Friday, June 10, 2011

Haiti Trip Summary 5/29/11- 6/5/11 Team Sinai-Operation Rainbow

Last Day in Haiti, tired but fulfilled!
After nearly eight days of hard work, the team finally made it back home, safe and sound, to the USA. All were exhausted, yet satisfied that we helped the patients and staff of Hopital Adventiste d'Haiti make it through another week of trials and tribulations that is the challenge of providing orthopaedic care in resource-poor, post-earthquake Haiti.
Strictly by the numbers, we operated on 32 patients. New for our team this year was a formal education component. Through the organizational help of Marc Julmisse, long term volunteer nurse education coordinator, our team delivered 11 lectures to the local Haitians. Topics ranged from Infection Control, EKG Interpretation, PACU Management, Ponseti Clubfoot Method, Diabetic Feet, Care of Spinal Anesthesia Patients, Care of Block Patients, among others. The audience included, at various times, local nurses, docs, and volunteer firefighters/first responders.  The lectures were either delivered in English, with Creole translation, or by some of the team members (Job Timeny and Tara Montplier) in Creole directly. Our team included four native Creole speakers (Job Timeny, Tara Montplier, Ron Delanois, and Francel Alexis), giving us a distinct advantage both in clinic, on the wards, and during the educational sessions. In addition to the lectures, we provided staffing to the orthopaedic clinics, including huge general and pediatric orthopadic clinics on Monday and Friday, a ginormous clubfoot clinic on Wednesday, and modest drop-in clinics on Sunday Tuesday and Thursday. Our family practitioners, Ram Shetty and Julia Ramberg, worked daily general pediatric clinics as well, in addition to doing pre-op medical evaluations on each patient being considered for surgery (H&P's). Based on their assessments, many patients who were selected for surgery were cancelled due to unresolved medical issues, or recent colds.  We strove to maintain this level of safety, similar to our practice at home, by doing site markings, and time-outs before each surgery. The post-operative recovery room, manned by both local Haitians and by our three ICU/PACU nurses was a welcome addition, further augmented by a generous donation of a sophisticated ProPak monitor thanks to Operation Rainbow. The local nurses have now been trained on use of the ProPak, and it will stay in HAH, hopefully elevating the level of post-anesthesia care for many years to come.
Our surgical volume was somewhat less than our trip last June 2010 (32 vs 50 operations), reflecting the downsized nature of the hospital volume as the earthquake related trauma diminishes. Last year, a full 1/3 of our cases were directly related to the earthquake. This year, only a few were earthquake sequealae. The majority of our patients were children with birth defects, and some adults with general orthopaedic and trauma problems.
The surgical procedures accomplished included (in order or prevalence), clubfoot related surgery (16), Ilizarov related external fixation (6), osteomyelitis-infection (4), knee arthroscopy (4), eight-plates (4), cerebral palsy (3), tibial hemimelia (2), hemiarthroplasty (1), and macrodactyly (1). Some of these were bilateral cases, so the total number of patients operated on was 32, though the total number of procedures performed was at least 41. Of special interest to our podiatric colleagues was the wide range of congenital foot problems, which will be the source of a future posting.
Of course, none of this could have been accomplished without the help and guidance of the long term volunteers: Terry and Jeannie Dietrich (Orthopaedic Surgeon and Nurse), Nathan and Amy Lindsey (Assistant Hospital Administrator and Volunteer Coordinator), Marc Julmisse (Nurse Educator), Lynn Byers (Nurse Clinician), and Brittany Blair (Lab Coordinator). We are very grateful for their help and guidance, and we are in awe of their commitment. For us, one week at HAH was exhausting. It is hard to even imagine what it would be like to volunteer for 6-12 months or more, as these brave souls are doing. Adventist Hospital has become one of the top orthopaedic hospitals in Haiti since the earthquake, though the future of this endeavor is still uncertain. Many long term questions remain: will it be fully Haitianized, or will it continue to be staffed partly by ex-pats? How will funding be developed for long term growth and daily maintenance? For the patients of Carrefour and surrounding areas, this hospital is a tremendous resource. It is obvious from the neglected clubfeet that we saw in young adults, that such care has not been available for many years past. Now that there is a weekly clubfoot clinic to cast infants with clubfoot, the number of feet requiring complex osteotomies and fixators will hopefully eventually decline. The problems are daunting, perhaps even insurmountable. One can gain some solice by remembering the old African proverb, "How do you eat an elephant?.....One bite at a time..."
One last comment, our hosts, Dr. Terry and Jeannie Dietrich left for a well deserved two week break, mid-way through our mission. The next team of overseas volunteers is not due for another two weeks, leaving HAH without Orthopedic coverage. Thankfully, two of our team members, Dr. Francel Alexis, a young Haitian orthopaedic surgeon finishing his fellowship training in pediatric orthopaedics in Santo Domingo, and Dr. Jeff Young, a newly minted attending orthopaedic surgeon and graduate of our fellowship in Baltimore, agreed to stay on for an extra week (Jeff) or two (Francel) to bridge the gap until Terry returns. These brave souls will not have the back up and support of our huge (n=20) team, and so we have dubbed them the Lone Ranger and Tonto (not sure which is which) for their bravery and dedication. We wish them the best of luck these next two weeks!
More posts to follow by various members on specific topics, but for now, we're all safe and sound back home!   -----John Herzenberg, MD

Sunday, June 5, 2011

Everyone has a hustle....

Reading the Sinai Newsletter ("Bridge") at the main gate
leading into the hospital. No guns allowed except for the guard!

Day Seven........rounds in the morning, followed by a trek to an orphanage( a trek it was up a windy dirt road in the mud, the van fishtailed)......two stories no real running water but electricity. There were 20 or so kids there. We brought toys, soccer balls, coloring books, frisbees, pencils. We tried to give everyone something, we even had the hand made blankets we were giving out to our patients the previous week. A few members of our group went and bought snacks and pasta and fixings so the kids had some food to eat. Most gobbled up the snacks right away, some hid them to save for later. It was an eye opening experience for me as I heard of the owner trying to get us to contribute an extra ordinate amount of money to buy another property. Claiming no money to run the place.... Everyone has hustle, a way to try and get more. Although motives are questioned at least they have a roof over their heads and someone watching them.

After going back down the hill, we started our tour of Port Au Prince, squalor is the best word for the worst parts of the city with destruction, like the earthquake was yesterday. Masses of concrete houses placed on top of each other along the hillside, decimation at the valley. This slowly weaves along some paved and unpaved roads into a less cramped area with a hint of manicured lawn( our driver said it's a club where tennis is played) along the winding road beautiful vistas pop through concrete a glimpse of the port and ocean.....

We stopped for lunch at Epi D'or a cafeteria style bakery/fast food/Haitian restaurant in a relatively affluent part called Delmas. There were a few boutiques, the roads were paved although caddycorner from the restaurant was a decimated building. About 1/3 of our group partook in the pastries, 1/3 "American food" and rounding it out was a combo of Haitian food and crepes. Coca colas, Tampico and champagne cola as well as coffee was enjoyed at our tables. Geteau simple( Haitian cake) was introduced to us by Ron and Tara.....Thank you. A lighter crumbly pound cake of sorts with a hint of coconut was a a great treat!!

After our enjoyable lunch, we headed to the presidential palace. Across the street is one of the tent cities where I overheard a man say 2800 people live. The palace once shining and standing tall, now sits a little shorter, askew and across from a constant reminder that something must be done. We followed the palace down to the PAP cathedral, where the presidents used to be inaugurated. It was a shell of it's former self, some stained glass left in a skeleton church.
Residents of the local area came asking for money or food, when we gave they just asked for more. A difficult situation.....one inspiring man was a double amputee in his own motorized wheelchair. He sat in this wood box with a captains chair of sorts. He had a hand crank drive that motorized his cart. Ingenious!!

We returned to HAH tired, rejuvenated and excited at the same time. Our adventure had taken us not only out of the hospital but off the grounds of the hospital. We topped off the night with a yummy buffet at la auberge Quebec around the corner and up the hill from HAH.
We shared a meal with the volunteers at the hospital as well as our amazing translators. We shared in an operation rainbow tradition of an awards ceremony, yours truly received Miss Congeniality something I now share with Sandra Bullock, :) you'll have to check in with the rest of our amazing team as to who was the happy curmudgen, the girl scout, macgyver, the brave one, the designated hitter, the octopus, the juggler, the lone ranger, the eager beaver, the scrub-a- dub-dub etc........
My reflections on this trip will likely come out later...after sometime has past and thoughts have settled!

Yo Jen Peacing out from Haiti.....what a long strange trip it has been...I mean that in a good way!

Saturday, June 4, 2011

Shabbos in Haiti

Day 6 is in the bag!!!
Kiddush for Shabbat in Port au Prince
We have completed 32 cases this week, a variety of congenital deformities and a smattering of other pathologies. Today was the last push, we had all be working since we got here. This is where the coca cola came in, just enough sugar and caffeine to get to the end of the day. Our day was filled with OR and clinic, pain control and cast changes. Our teaching came to a close with defibrillator lessons, some EKG reading and clubfoot lectures as well as a practical lab for our great technicians!!! All in all, heat, rain and mosquitoes...it was an amazingly wonderful, heartbreaking, educational trip. It is amazing when there are a group of relative strangers with a common goal that can get together and get along! It's like the reverse of The Real World!! We have worked together and broken bread (MRE, Protein bars, Tuna, Mac and cheese). We have our routine, by the time I gather my bars and cup for coffee, John and Chris have heated up the water for their coffee and generously share with me! Cindy comes in to prepare our coffee and everyone elses starts filtering in. We set out for chapel or OR and get our day started, at the end we meet up casually checking email, eating dinner, chatting and getting to know each other. I am excited for tomorrow no real cases, no scrubs and a chance to really hang out although I feel like I know everyone....an amazing surprised was left in the break room tonight, courtesy of Brittany Blair, the long term lab tech volunteer serving here at Adventist. Brittany was a religion major at LLU, and she studied Biblical Hebrew and Judaism, among other topics. In order to make us feel at home, she prepared Shabbos candles, grape juice and challah bread, braided and doubled. Although I myself am not Jewish I felt a great sense of comraderey as Dr. H and his family lead the prayers. Shabat Shalom every one, Day 6 is done!
Yo Jen

Thursday, June 2, 2011

Day 5 ain't it great to be alive

Today was a day unlike any other, Day five had no clinic patients but a wealth of surgeries. It also said goodbye to a new friend( even though he's a red sox fan) Dre Dawg was missed today and we hope he had a safe trip back to Albany! Today would be the day for all the regional blocks! Day five welcomed a familiar face, Jeff the younger who joined us after a stay on the east side of the island to follow up on patients seen at the CURE hospital. Day five also saw a transition, a culmination of our work here, although we have a very busy clinic/ OR day tomorrow, we will be leaving this Sunday. Jeff will be heading up things as we leave and we are helping to train not only the nurses and EMTs and local docs but the fantastic OR staff as well, helping show our tricks quips and pearls to many of the trickier procedures...Day Five would not be complete without a few things.
1- JJ and Jeanty are two of the most caring, respectable and kind men I have ever met.
Jeanty left nursing school to help work at HAH 1 week after the earthquake, inspired by a
visit to this hospital to visit a friend who had been crushed. JJ is our glue in the OR, never hesitating to help us which is a big reason Nathan hasn't heard anything from our group except "hello and Bonjour"
2- Tara and John and Merrill. Our PACU team is amazing, working in a 2 bed room with a side table full of everything you need over flowing with all the generous supplies donated. On the cupboard top, blankets made for the children by some wonderful human beings who even sewed a pocket with a beautiful note- in creole. We have two loaner pro pac monitors for excellent post op care and AC which if we stopped running in and out would be more effective in cooling that tiny room! Charting is key here as the patients end up taking their post op instruction and operative slip with them when they are discharged. Merrill and John R keep us on task!! They are the unsung heroes, while the surgeries may be over for the surgeons at 7 their day continues until our patients are fully recovered, well enough to move to less monitored beds and sometimes it continues into the night to check on a girl that although an outpatient surgery lived to far away to realistically send her home.
3- Cindy, Jenel and Chris And Alex you guys are great. Alex and Chris wow what fast leathers you are- circulating running back and forth getting this suture and that wire or half pin.Cindy and Jenel have a solid experience base allows time to teach, Thank you for taking time to allow JJ and Jeanty to scrub and learn.
4- I saw a woman cry today, tears of disappointment, despair and longing. Tears we had caused. It was a day of long complicated cases, executive decisions had to be made as our most valuable resource, the team, if burnt out would be no good for any one. The shear amount of pathology we saw this week and likely adding to it tomorrow was a bit overwhelming, unfortunately the deformities we were mostly seeing were complicated corrections that take a bit of time to complete, leaving us at a loss for just how many we can help. These are the facts. I cried when I saw that mom. I felt for her and understood her despair. In certain towns, villages and cities around the world, foot deformities are of some of the more shameful conditions. This mother likely thought she would come, her child would be fixed and no more stigma, ostracizing or ridicule would be put on them....the hope in this story is that there are amazingly generous souls that do what team Sinai does and will be here to help her daughter soon, the tragedy of this story is....Now that the tragedy of the Earthquake is a years old....how many will still think about an island nation in the carribean with no front page news story? Operation Rainbow, team sinai and CURE will because they are dedicated to helping anyone and everyone to aid in contributing to a quality of life some of these children have never known. Now that the dust has settled, new tasks must be accomplished, new goals must be attained. We saw very few people affected by the earthquake this week. The majority the population were people, babies and children with congenital deformities that need our help. Need our supportus need us to not forget them when the hype dies down.
Love and Peace
Yo, Jen
P.S. Dr. Ron......thanks for the coca cola great end to a long day!!

Greetings from Ayiti!

Greetings from Ayiti! Day three started with a beautiful Haitian morning, nice and warm way to wake up for the day. I slept like a rock (on my very comfortable cot) and managed to take a few moments to really take in the view of the hills behind the hospital and the chickens as they scavenged among the banana trees next to the hospital. While the day did not fully get rolling as early as many of us had hoped, but it was definitely a full day of work. It was so great to see the ortho/podiatry team doing their thing, pinning, releasing, and casting left and right. I thoroughly enjoyed swinging the C-Arm around and watching the xrays as Dr. Herzenberg, assisted by two Haitians (JJ and Dr. Alexis), placed each pin carefully into a TSF. The most memorable part of the day was seeing a young little girl, tears streaming down her face, gripping her arms around the smiling nurse Cindy. My feet are pretty sore right now. I will take that as a sign that I put in my days work. To quote one team member who was kneeling on the ground just outside the OR, “I feel good right now, I don’t think I can make it up the stairs.” The night ended with a rain storm, bringing coolness to a very hot day. Anyways, another day another dollar. Just kidding!! Its so great to be here, can’t wait to see what tomorrow brings.

Wednesday, June 1, 2011

Mango tasting party

17 year old girl with never-treated
congenital clubfoot
What does the siani team do to unwind after a challenging day which included two tumor cases and bilateral cases on 8 month olds......A mango tasting party while perseverating on the days cases and our cravings for......shhh don't tell anyone at the hospital. MEAT. Although the food is really good here at HAH it is vegetarian and most of us are omnivores who enjoy red meat at times. I have a feeling that first taste of meat when we get back to the states will be the best any of us have had. Even with the mosquitoes biting( I had a target lesion, no worries not lymes diseas) and my DEET not working team Sinai came together over mangos and for most of the night...a very large brown speckeled orangish fleshed fruit that for the better part of the night, we had no clue what it was but some did partake, about an hour later Jaunty came in and told us it was an abricot!!! It was the largest apricot we had ever seen. Fun times were had by all Tuesday evening. This morning brings TSFs, arthroscopes, Triple arthrodesis, and a few Tals and maybe dinner at the auberge???

Same girl, after Penny modification of the
Lambrinudi triple arthrodesis
Yo, Jen
P.S.
Together We Move, a photo essay book about HAH is coming out next week. Check out Hatitogetherwemove.com to buy a copy next week. All proceeds go to help run the Hati Indigent Patient Fund which allows them to treat poor patients with debilitating conditions. Please support this wonderful community.

Thank you to our host Terry Dietrich, MD good luck to you and Jeannie on your travels back to the states!!!

dre dawg

Dr. O and I blocking the popliteal nerve
From this side of the ether screen:
Day two of operating is in the books here at HAH.  No clinic today for the orthopods, which meant that we could get through some serious cases in the OR with Drs. Herzenberg, Delanois, Dietrich and the fellows that are here.  So we fired up early, with cases that are now blurring in my memory.  Dr. Sauter popped in spinal after spinal and took care of many of the adults.  Incisional biopsies, knee arthroscopies and the full range of adult orthopedic care.  Dr. O'Loughlin is a master of the pediatric neuraxis.  Caudals, caudal catheters confirmed by fluoro, and spinals that lasted the full duration of the complicated orthopedic reconstructions that Dr. Herzenberg undertook in OR 2 were placed and secured with smiles and good humor.
My trusty sonosite nanomaxx
that almost didn't make it past the TS
It was a fulfilling day for me as well -- I powered up the Sonosite Nanomaxx and put in a femoral nerve catheter on one patient who underwent a tumor resection from around the soft tissue of her knee and then a popliteal catheter on a teenager who had a unilateral club foot repair.  Good, good times!  I'm stunned at some of the medications that I have the priviledge of administering to my patients here.  Clonidine, an adjuvant for regional anesthesia, is well known to increase the duration of a nerve block as well as enhance the quality of the block.  And clonidine is available here at HAH!  So all of the block patients received 2mcg/ml as part of their block and looked very comfortable when we tucked them in for the night.
Another day awaits tomorrow.  The team is great.  The HAH staff is welcoming, supportive and incredibly helpful.  And the patients are the best of all.  The trust they put into all of us is palpable.
Five Stars at the Adventiste
Arup De (aka Dr. Dre,aka  Dre Dawg)