads covered in sewage. Trash removal was provided only by wild pigs roaming the areas, they said.
Dr. Herzenberg, head of pediatric orthopedic surgery at Sinai and director of the International Center for Limb Lengthening, said Haiti was “orders of magnitude worse” than what he has seen on 13 other relief missions. He said Haiti was “three levels worse” economically than prior to the disaster.
The Sinai team was based at Adventist Hospital in the capital. During 6 1/4 days, they performed 54 surgeries, on little to no sleep. Dr. Zuckerberg, a pediatric anesthesiologist/intensivist who is director of the pediatric intensive care unit at Sinai, performed anesthesia on 31 of the patients, while Haitian medical personnel anesthetized the rest.
“Normally, [anesthesiologists] get the day off after a late night, but not here,” said Dr. Herzenberg. “Aaron would work all day, get a few hours of sleep, and be up again bright and early the next morning. He personally saved the lives of two patients. He went above and beyond what he was trained to do and performed two very important surgeries. With any other anesthesiologist, those two
patients would have died.”
The team grew particularly close to an 8-year-old girl named Mia.
“Every mission I go on, there is one patient that sticks out in your mind,” said Dr. Herzenberg. “[Mia] had been struck by a car and broke her femur. Her leg from the knee down was completely dead. She had a fractured femur that was completely infected. She was very anemic, with her hemoglobin down at 3.5 [the normal rate is 15].”
The Sinai team operated on Mia four times. “She needed blood, but it was taking too long,” said Dr. Herzenberg. “My wife [registered nurse Merrill Chaus] donated her own blood in order to receive blood for Mia. During the transfusion, Mia began bleeding profusely. She had citrate poisoning, meaning her blood wouldn’t clot. That night we decided to operate, even though we had wished to do it the following morning.
“I was convinced she was going to die on the table,” he said. “Thankfully she didn’t, and we successfully amputated her leg. We took her back two days later to redress her and see how things were doing. There were bits of dead tissue we missed the first time, so we went in to clean them out. Suddenly, the femoral artery burst and was spewing everywhere. With the team working together, we saved her. The next morning, we went to check on her before we left, and she was sitting up brushing her teeth.”
Despite language and cultural barriers, the team communicated with Haitians “through smiles and laughter,” as Dr. Herzenberg’s daughter, Brittany, put it to Dr. Zuckerberg.
Team members were particularly impressed by the Haitians support for each other. They said nearly every patient had at least one family member with them at all times, and if a patient did not have any relatives, a stranger would step in to help.
In addition, the team members said they were impressed by the Haitians’ commitment to their faith system and respect for other religions.
“The Haitian nurses and doctors pray before every operation and have a prayer service every morning,” said Dr. Zuckerberg, who was one of the shomer Shabbatteam members. “They tried incorporating Judaism into common practices, making it very workable. There was an understanding that life-saving operations fell under the umbrella of work allowed on the Sabbath.”
At the end of the trip, all of the team members were in tears. “We were all very touched by this,” said Dr. Zuckerberg. “We were all crying when we left. We all want to go back. The question isn’t if, it’s when.”
Check out the team’s blog at teamsinaihaiti.blogspot.com/.
Photo captions:
Sinai Hospital’s Dr. John E. Herzenberg chats with a Haitian patient.

Team Sinai’s Haitian-born Dr. Job Timeny gives a patient Mia, 8, a big squeeze.

The team’s John D. Logue examines an earthquake victim.

(photos provided)

Getting to Haiti




Reading through the blogs of first responders to the January 12, 2010 earthquake, travel to Haiti at the time was difficult, as all commercial flights were cancelled in the initial emergency phase. Those intrepid volunteers who ventured to Haiti in the early weeks hopped aboard military transports, freight planes ferrying relief supplies, or flew commercial to the Dominican Republic, and took a long overland route on four wheel drive vehicles from Santo Domingo, DR to Port-au-Prince (PAP), Haiti. For my first trip to Haiti in late January, I went the latter route. At the time, the border between Haiti and the DR was free flowing so we went through without so much as a glance from border officials.   However, the mass exodus of Haitians created a bottleneck at the border gate, as throngs of aid workers tried passing them on the narrow dirt roads.

Commercial flights from Miami to PAP resumed in March, so now the American Airlines flight is a mere 90-minutes from Miami to Port au Prince (PAP). For our recent Team Sinai mission, we flew American Airlines from Baltimore to San Juan, Puerto Rico, and then caught a small American Airlines commuter jet from San Juan to PAP. There is one inviolate rule that I have learned over the past 10+ years of mission work, namely, “something always goes wrong”. For us, it began early, at 5am in Baltimore. We had arranged for our entire (n=18) team to meet at BWI airport at 6am, a full two hours before our departure.  As team leaders, John and I decided we ought to arrive 15 minutes early, to set a good example, and scout out the landscape before the rest of the team arrived. We had spent most of the night before doing our final packing, weighing and re-weighing each bag to make sure that we were exactly at 50 lb. maximum allowed per checked bag, using extra packages of “Plumpy Nut” as ballast to bring us up to exactly 50 lbs on those bags that were a tad under. Our family (John, Brittany, our nephew David, and myself) woke at 4:30am, washed, dressed and waited for our 5am pick up. I had arranged for a car service to take us to BWI, as that would be less expensive than parking our car for 8 days at BWI. I even managed to find a budget car service that would take our luggage and us to BWI for $100. (The first company wanted $150).  A 5am pick up would give us plenty of time to make it to BWI before the required 6am meeting time.  After waiting 20 minutes, we began to become suspicious that something was wrong. I called the car service, and they initially pretended to not know who I was, and then claimed that the pick up was scheduled for 5pm not 5am. We immediately went into crisis mode, putting together Plan B, despite the reassurances from the car service that they could send someone out right away, to arrive at our house by 6:15am. OK, we’d be late for the meeting time with our group, but still in time to make the 8:00am flight to San Juan. Not willing to bank on that, we woke up our daughter Danielle, just home from graduate school, and prepared two vehicles (we couldn’t possibly all fit into one vehicle with our luggage). We would have to leave one at the airport, but that was the least of our concerns. We piled the 8 large duffels, and 4 carry-on bags outside our house, and began to wait once again for the car service. We decided on a drop-dead deadline of 6:30. If the car service did not show, we would leave without them. Danielle wasn’t happy about being woken at 6am, but she put on her best game face and waited on the ready with us. At 6:20am, we called the car service again, and they confirmed that they were on the way, and only about 15 minutes away. On a whim, I asked them what kind of vehicle they were bringing, as we had originally agreed on a van. The answer came back, “Lincoln Town Car”.  Knowing that there was no way we could fit four of us and all of our bags into a Town Car, I said, “Thanks, but no thanks” and vowed never to use that car service again…

Next came the frantic piling of suitcases and bodies into Danielle’s Ford Escape, and my Acura MDX, and we were off the runway (well, actually the driveway) by 6:30am. John called ahead to our anesthesiologist and chief medical officer, Aaron Zuckerberg, to let the rest of the group, by now fully assembled at BWI, minus their team leaders, to explain why we were running late. Aaron, always cool, calm, and collected, was in full relaxed mode. After all, he deals with disasters and emergencies every day as Director of the Sinai Pediatric Intensive Care Unit.  He answered John’s frantic call not with the usual “Hello…” but rather in the calmest voice imaginable, “The patient is asleep, prepped and draped, ready for you..” John had to laugh, and went into the lengthy explanation as to what was happening on our end of Baltimore. What a great way to start a mission. We were sweaty and breathless and in crisis mode, yet we had barely left our driveway….

More excitement awaited us at BWI. One of the team members had forgotten her passport, and her husband was racing back home to pick it up (left on the photocopy machine while making the recommended copy of her passport to keep in a safe place in case the original was lost). We checked the rest of the team in, and only had to pay for a few overweight bags. (The trick of placing your toe under the edge of the bag while it was being weighed hadn’t been adequately disseminated to all the team members…) Some scrupulous pre-trip planning had averted a minor disaster. Aaron had packed his sensitive and delicate anesthesia monitors and glass vials of medicines into hard sided packing cases. Merrill spoke to AA a few days before we left about extra bag fees in case we wanted to bring more than the two bag, 100 lb limit per person. She was informed of a baggage “embargo” to the Caribbean so NO extra bags (even if you’re willing to pay) were allowed, and NO packing crates or cases either, only soft-sided luggage or duffels, thank you very much. That bit of information came in handy, as it allowed Aaron a few days respite to re-pack all of his anesthesia team gear into some quickly acquired duffle bags.  As an aside, a colleague from Pennsylvania who traveled last week to volunteer for the Adventist Hospital, was not aware of the embargo. He was not allowed to board last week on AA out of Philly because his two checked bags were plastic hard sided packing cases. He had to rebook for the following day, and repack everything into duffels. We had a similar experience years ago on a mission to Nicaragua, though we managed to run to an airport luggage store and purchase (at exorbitant prices) from Wilson’s Luggage some soft sides suitcases, and transferred everything on the floor from our cases into the newly acquired bags, while being stared at by everyone else in line at check-in.  Having experienced this, we were vaguely aware of the potential for a clerk at check-in to turn you down for the unmentionable sin of packing your gear into hard sided cases, even if they do fit the 62” linear size limit and the 50 lb weight limit. Go figure. It’s an “embargo”. (I thought an “embargo” was what we are doing  to Iran for not allowing nuclear inspectors…)

John waited behind with our passport-less member (name deleted to protect the not so innocent), and the two of them caught up once hubby screeched to a halt in front of the AA terminal with the priceless passport. One last hurdle, no-passport team member also had a rough time going through security screening due to an excess amount (according to TSA) of little Jello cups in her carry-on bag. Apparently, liquids must be not only 3 oz or less, but also the total volume of liquids must fit into a one quart plastic baggie. I’m not sure how anyone would hijack a plane with a few cups of Jello, but it’s generally not a good idea to argue with a TSA inspector, so we said goodbye to six individual serving cups of Jello.

We all made it to the 8am flight to San Juan, and picked up two out of town team members who had flown from Dulles and Montreal.  After a 45-minute layover, we trundled into a small commuter jet bound for PAP. One more roadblock….one of the ground crew members packing our luggage into the fuselage smelled something suspicious coming from one of our team bags. Apparently, a plastic bottle top from a large Purell dispenser broke, and the entire 16 ounces of Purell spilled into the duffel bag.  After a standoff of 45 minutes, with detailed negotiations between the captain, ground crew, Aaron, and the tower chief, AA agreed to let us empty the contents of the offending duffle bag into a plastic garbage bag. The duffle, sadly, was not allowed to travel, and is now enjoying a new, and very sterile life in San Juan.  At least we made it off, with all of our 36 duffels, headed towards PAP. The commuter jet was only half full, and the flight attendants carefully balanced the plane by asking some of us to move from one side to the other so we could presumably fly straight. I couldn’t help but notice that the passengers were either wearing blue Ekip Sinai Lespwa pou Haiti shirts (us) or they were Haitian nationals. I guess Haiti is not much of a tourist destination these days.

To summarize, we had more than our share of misadventures on the first day, and we hadn’t even arrived in PAP. More about our arrival in another posting…

Monday, June 28, 2010

Prosthetics in Haiti

The following is a post from John Logue, CPO at D&J Medical in Baltimore. He accompanied Team Sinai to Adventist Hospital, and spent the first three days with us. The original plan was for him to uncrate a prosthetics lab that had been shipped by freighter from California to Adventist. However, the freighter was delayed at sea, and the scheduled arrival of the prosthetics lab is indeterminate. Therefore, on Sunday of our mission, John was drafted to join a prosthetic unit at Mission of Hope, one hour away by car, northwest of Port au Prince. Here is his report...


Its 86° at 10:30am in Baltimore on Sunday, June 27, 10 days after returning from Haiti. Its already a little hard to go back to Haiti, even mentally. Its going up to 98° later, but we’ll be in the AC enough not to be bothered by it. Debbie and I are back from the Baltimore farmer’s market. What a stupendous wealth of grown things. Debbie will start volunteering at her friend, Pam’s organic farm tomorrow in exchange for boxes and boxes of fresh grown food. I emptied my perforated trash can that was supposed to be making beautiful compost. It wasn’t too good. Its OK though, because I know I’ll adjust and it’ll get better, and then good, and then ‘very good.’ That’s the trajectory of good living.

Its hard to imagine upward trends like that for most Haitians anytime soon. Still, check out the latest photo update from my patient/friend Myrline:

I thought we had made a prosthetic liner. I didn’t know we were making for a Saturday Night Live conehead flashback. Haitian people are irrepressible.

My time in Haiti was much more of a vacation than it was for the rest of ‘Team Sinai’: no problem with heat (Alabama upbringing?), no mosquito bites (with or without a net or deet), plenty of sleep, not one but two Sabbaths (Saturday with the Adventists and Sunday with Mission of Hope), a pretty light load of patients, and no life threatening emergencies (the closest thing being when I thought I was messing up my prosthetic work). It doesn’t seem quite fair. Especially the part where about a dozen super attractive young women came into the shop and bared their legs, and took turns casting each other to make cosmetic covers for future Haitian prostheses. And cosmetic they will be. I am sure there is some sort of Halacha (Jewish law) saying I shouldn’t have been witnessing such a thing. If I chuckled when it was happening, the devil made me do it. Yeah, Haiti was tough.

The thing about the work I do is that its not done in a week, really. The real outcome depends on a longer dynamic process and responsive relationships. The real outcome doesn’t show itself for a while, maybe a few months, and several people need to put their bit in: There needs to be therapy, fitting adjustments to accommodate limb changes, and the user needs to develop various patterns of understanding and behavior. Maybe the best thing that remains from this trip is the set of connections that are still functioning which can support some of that longer term sort of thing.

After I write this I will review the report that Dhinesh made for me. He is a ‘personal assistant’ in Bangalore, India who works for the company GetFriday. (You should check it out and say I sent you when you use the service so I can get my service for free.) I share him with a patient/dear friend in New Jersey. He investigated how a free listserve can be done for the various prosthetists who volunteer at Mission of Hope. If it works, the participating prosthetists might pool resources and coordinate with Diana Cherry, the prosthetic coordinator and up and coming prosthetist at MOH, so that whoever is going down next can take with them the optimum amount of exactly what’s needed, and we (the prosthetists) can speak to each other to refine techniques and solve whatever problems show themselves. One practitioner has already offered to host a Haitian for a year to train him or her in prosthetics. That’s a line of input to be supported for sure. Its just one more puzzle piece that might support moving things from not good, to better, and eventually to very good for as many people as possible, and for Haiti itself as much as possible. Haiti is a blessing to me in the sense of having the chance to connect to people literally all over the world for a worthwhile common purpose that involves a dynamic, very human, set of relationships and developments. Its engagements like that, even more than any trajectory, that makes for real living, Enough preachy stuff. Sorry.

Team Sinai is superb in that each person is super competent, super to be around, super organized, and super effective as a team. My own orbit is not exactly the emergent hospital thing, but there is enough overlap for real connection. I am so grateful that it exists.

John Logue CPO

Sunday, June 20, 2010

Deadly Mangos of Haiti

Haiti is definitely hungry. Native grown mangoes and plantains are the staple, along with imported rice and beans. Fortunately, there is an abundance of Mango trees, and therein lies the problem. Mangoes can be deadly. Not eating them. They have a thick skin that must be peeled to reach the underlying, sweet, succulent meat. The rind shields the edible fruit from bacteria and other pathogens. It is not eating the mangoes that is deadly, but harvesting them. While we were at the Adventist Hospital last week, we admitted two young men with serious injuries sustained when they tried to quench their hunger by climbing mango trees to pick the fruit. It turns out this is an international problem, not limited to Haiti. In all parts of the developing world, the mango is known to be deadly to those who climb in search of its fruit.

Our first mango victim was a 17 year old boy, electrocuted by a wire passing through the branches of the tree he was climbing. In electrocution injuries, there is an entrance wound, and often multiple exit wounds. For Jeff, the entrance was in his left wrist, permanently frying his ulnar nerve, and the exits were multiple, in both Achilles tendons, both thighs, and both feet. 

I haven’t seen many electrocution injuries, and so I used the marvel of the internet to e-mail a quick photo from my iPhone of the severe wrist burn to my friend Dr. Andrew Pollak, head of orthopedics at Baltimore’s Shock Trauma Hospital. His reply by phone was immediate. “No need to operate immediately. OK to admit, apply Silvedene burn cream dressings, and evaluate in a few days.” Perfect! There is a plastic surgeon from Washington state scheduled to arrive in a few days, right after we leave. This will be right up his alley. We admit Jeff, give him pain medicine, burn dressings, and ask him to wait. For the next two days until we leave, Jeff lays on his canvas army cot in the hallway, never complaining, waiting for the plastic surgeon. I don’t have the heart to tell them that he would lose half of his wrist, and that his ulnar nerve will never again function. By coincidence, Dr. Pollak, who has been heavily involved in rebuilding Haiti’s orthopedic infrastructure, will be in Port au Prince the next day, and I show him Jeff during a quick visit he made to Adventist Hospital.

The second mango victim was even more severely injured. John, originally from the Dominican Republic, desperate for food, fell from the mango tree he was climbing, and sustained a devastating and irreversible spinal cord injury when his 12th Thoracic vertebra dislocated one inch away from his 1st Lumbar vertebra. He stoically accepted his fate, though one point indicated he would prefer to be dead. There is not much that can be done, other than to repair the bone injury with rods and screws, allowing the patient to sit in a wheel chair. We heard that there is a spinal cord rehabilitation unit somewhere in Haiti, so there is hope for John after all. Haiti is tough enough with an intact spinal cord. As a paraplegic, you are really in big trouble in Haiti.  Scott Nelson, our host, is an accomplished spinal surgeon, and he deftly reduced the fracture dislocation, and rodded the spine with modern state of the art pedicle screw instrumentation, allowing John to be sitting up the very next day. The surgery came none too soon, as when we turned John to position him face down for the surgery, he had already started to develop pressure sores on his back from laying on the narrow canvas army cot.
The surgery had been put off in favor of more urgent procedures, but finally, after waiting for two days, we put him on the schedule yet again, even though it meant starting the case at 9 pm and finishing at midnight (with one more to follow...) To my knowledge, Adventist Hospital is the only facility in PAP set up to operate on spinal fractures. Scott has really built up an incredibly versatile orthopedic unit here. 

--John Herzenberg

Saturday, June 19, 2010

Job, the Prodigal Son--I'm SO glad you came!

Somehow, the mantra of our mission came to be, "I'm so glad you came!". We think that this originated with a comment that John kept on saying to Job, in tremendous appreciation for all of his hard work and efforts. Gradually this came to be the Mantra and greeting for the entire team, with a wink and a smile. One of the most beloved members of Team Sinai is Dr. Job Timeny, podiatry resident from Regional Medical Center in New Jersey, who spent a two month rotation with John at Sinai. Job brought to the table not only his work ethic, medical/surgical expertise, but also his linguistic skills. While HAH did supply us with skilled translators, Job had the unique ability to convey the medical issues with the most accuracy due to his understanding of both the medical intricacies as well as the Kreyol language. Job is a native of Cap Hatien, and moved to the USA when he was 16 years old. He graduate from the New York School of Podiatry, and is now a second year surgical podiatry resident. On Wednesday of our mission, he staffed the unusually busy and hectic Clubfoot clinic and applied more clubfoot casts in one morning than he cares to remember.  We can't help but believe that the Haitian patients felt a unique connection to Job, the Prodigal Son, returning to his native land to provide expertise and succor to the sufferring people of Hiati. Job's perspective as a Haitian American is special, and he shared his feelings with the rest of the team on our return in this email.....



Bonjou!
 I thank all of you for your willingness to forsake the American life just for a little while to wipe away a bit of our sorrow. Your dedication to help my country gives me hope that tomorrow can be better; but more than that emboldened me with courage to embrace my reality and be part of the solution. you went to help a nation you could have ignored and blamed for their destiny but instead I saw tears in your eyes and a burning desire to return; I saw your closing eyes that pray for a nap but a huge heart that thought about one more life to save and one more smile to brighten. It was 11:00 PM but the consistency of your steps  made it feel like it was 3:00 PM. I am so glad you came! and I'm sure the Haitian people are saying the same thing but in silence.
I sometimes looked around hoping that someone else of my cultural background would  come to counterbalance the foreign volunteers but my 8 days were spent as the only one helping my owns. I finally realize color and geographic barriers are just metaphors and we are all ONE through the living air that was breathed into us by the Almighty.
I have so many story to tell but one that stands out in my mind is the selfless act of Merrill who gave her own blood to save a Haitian life. I think the instantaneous nature of the decision was enough to make me realize that she was one us as all of you were.
May your blessings be countless and hope to see you soon!

mesi bokou
 

Job Timeny

Apology

Our team is back home, safe and sound, after an amazing and exhilirating week of hard work, blood, sweat, and quite a few tears. I would like to apologize to our readers for the long delay since our last posting. I had intended to post daily, but both John and myself found ourselves to be utterly exhausted by the end of the long days, and came to the realization that we would have to post in a non-contemporaneous fashion when we got home. So there you have it. Now that we are back to our normal routines in the USA, we will endeavor to catch up and in a thematic format, rather than a diary format.
Luckily, our nephew David Herzenberg, a newly minted Graduate Nurse, had the youthful energy to write a daily blog, in a classic stream of consciousness style, that is at one person's view of what happened this past week. Here is David assisting Dr. Job Timeny, our Haitian American podiatry resident.

 Reading it makes me think of the old parable of the blind men and the elephant, in this case, Haiti, as viewed by the viewpoint of a newly minted rookie nurse. I think you'll find David's writing style refreshing, and reminiscent of the classic novel about the First Year Intern's life in the House of God by Samuel Shem....

Here is David's vision of the elephant that is Haiti...



David’s Impressions of Haiti

Another day…
I must say, I severely dislike the cot I’m sleeping on. If feels like I’m laying on the stretched skin of a tambourine. Similarities end when I toss and turn on the cot. Rather than the charming jingle of a tambourine, my cot more mimics a creaking door in an Alfred Hitchcock movie. I attempt to erect my mosquito net and acquire my much-needed nighttime comforts. I am deeply saddened that I cannot construct my signature pillow nest. Thus I lay in discomfort and attempt to will myself to sleep. I am actually almost successful, just as my subconscious begins to cross the threshold of my mind my animal brain is thrust into action. The scream of a patient’s mother sends bolts of adrenaline throughout my body. I’m up and running to her room before I realize I’m not dreaming. Apparently the child just had a seizure, and now she is lying, post-ictal, the stares blankly up at the ceiling while her respiratory level continues to drop. “Who has the key to the O2 tank?”, yells our pediatrician. “Key!?” I think to myself. Now seriously, why would you need a key for an O2 tank? On a side note this is the second time I’ve been in a situation where no one had the key for the O2 tank. That’s like putting a combination lock on a toilet. 

After much cursing, crying, and possible voo doo, the girl is stabilized and I wander through the darkness back to bed. Struggling to fight my way through my mosquito net into my bed I find myself relating to sea turtles that are unfortunate enough to find themselves trapped in fishing nets. I lie in bed still, and contemplate the unyielding heat. Even at 2:30am the heat is oppressive, the air sits heavy and thick around me. I feel like I could bite the air and spend a good deal of time chewing it. I fall in and out of sleep for the next few hours. Fact about Haiti, where there is no Daylight Savings Time, the sun rises at 4:30 am. Once again I wake up sweating and sticking to my cot from hell. I count at least three mosquito bites and contemplate the possibility of a lifetime living with malaria. … I stagger to the 6:30 am morning meeting, doing my best zombie impersonation… how appropriate for Haiti. I quietly give in to the heat and accept the fact that all the baby powder in the world won’t keep my butt dry.There is no way I can sum up everything I experienced today. Suffice to say, I learned more today than I did over the past year in nursing school. I must have seen 40 patients myself on the floors. I lost count of how many dressing changes I performed. I struggled with language difficulties. I witnessed children and adults cry. I saw injuries that made me sad. I discharged patients that wanted to stay in the hospital because, while primitive, it was far better than their own living conditions. I scrubbed into two surgeries in which I suctioned, helped suture, and stapled wounds. I learned a lot more about what people look like on the inside. I saw bone being harvested from a hip. I ate rice and beans. I made new friends. I surprised myself. I missed people back home. And finally, I felt really good about what we accomplished today. It’s getting late and there is just too much detail to get into. 

Another day…
Drained… totally drained. Again, with the 2:30 am crying. I have a feeling this is a nightly occurrence . Hopefully I won’t strike out with the whole sleep thing again tonight. I’m draining my batteries faster than I can recharge them. 

Today was Sabbath, the day God rested… I’m not a god. I awoke to the sound of church music and prayer. Saturday was supposed to be our slow day. Our usual 6:30 am meeting was replaced by 6:30 am rounds so we could get some rest… explain to me how that works exactly? Anyhow, rounds gave way to our frenetic pace, (I assume this to be the standard). I have my hands in a little of everything here, med. surg., OR, ER, social worker. After sweating like crazy in pre and post op, a couple quick dressing changes and finding adequate staffing for the ER, I found myself back in the OR. I seem to be spending a lot of time in the OR, not specifically because I prefer it, but because I feel like I know the least about this area of nursing practice (Its also the only air conditioned patient care area). There are so many protocols and procedures that must be followed in specific sequences. Even the act of putting on your gown requires a significant amount of planning and thought. 

I was the scrub nurse in one of the OR’s today. I was responsible for setting up the table, getting all the gear/tools/supplies, getting everyone’s gown and gloves, helping everyone get dressed, setting up the sterile field, knowing the names of all the instruments, killing insects (yes there are flies in our OR because of swinging doors that do not stay shut), and producing the correct instruments when requested by the surgeon. I was basically wearing a really ugly light blue sterile burka. What with the mask, hair net, eye shield, lead vest, gown, shoe booties and two pair of gloves I was following Sha’ria law to the T. 

Our first case was a simple wound vac dressing change. Unfortunately we seemed to hit a snag with every step. What was supposed to have taken an hour ended up being more like two to three hours. Our patient’s IV was infiltrated and was of course a hard stick. And to add the icing to the cake, guess who our patient was. Yes, the unfortunate little girl who has been keeping us up every night. A little history on our girl… Compound fracture of the right femur during the January 12 earthquake. External-fixator put on to keep the leg healing straight (think pins and braces), and a skin graft flap in an attempt to cover the skin defect, (think really big open wound that is too wide to close on it’s own). Since January, every team who has come through our hospital has attempted to treat our young lady. In that time her wound has been infected and debrided, and flapped and VAC’d on many occasions. In that time she has developed quite a tolerance to opiate and narcotic drugs. I’m beginning to understand why she cries every night, she’s in pain, not so much because of the injuries themselves, but because she’s in withdrawal. Morphine is hard to get in Haiti. Our team brought drugs with us, but no narcotics, as it is difficult to go through all the DEA diversion paperwork to carry narcotics on the plane. 
Attempting to get an IV back into this girl proved to be a challenge. As you can imagine, the majority of her veins are all used up, I’m sure she has been stuck a thousand times by every team since the earthquake. We wanted to change her wound VAC with conscious sedation and needed to have a line in case we needed to load fluids. In an attempt to calm her down, (she was already hysterical), we gave her Ketamine, Fentanyl and Propophol. And during the entire procedure it was clear that she was still feeling it. She kept repeating in Kreyol, “I’m in pain, I’m in pain”, over and over through out most of the procedure. Even at her most sedate she was still moaning and trying to wriggle off the table. We had some trouble getting a good seal with the wound VAC. What’s a wound VAC (Vacuum Assited Closure). Imagine an open, infected wound the size to two bananas, side by side, on a 60 lb. girl’s thigh. Now, imagine a bunch of 1/4” diameter pins sticking out of the femur above and below the wound; each connected by an articulating rod the width of a toilet paper dowel. All this is on a hysterical frightened little girl who has been traumatized, continues to live in trauma and is going through opiate withdrawal. Ok, you with me? Take out the old dressing, and vigorously brush down that wound. Pack it full of new sponge, cut it to fit of course, and seal it with really sticky flimsy sheets of tape. Make sure to wrap each of the six pins to prevent any air from entering or escaping the wound. Now, cut a hole and reattach the vacuum pump. The suction should pull infected fluids out and promote tissue granulation and healing. Oh yeah, and keep the procedure sterile.
Ok, so we do all that and we find out we don’t have an airtight seal. Jiminy Cricket! I’m so sick of wearing this mask and not being able to scratch my nose! I can feel my finger tips pruning up inside my gloves. We work on it for another 45 minutes. That’s it, we can’t get it to seal and she’s been sedated for a long time and we don’t want to keep her under any longer than we have to. I break my sterile field and race back to the hospital ward. As it so happens, a volunteer from another team here this week is a wound care specialist. It’s time to bring in the ringer. We get her in and within 30 min. we have the wound dressed and re-sealed. Guerilla medicine is awesome. It feels so free to conduct our procedures based on need rather than protocol. We are working in reality; the ivory tower of NCLEX seems so alien and distant. I’m going to have to will myself back into NCLEX logic when I return to S.F. But until then I will fully enjoy implementing need-based practice. There is so much more that went on today… I’m just too tired to relay it. 

Final thought… I’m spoiled, really spoiled, so spoiled in fact that I have the audacity to complain about my sleeping situation in the face of all this disaster around me.  I may not be totally comfortable… but just down the hall are all my patients, just as hot, with broken limbs, only getting one meager meal a day, staring down an incredibly difficult future of rebuilding their bodies, lives and country. They are sleeping on the same miserable canvas army cots as me, and their families are sleeping next to them on the floor. And I complain about heat and mosquitoes… Get yourself in check David!
-- 
 


Another day…
Before I write anything of substance just know that my feet feel like hotdogs that were cooked in a microwave… all bloated and tight… about to pop and spill foot meats all over. I’ve been standing up all day.

As if the conditions in which we operate aren’t difficult enough, imagine trying to perform surgery without electricity and solely by headlamp. Yikes! Don’t ever get sick or injured in a third world country. But I’m getting ahead of myself… lets start with how today began… or rather how last night ended. I’m trying to write a blog a day which is proving to be difficult. Not because there is a lack of content but rather because I’m so tired by the end of the evening. The lack of quality sleep is catching up with me. Last night the same ol’ song was playing again. Same girl, same weeping. I’m a little ashamed to say just couldn’t face it again last night. I crept out of my cot and made my way into the dining lounge, which is much cooler.
Anyhow, had lots of surgery cases today. Here are some highlights.

1. We took off a guy’s external-fixator and opened up his leg. Wow, necrosis… Dead muscle is gross, but dead bone is just sad. The total operation took 6 hours between removing the ex fix, removal of dead bone, insertion of antibiotic cement beads (which I made myself), and application of an Ilizarov cage fixator. This case requires extensive set up. Tons of tools, drills, pins, needles, hundreds of little nuts and bolts of all sizes and variations… Orthopedic surgery is very similar to carpentry… or a really complex piece of IKEA furniture. 

2. I did my very first sterile set up all by myself today, Yay, all by my self; I’m such a big boy! (Just a side note, a young man was brought into the ER basically lifeless, and was coded by our team, but without success. This is the second one today like that…) Ok yeah, so my very first sterile set up, we put an ex –fix on a ten year old girl with a fractured femur (very common injury). I had everything dialed in, and was totally sterile. I only forgot one thing…my lead… and yes we were using Fluoro (real time X rays). We must have taken at least 150 x-rays during this case. I found myself ducking and diving behind the other surgical team members who were leaded up. I will consider that my workout for the day. I’ve been doing push ups, sit ups and various other exercises every night… but I don’t think it’s gonna happen tonight. It’s already so late. 

3. Last case of the evening, open reduction of a hip dislocation on a 44-year-old woman. Basically her hip was dislocated during the earthquake. We think she was trapped under rubble and her hip dislocated when she was dragged by her leg out from under rubble. The dislocation was severe, so severe the femoral head, (very top of the thigh bone which connects into the hip), tunneled through near by connective tissue and settled near the internal lady bits. The head surgeon asked me to insert my hand into the would and probe into the tunnel to feel calcified bone/scar tissue that had formed and prevented the hip from settling back into place. I almost got up to my wrist. I must say it was kind of exhilarating… I know how strange and perverted that sounds but don’t worry, I’m not a serial killer. We lost power several times during this case and worked by headlamp… that too was exhilarating. 

4. I finally left the hospital today and ventured into the outside world. A local Haitian anesthesiologist was kind enough to work with us all day. She worked till 9 pm (well after dark) and expressed her concern regarding driving home alone tonight. Apparently, our hospital is located in the second worst neighborhood in PAP; only to be outdone by our neighboring area of Cite Soleil with is the worst and most violent. So I offered to ride with her to her neighborhood and be followed by one of our vehicles, at which point I would ride back with our transporter. It’s pretty apocalyptic out there. Trash fires, rubble, police, UN soldiers, burned out vehicles, and chaos everywhere. Life it tough… If you are reading this on the Internet, you will probably never struggle through life like these people are. (Obviously myself included). 

Every day here is sobering. It’s really difficult to describe in words what I’m seeing and experiencing. How do you describe a hopeless moaning child, or driving through a population wild with desperation in the dark, or hearing that a mother just stopped by the hospital because her baby is dead and is asking for verification so she can have her child buried for free, or the look of gratitude when you see a patient smile even though you know he doesn’t understand you and is scared out of his mind. I’m not a poet; I’m trying my best to bring you guys here with me, its not all mosquitoes, heat and insomnia. This stuff is a real guys… it’s real and I don’t see any solution.

Sleep, glorious sleep! Finally, a full 5 hours. I feel moderately recharged. Today began without power or water, kind of crummy considering you wake up sweaty and gross. The one comfort I’ve been able to keep constant is my oral hygiene. It took a while but I was finally able to brush my teeth today. There is nothing worse than smelling your own bad breathe inside a facemask in the OR for hours in the heat.
Today’s highlight: I drove with Aunt Merrill and a translator to the Red Cross to get blood for two patients whose labs made them ineligible candidates for surgery. The first, a little girl who needs a high above knee amputation who has a hemoglobin of 3.5 and the second is a young man struck by a car with a femur fracture with a hemoglobin of 5.0. Getting blood is a major chore, as there is only one donor/collection site in PAP, at the University Hospital (much grittier than the name sounds). Families are supposed to donate four units for everyone that they get, but certain blood types are in high demand, and our patients fall in that category. We were so desperate to get him blood that Merrill actually donated her own blood (she’s O-negative) for him yesterday. Even so, we had to come back the next day to get the two units we needed for our patients, as it was a Saturday and the technician who cross matches the blood doesn’t work after a certain hour. Of course this being an island third world post disaster country, nothing happens quickly. So they asked us to wait till today. Waiting for blood is never good. So we make the trip back to the Red Cross to get blood again today. And once more we are asked to wait an additional day. This, we cannot accept, our patients condition is growing more critical and an additional patient requires a transfusion as well. We attempt to explain our situation to the receptionist at the Red Cross without any success. Everyone else waiting in line at the Red Cross, (all Haitian) have similar stories if not worse. Let me back up for a min. Obviously we had to leave Adventist Hospital for this particular adventure. We hired a Tap Tap, which is basically a covered pick up truck with an open tailgait that are used as communal taxis. Most are extremely colorful and painted boasting either religious references or music lyrics. The Red Cross itself was shockingly in disrepair. How may advertisements have you seen by the Red Cross asking for donations for Haiti? Seeing the actual Red Cross in Port Au Prince makes me wonder where all those donations actually go. This country went through its worst disaster in recorded history and the Red Cross which is multimillion dollar NGO only sponsors 1 blood donation site in all of Haiti, and its dilapidated, understaffed, and falling apart?! 

We even offered to pay for the blood, but were informed by the Red Cross technician that the blood was free, albeit with a long long wait to get it. We finally got our two bags of cross matched blood, in a neat little cooler on a bed of ice. Ironically, as we are leaving, a California surfer dude in Banana Republic clothing driving a brand new shiny, tricked out SUV with a Red Cross logo pulls up, beeps and waves at us… is this where your Red Cross dollars are going? To pay salaries, hotel fees, and buy new SUV’s for expat relief workers? How about updating the blood collection center and hiring more technicians so that people don’t have to wait two-three days for their emergency blood transfusions. Whatever…

Don’t remember if I described what driving in Port Au Prince is like. I took some video and I’ll post it when I get a chance. Although it’s not as bad as Sri Lanka or Java, it’s pretty darn bad; the combination of short burst acceleration and roads that are totally messed makes for dangerous travel. I almost messed in my pants when we were speeding down a one-way road into oncoming traffic, on the wrong side of the median, during rush hour, for like 5 minutes straight!

 So we get back, we are heroes, we transfuse the blood, we break and anticipate surgery. I sit down to check my Facebook and begin this blog. That was almost 5 hours ago. A team member runs up to find the rest of us. Our little girl is getting her blood, but suddenly starts to bleed heavily from her leg. Starting off with a Hgb of 3.5, and it seems like most of the precious blood we finally were able to transfuse into her is now pooling beneath her leg on the canvas cot. My uncle John applies femoral artery pressure and we rush her to the OR, scramble to prepare, and hope for the best. It was tense in the OR. Aaron our anesthesiologist stabilizes her and John and Scott wrap a rubber touniquet around her groin. We knew she was definitely going to lose her left leg, but we had hoped to do it in a more orderly fashion the next morning. Aaron figures it out. The sudden bleeding must be from citrate toxicity. The Red Cross adds Citrate in the blood bag to keep it from clotting, but if they have too much in the bag, it causes a clotting disorder when transfused into the patient. Aaron gives the antidote (calcium) and her clotting stabilizes. John and Scott proceed with the definitive amputation, now that she stable (if you can describe a Hgb of 3 or 4 as being stable) enough to survive the procedure. Mind you she is an 8-year-old girl with a bad infection from poor treatment that she received for an open femur fracture in another hospital far away. After languishing in the other hospital for a month, her father had the gumption to take her out, and bring her to Adventist. Unfortunately, the foot was dead and the thigh massively infected and swollen when we met her. We had operated on her the night we arrived, draining 2 quarts of smelly pus from the thigh, with the intent of stabilizing her for the definitive amputation. We knew we would have to amputate. Knowing you’re going to have to amputate a beautiful little girl’s leg conjures bizarre sensations. On one hand you feel terrible because you know you will take part in a life-altering event that will most likely affect someone’s life for the worse. (Forget being an amputee in the US, imagine it in Haiti) But on the other hand you are kind of excited to be part of this complex high-risk medical procedure. I still don’t know how I really feel about the whole thing. It was fascinating and gruesome at the same time, I found myself amazed and horrified at the same time. Not so much because of the gore, but because she would have to live, (fingers crossed), with the outcome of this savage procedure. There were many tense moments; no one was totally confidant we could pull this off. Despite all the blood, bone and flayed flesh, the most disgusting part for me was after the leg was actually free. The sound the leg made as the surgeon dropped it’s dead weight into a plastic bag really bothered me. The sickening thud accompanied by the sound of the femur piercing the plastic brought me back to the reality of what we had just done… We cut of this girls leg… Oh my god… we really just cut off this girls leg.
Confused, disgusted and upset, I found myself sitting alone on the front steps post op. I have seen a lot of crazy things on this trip in the past few days, but I haven’t cried. I even walked through a tent at University Hospital when we went to get blood, and saw at least 2 dead or nearly dead babies and managed to remain stoic. But I just let loose tonight; the seal broke and I sobbed, letting all my emotions drain. I dried my eyes and gathered up the strength to go see her in post-op and say a few encouraging words to her fully knowing there is no way she would understand. I did, and I felt a little better. I can only hope that this scared yet stoic little girl derived some measure of comfort from my touch. On my way out of post op 1, I crossed the hall to post op 2 to check on our other guy who received a transfusion as well.

Although we could not communicate well, we knew each other. I always greeted him and we had somewhat of a connection. Kind of difficult to explain. I smiled at him, he did not return. I looked closely, something was not right. He looked paler than usual and was shaking slightly.

Oh damn, transfusion reaction was the first thing that entered my mind. I got a quick set of vitals HR 129 (very fast) BP 130/90 (a little high, nothing serious) Respiratory Rate 25 (elevated), and Temp 104, (really high). I called for help, and our team arrives, the tremors become more violent, the temperature climbs to 107, his heat races, and his mentation changes. We slam some steroids, pain meds, Tylenol, and fluids.

We are trying to cool him down. Ice, where can we get ice? I don’t know who brought it, but now I have it in a basin. Carotid arteries, armpits, femoral arteries, neck, forehead, and abdomen. We pack his body in ice. We put a Foley catheter in him, we run the IV lines through ice baths; There is running, shouting, sweating, running, tripping and searching. All without any privacy whatsoever. Every other bed and family member in this small room is watching exactly what’s going on. And his shaking gets worse, and his speech more garbled. Gradually he responds to treatment, and we set up a rotating mini-ICU. Gratefully, there are some SICU nurses and a cardiologist in the other team this week, and they offer to stay up with our guy throughout the night.We are not made out of the same things the Haitians are made of; they are so much tougher and resilient in almost every way.
The Days feel like weeks and the weeks feel like days.  I can’t believe this week is coming to an end so soon.  Although I feel like I’ve been working my ass off, there is so much left to do.

It’s no stretch of the imagination that I didn’t get much sleep last night.  Strangely, I’m getting used to running on fumes.  I am, however, totally over drinking instant coffee… what I wouldn’t give for a large ice coffee with a Splenda.  Soon enough…  Anyhow, despite not having adequate caffeine I still managed to power my way though another marathon day.  In fact, it’s not even close to being over.  Turns out I’m going to have to scrub for a late night case.  I probably won’t even begin to prep. the case until 11: 30 pm.  Oh god, last one… well, until tomorrow.  I think we are going to squeeze in a couple before we head to the airport.  I really hope we don’t have any complications tomorrow and we can just make our flights.  Not that I’m eager to leave or anything.  Haiti has captured a part of my heart.  I’m sure this is not the last time we will meet and our paths are destined to cross once more in the future. 

There is just so much work to be done.  There are so many obstacles to overcome.  And there are so many desperate people here.  Patients are getting word of our impending departure.  I always feel awkward around this time.  I’m almost embarrassed that I get to return to my American lifestyle.  Like I said before, this is just an adventure for me, something that makes me feel good and gets attention and praise from others.  But it’s weird, I’m not some angelic savior, sent from the heavens to save the people.  I guess I’m here for a couple reasons. 

First, someone needs to go.  I have a really hard time watching people suffer. And second, it makes me feel good.  A big part of why I do this is for myself.  It makes me appreciate who I am and what I have.  Although I really appreciate the fact that you have been reading my blogs; commenting and giving me such positive feed back, just know that I’m no hero. I’m not doing anything that is beyond any of your capabilities.  Just like Michael Jackson said, “If you want to make the world a better place, just take a look at yourself and make a change”.  Yeah, I know, uber cheesy, but very true.

Ok, enough preaching.  Lets talk about today.  Nothing shocks me anymore, well almost nothing.  Today was swelteringly hot, the kind of hot that makes you actually feel like your being slowly cooked.  I had that gross wet pant leg stuck to your calves and thighs feeling all day. So again I bounced back and fourth between the OR and Post-op again today.  If I wasn’t wet enough from my own perspiration, I walk into Post-op 1 and into an inch deep puddle of toilet water.  Apparently a pipe burst in a nearby bathroom and flooded.  Ugh, great.  Now my scrub bottoms are soaking up poo water and the water line is having a race to the back of my calves.  Sigh… But like all toilet tragedies it isn’t the end of the world and eventually gets taken care of.  The morning dressing changes continue.  I become intensely focused on changing a complex dressing on an Ilizarov fixator.  I kneel down on the tile floor silently, super silently.  So quietly in fact that I touch down without any sound at all.  That’s odd, I look down at the far end of my thigh and am horrified that I just knelt on a turd, a wet, loose, lonely, brown turd.  Good thing my knee decided to keep it company….

A bunch of us are in the breakroom when my uncle comes up to let me know that I need to take over for his usual scrub nurse who has been working all day, and at 11pm has hit the wall of exhaustion. There is still one more case to go, and I need to scrub in to fill her place, Our surgeons started a spinal fusion at 9pm on a 23-year-old kid who was recently paralyzed from falling out of a tree while picking mangoes. One more case to go (dressing change on our little 8 year old amputee from the other night). Ok, I’ll write more if I have the energy when I get back from both of theses cases.  We’ll see though.

Can’t write any more, need to be awake in 4 hr.  Very dramatic case, thought she might bleed to death… never been part of anything like that. She made it
OK, well I wanted to post that last night but the Internet was down by the time I returned from the OR. I ended up catching the very end of the Spinal case.  Although I didn’t end up scrubbing the spine, I saw them suture and close.  The final case was to debride and do a dressing change for Mia, the little girl who had the amputation and captured our hearts. We didn’t even bring her to the OR until midnight, always a bad omen.  I went to retrieve her from post-op one and found the room dark and everyone to be asleep.  Rather than wake everyone up, I decided to carry little Mia into the OR.  She is so brave, she hardly protested at all. 

She knew what we were going to do and what kind of pain she would wake up with.  She buried her head in my chest and held on to my neck with her tiny arms.  That’s it; she crushed my heart right then and there.  It’s a bizarre feeling; causing physical pain to children with the knowledge that it’s for the best.  Although I knew I was taking part in an operation that was certainly going to save her life, I had to battle with the reality for how much trauma we were going to cause her, both physically and emotionally. It tore me apart to wake her from her fitful sleep to take her to the OR. 

I take care to step over sleeping family members asleep on the floor at the foot and sides of our patient’s beds.  It’s truly amazing how devoted Haitians are to each other.  They do so quietly, and with out any protest; thankful for the fact their loved one is receiving any medical attention at all.  Seriously, think about that. They sleep on the dirty tile floor, most without a blanket, some with the luxury of an unfolded cardboard box to lie on.  Each patient has at least one family member who stays overnight with him or her.  In the short week that I’ve been here I have never seen a patient alone.  The difference between American and Haitian hospital culture is astounding. I walk down the hallway in the dark, guided only by minimal light and a sense of familiarity I have developed over this past week.
We got her on the table and Aaron gave her the anesthesia drugs.  She cried a little and went to sleep before she made it to the point of being completely hysterical.  We estimated the entire procedure would take around 30 minutes from start to finish.  Just a dressing change, maybe a little debridement of any residual necrotic muscle. She goes down, we open her stump back up and are immediately blasted by the stench of infection and necrotic tissue.  That smell is unforgettable, and indescribable.  There is no known substance or combination that accurately mimics the scent of infected necrotic flesh.  Although the wound didn’t look terrible, it certainly smelled that way.  So we go in, scalpel, forceps, retractor, Bovie (an electric cautery tool that sears blood vessels shut)…. Sponge…. Hold here…. Irrigation… suction, irrigation… suction, scalpel, forceps, bovie…. Scalpel… And oops… looks like we nicked an artery… bleed, bleed… ok pressure right here with those sponges…. Bleed, bleed.   Wow this one is really going, do you think it’s the femoral artery?  Squirt, Squirt, Spray, Ahhhh, holy crap, Sponge!  More sponges, get more sponges.  At this point the sponges are soaking through just as fast was we can press them down.  Bright red oxygen rich book flows out from around the sponges and floods the opened stump and runs onto the blue table dressing and down the sides of the table.  These shoes are definitely not coming back to the United States with me.  The possibility of Mia bleeding to death right here in front of me is becoming a terrifying reality.  My uncle John and I are furiously fighting to stop the bleeding long enough to have a clear view of the hemorrhaging artery so we can clamp and suture it closed. 
She’s down about 300 ml of blood.  We cannot keep losing blood like this.  John asks Scott to scrub in and help him search. Although I have learned A LOT this trip, I know when the limit of my skills has been reached.  Looking at anatomy books and identifying color coded 3-D models is one thing, trying to pick through a mutilated, necrotic stump for an elusive artery as it is constantly being submerged in rising levels of blood is another. My role changes from stopping the bleeding to retracting the wound as wide open as possible so that John and Scott can search for the femoral artery.  We need to find where the bleeding is coming from!  It’s really squirting now, high enough where it sprays my goggles and gown. More sponges!  We continue on like this for a few more minutes that seem to stretch on forever.  Adrenaline pulses through my body and I am hyper aware of every passing second and ml of precious blood that is lost.  Damn, we can’t lose her tonight, the night before our departure, not after everything she and her family have been through. 

Ok, ok, one clamp on, finally the bleeding subsides.  We quickly suture the artery and finally take a moment to breathe.  We cautiously continue on with the debridement, and remove bits of dead bone, muscle and tissue.  I cannot accurately describe what this wound looks like, nor would I want you to be able to clearly picture it in your head.  Just know it does not belong on this beautiful little girl.  Life is cruel and indiscriminant.  Being here in Haiti, I am reminded of how fragile humans really are; just membranes full of meat and bit of bone.  We finish removing the odious tissue and pack the wound full of clean gauze.  A couple of loose sutures pulls the skin flaps around the gauze and recreates the stump.  We tightly wrap the stump with an ACE bandage. It is so high that we have to wrap around her little waist to get the dressing to stay on. I hope the compression prevents any additional bleeding.  As it stands, little Mia is going to have to face a wound debridement and dressing change in the OR every day or two for a while, hopefully minus the severe blood loss.  But for now she is stable and sleeping, and we bring her back to bed….Sigh…

It’s 2:30 am; finally time to get some rest before my 5:30 am wake up call from the sun and the heat.  One more day.  Not even a full one. The days have melted together to the point that I can’d distinguish one from another. I don’t want to leave….