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

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 12^th Thoracic vertebra dislocated one inch away from his 1^st 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

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….

This is day 5 of Team Sinai's adventure in Haiti. We can't believe that we are this far into it. Even those of us who have been on mission trips before have never quite had an experience like this.  We are living on the second floor of the hospital which is open to the outside and open to a patient ward.  We hear everything especially at 3 in the morning when a patient with PTSD wakes up and starts screaming. When we try to get back to sleep the roosters start crowing.  We start our day at 6:30 with a meeting out on the front steps (Aaron can't find the lid to the percolator so we can't even have real coffee!)  Last night we finished at 1130 tonight was earlier for some of us but others are still in the  OR....
The need is so great here.  We have many patients scheduled for the OR each day. The ortho team round on between  40 and 50 patients a day. As well as taking care of the patients there we have a pediatric ward which has between 5-7 patients a day.  The urgent care center is closed when we are busy but people still come.  People are waiting outside by the time we go out to our morning meeting. W e have been seeing at least 15 pediatric patients a day (another pediatrician also is seeing kids at the same time). The ER is hopping with interesting cases.  We have seen the beginnings of life as well as the end. Many happy moments and many sad.
The people are wonderful and so appreciative of everything we do.We are working with other volunteers from the US who are also great and very helpful.
The nurses who work in the hospital are paid very little and have many patients to care for.  Most others who work in the hospital are volunteers.  All of the translators (our best friends) volunteer.  They are great!  Sometimes you are not quite sure that they have told the patient what you want them to say of if they are saying what they think they should be told. Sometimes they say much more than you have told them to. :)
It has been an extremely tiring week but one none of us would ever take back.
Goodnight.

Welcome to Haiti... this is what you wanted!

Posted by David Herzenberg, GN, our beloved nephew...

Let me preface this blog with a couple truths.

1.     I only slept 3.5 hours last night

2.     I woke up at 4:30am

3.     Been traveling all day

4.     I refuse to check or edit this blog for content save for spelling errors

     The Herzenbergs plan a disaster relief mission to Haiti in wake of the most recent earthquake… hilarity ensues.  Keeping in tradition with past travels, our late night of packing is not to be out done by our early morning emergency.  Our transportation to BWI airport seemed to have overlooked a minor detail of our reservation.  It’s in situations like these that I see the true value in using military time.  We somehow rise to the occasion and hit the road by our own volition at 5:30 am, or 0530hr to clear up any confusion.  Miraculously we arrive at the airport with time to spare, greet the rest of the team, and manage to board the plane with thoughts of anticipation, excitement and nervousness. 

            

     And we’re up and off… and for the most part the first flight was uneventful, which happens to be a quality I quite enjoy while flying.  Sleep, sweet, sweet much needed sleep. We land in San Juan around 1200hr local time.  The reality of our mission is becoming more of… well… a reality.  Although we are still in the terminal I can feel the sweet sensation of tropical heat though moistened breaths.  I am slightly disheartened to see a Cinnabon in the terminal… Don’t get me started!!  Anyhow, we board the tiny double propeller plane on the tarmac and I instantly feel like I’m sitting in a giant croc pot, stewing in my teammates juices.  We have an issue with one of our bags that delays our departure.  Apparently a few moderately large containers of hand sanitizer have managed to spill contents and the smell has alerted the crew.  Unsure as to the source of the smell, the crew spends an additional 45 min “solving” the issue before we depart. 

            

     Finally we are up and off again…  Just a quick oceanic voyage from San Juan to Port Au Prince.  It is instantly clear we are traveling in the midst of the rainy season.  I play a long game of charades with the low hanging cumulonimbus clouds.  It was not difficult to appreciate the Dominican landscape… rolling green pastures enclosed by even greener mountain ranges.  My eyes pick out several unexpected yet familiar shapes.  The landscape is dotted with a myriad of baseball diamonds, so many in fact; Sammy Sosa himself would be impressed.  However, this wondrous backdrop does not continue forever.  Like a slide in a power point presentation, our lush greenery is abruptly replaced by a landscape that is stripped and brown.  My mind is jarred by the contrast and is searching for answers as to how such a dichotomy can exist.  Static from the overhead speakers is followed by the captain’s voice, “Attention passengers, we have just crosses into Haiti’s airspace.”  Closing in on the capital, tell tale signs of disaster make themselves known.  Those bright blue dots, some spread out, some so close together, what are they, they seem so familiar.  No, those drops of bright blue are not swimming pools, they are the lengths of blue tarp that are covering damaged homes and providing extra shelter from monsoon rains.  Welcome to Haiti.

            We land, we deplane, we make our way across the tarmac into the terminal.  Unapologetically Haiti greets us in the only way she can.  We are blasted by heat, assaulted by humidity, overcome by noise, and intimidated by a culture that remains a mystery to most of us.  We rally, we steady our nerves, we collect our baggage.  We feel good with the knowledge that all of our bags and our entire team has made it, at least, to the airport.  Only one problem remains… does anyone know how we are going to get to the hospital?  I’ll spare the details, but if you have ever traveled in a third world country, much less after a disaster, you understand how difficult it can be to get to your destination from the airport.  Our arranged transport arrived, somewhat delayed by unpredictable PAP traffic, and underequiped to transport of team of 18 laden down with 2,000 lbs of geat. After another hour in the sun, we wade our way through the airport loiterers and solicitors and fill three vans with our crew and bags.  We are moving again. 

           

     I’ve had the honor of volunteering in the wake of several disasters; the atmosphere here in Haiti is no different.  Filthy streets, undulating crowds of people, outstretched hands reaching into your vehicle looking for a donation, animals rooting out a meal, piles of trash clogging the streets, rivers of plastic damming up the gutters, the sweet stench of rotting organic matter, that dry feeling you get in your nose from swirling dust and diesel fumes, crippled buildings, roads, and infrastructure, numerous tent cities, and traffic, my god the traffic!  Ladies and Gentlemen of Team Sinai, you have arrived; this is what you asked for. 

     There is more… but I’m just too tired to write.  Part of the team got drafted to the OR within an hours of our arrival. The rest of us unpack, set up our mosquito nets on the open air veranda. We have a 6:30 am preconference tomorrow before we hit the floor. Just know that I’m safe, (perhaps not from the Mosquito’s) I’m at the hospital we are staying at, and it’s hot! Hotter then… well… Haiti… 

Again, sorry for the bad grammar and poor usage of imagery. More to follow...

Stay tuned.Publish Post

Carlene "Central Sterile" Williams

Team Sinai is getting ready to depart for our long planned mission, and final preparations are at a fever pitch. Pictured here is Carlene Williams, Central Sterile Technician at Sinai Hospital. She will be responsible for organizing, cleaning, and sterilizing all of our surgical equipment. Pictured here with Amy Montillano, O.R. nurse, Carlene has contributed significantly to our preparations and organization. Carlene was in the U.S. Army for more than 10 years, so she is no stranger to working under difficult field conditions.

Dumpster Diving

We'll be in Haiti next week, so we're down to the wire on our preparations.  Aaron and his crew are busy readying the anesthesia and pediatric gear, John is preparing surgical sets, and the rest of us are getting our gear together for wound care, nursing care, nutrition, and any number of miscellaneous items. Just when we thought we had all bases covered, we heard that the hospital is "very very low on IV fluids...." so now wer're scrambling to locate IV bags of Lactated Ringers Solution. Luckily, our hospital has a corner of the Recieving Dock set aside for discards from the hospital. We are allowed to "dumpster dive" for all kinds of goodies that would otherwise be periodically picked up by a distribution group called Project Hope. (Sorry Hopers.....we diverted some of the discards that were coming your way...)

 It's been weekend of packing. We were about 90% done when American Airlines threw us a curveball: there is an embargo on any extra bags to Haiti. We were hoping to have several of the team members take three checked bags so that we could bring in more gear. AA says ixnay on that. Now we're scrambling to jettison that which is not "mission critical" and make our selves leaner and meaner. AA also decided that they will only accept duffle bags (no crates). Great news for Aaron who just finished packing his delicate anesthesia monitors and other breakables into 6 shipping crates and now has to move everything into duffles. It could have been worse, we could have found this out at the airport during "check in"....

Packing is an event, and in this picture, you can see Amy Montillano (the O.R. nurse on Team Sinai) and Ella Joy Napoles. Ella is a Sinai O.R. nurse who has been on missions past with us, but unfortunately can't make it to Haiti. However, she is planning to go with us to Ecuador in October. Ella is a great sport, and spent Sunday afternoon at Chez Herzenberg helping us with the packing.

Who shot JR?

John Russell ("JR") has been a PACU nurse at Sinai for ten years. His hobbies include fixing broken things, gardening, cars, and cooking. (John: should be plenty of broken things to fix, not much gardening, no fancy cars, and not much cooking at HAH...bring your own food!)  John tells us that "I am looking forward to Haiti for the opportunity to work with a group of people who are there only to do what is right, not for money, fame or prestige."

John is an avid camper and hiker, and has already staked out his corner of the hospital roof to pitch his four-man tent, to be left behind as a gift for a homeless Haitian family.

The Three Musketeers (Les Zuckerbergs)

"You are not required to complete the task;

nevertheless, you are not exempt from beginning the work".

            "If I am only for myself, who am I?"

"The more charity you do, the more peace you will create"

                                                --Ethics of the Fathers

Gabe, Jeremy and Aaron Zuckerberg are honored to join Team Sinai's mission to Haiti.

Gabe, a Beth Tfiloh High School junior and Jeremy a University of Maryland sophmore have spent long hours working with children both in and out of the hospital setting, and are anxious to bring smiles and friendship to the patients in Port au Prince.

Papa Aaron is double boarded in Peds and Anesthesia. His day job is Pediatric Intensivist, but he dreams of being a professional cyclist. This photo of Aaron in Sponge Bob Land (his unit is a shrine to the Bikini Bottom group..) is taken from the article in 2009 Baltimore Magazine's "Best of...". Aaron was voted the Best Pediatric Anesthesiologist in Baltimore.

Plumpy'nut and Medika Mamba

In the simple yet eloquent words of Haitibones blogger traumaqueen, “Haiti is hungry. Very hungry”.  http://traumaqueen1.blogspot.com/2010/05/everyone-here-has-chest-pain.html

Most people in Haiti eat only one meal per day. Even the patients hospitalized in Hopital Adventiste d’Haiti (HAH) are given only one meal per day. Even if that meal is 500 calories, it is still inadequate nutrition to heal wounds, clear infections, and knit bones. Many returning volunteer docs and nurses we have contacted after their return from HAH confirm that malnutrition is a huge problem.

 A little research on the Internet, and we found “Plumpy Nut”, a Ready to Use Therapeutic Food (RUTF). That's NGO-speak for a food product especially designed and manufactured to treat hungry children in Africa suffering from moderate to severe malnutrition. Where to find Plumpy Nut? There's a great story by Anderson Cooper that explains the origins of Plumpy Nut and how its use in Niger and other African nations has made a huge dent in the need to hospitalize children with malnutrition.          http://www.cbsnews.com/stories/2007/10/19/60minutes/main3386661.shtml

Plumpy Nut is manufactured in Niger, Ethiopia, Malawi, Mozambique, and the DR of Congo. How are we supposed to get PN to bring with us to Haiti? A little more research and deeper drilling on the internet reveals that a new factory (Edesia.... http://www.edesiallc.org/index.html) recently opened in Providence, Rhode Island (and Plymouth Plantations) for manufacturing Plumpy Nut. Our daughter Danielle happens to be a grad student in Providence at the Rhode Island School of Design (RISD), and just finished her first year in the Interior Architecture Department. What an opportunity to kill three birds with one stone, so I flew up to Providence this week, had a back stage tour of Edesia (see photos of our Edesia tour), purchased 500 lbs of Plumpy Nut, threw the 15 cartons (34 lbs each) in the back of Danielle's Ford Escape, and drove back to Baltimore with Danielle, Matisse the cat, and 15 cartons of Plumpy Nut (each containing 150 sachets, 500 calories per sachet, 75,000 calories per carton). Now all we have to do is figure out how to distribute the 15 cartons into the checked bags of Team Sinai along with all the other gear and supplies we're bringing! More about Plumpy Nut and the Haitian factory in Cap Haitien producing Medika Mamba later...

The Huddle before the Storm

Team Sinai will be departing soon for our mission week in Haiti. In preparation, we put together some words of advice and hopefully wisdom and maybe even inspiration for all team members to consider....

Bonjou Team Sinai,

As we approach this mission, our collective thoughts and consciousness subtly but inexorably will shift away from our natural day to day activities stateside, and towards the mission ahead of us. Today we want to talk about the issue of cultural sensitivity. This is going to be a daily challenge during our entire stay in Haiti. Here's some thoughts to consider:

1. We are guests in a Haitian hospital, and so we must always behave as the gracious guest. There may be times when you are feeling exasperated by some of our host doctors/nurses/staff/patients. Take a moment to compose yourself, and act graciously. Always defer to the sensitivities of our hosts. Scott Nelson, our orthopedic host, has pointed that it is more important to build relationships than to simply provide medical expertise.

2. While we are "Team Sinai", we are not competing with any other team, other than ourselves.

3. Make a serious effort to use Kreyole or French phrases whenever possible. Say "Bonjou" (good morning), or "Bonswa" (good afternoon) to every Haitian staff or patient you come across. By using their language, you are sending them a message that you value and respect their culture, their language, and them. It is also a great ice breaker when you mangle a phrase. While we are in Haiti, make an effort to learn MORE phrases. Arm yourself with a phrase card you can study from. Here's one:   http://steelsculpture.us/haiti_cheatsheet.htm  Your homework (BEFORE WE ARRIVE) is to learn how to say in Kreyole "How are you?".....there will be a quiz when we meet in the airport....Hint: there are two correct answers to this question...Extra credit for anyone who gets both...

4. Make an effort to work with the local Haitians, not around them. Ask them what they think is the best way to treat something or deal with a problem. The entire nation of Haiti is in the lowest, most desperate point in their history. The last thing they need is to feel their pride or integrity or intelligence challenged. We are going to be in Haiti for a mere seven days. They live there forever.

5. Be kind and sensitive to the patients. Explain (with the help of a translator) what you are doing, if it will hurt, and why you are doing it. You may want to take a photograph of a patient. Ask permission first. Back home you would never think of whipping out your camera and photographing a patient without first asking permission. The same standards must be observed in Haiti. If you photograph someone without their permission, particularly if they are in a compromised situation, in pain, or incompletely dressed, then you are relating to them as if they were less than human. Kindness and consideration should always be at the forefront of your actions.

6. If you witness another team member acting inappropriately, take them aside and gently point out to them that their actions may be interpreted as insulting or dismissive. 

7. Don't do anything in the hospital that you would not be allowed to do back home. This is particularly important for the young people in our group. The Haitian nurses and doctors and patients will be constantly observing our every action. The Haitians are sensitive to the concept of having to suffer with a lower quality of medical care than most of the rest of the world. Nonetheless, as a matter of pride, they will reject any medication that is beyond its expiration date. Please do NOT bring any expired items! Many of you may be willing to take a Tylenol in your own homes that is slightly beyond expiration date, but this is not acceptable during our mission.

8. Dress modestly. In the USA, it is common for men and women wear shorts. Many young women in the USA bare their midriffs. In Haiti, this is not acceptable. Remember, we are guests. Be friendly and engaging. Make an effort to talk and interact with the Haitians. Do not spend all your time with the other Team Sinai members. Make local friends.

9. We are working in an Adventist Hospital, affiliated with the Seventh Day Adventist faith. The Adventists pray frequently, openly, and often use biblical references. Team Sinai is comprised of a multicultural and multiethnic mix. We must always be respectful of our SDA hosts. When our hosts pause to pray, your appropriate response is to also pause, lower your head, and be respectful.

10. We are going as volunteers, and must be willing to do whatever the local authorities deem important for us to do. Be gracious, be flexible, and always cheerful. We are not heroes. We simply have the privilege to serve.

Orvwa,

Merrill and John