A bottle of Coke

Thursday. Today's a surgery day so it's time to put those rollerskates on. Up at 5:45, shower (I don't know why I bother because you get sticky again in about 3.2 seconds after you get out), and down to the lab to retrieve our young patien'ts blood sample to take down to General Hospital to get a crossmatch so they can find the correct type of blood for him. Fortunately Randy, who's an electrician back home in Yakima, WA but the de facto local jack of all trades guy here at Adventist, has volunteered to bring it down to the General for us and pick up the blood so we can keep operating. As the day goes on, we're wondering how his quest is going ... until we find out it's for a patient at the MSF hospital. We suspect the staffers at the General assumed he was from MSF, and gave him the MSF guy's blood. And we're not about to give our guy the wrong unit of blood. Well, I feel a little unsafe about operating on our poor guy without blood ready to transfuse him with - he broke his femur 8 months ago and you know it's going to be a bloody mess taking it apart and putting it back together. So unfortunately for our guy, it means another chat with him explaining that I'm sorry but the General sent us the wrong blood and it'd be safer for him to wait till tomorrow. It's a conversation, unfortunately, that you have to have with folks a lot here. Fortunately he's really understanding, shrugs, and start to tuck into the sandwich sitting previously untouched at his bedside - happy that he can now finally eat.

Tonight it's raining farily hard. This is the rainy season so it rains most nights here. Pat Ebeling has a hankering for a Diet Coke so we put on our shells and venture out down the street with Jimmy in search of a convenience store. There's a pretty big one just off the main road that runs parallel to the coast and connects Carrefour (where we are) with Port-au-Prince. As we walk down the side road that connects Adventist with the main road, rivulets of water are running down the gutters, washing away piles of trash. You try not to think about what your feet getting wet with. But it's hard not too. You don't flush poopy TP down the toilet here, but rather throw it in the trashbin. The hospital burns its trash, but a lot of people simply dump it on the sidewalks. Yup, that's what you're walking through. As we approach the main road, these little rivuelts converge into a huge flowing brown river running alongside the busy thoroughfare. There's no overpass, no underpass, no raised blocks of stone to cross the road with like they had in ancient Rome. As we walk up and down the sidewalk looking for a way to cross, we see more streams of brown sludge feeding into the brown river. A ripe, putrid stench wafts up to us and suddenly I really don't want to eat or drink anything. So get across the Port-au-Prince road tonight, you'd have to wade through the brown river, dodging cars, in the dark, with pouring rain. Folks are doing it left and right - wearing flip-flops. It's tantalizing to see the convenience store across the street - so close, yet so far. We turn back. There's a small mom and pop stand on the way back to Adventist with bottles of Star, the local brand of cola, and we pay 8 Haitian dollars for 2 bottles, or 1 US dollar. Sounds like a small price to pay for avoiding the big brown river. Even now, warm and dry inside the hospital, we're bathed in a fetid miasma of sewer gas. Well, at least it goes well with the Star cola.

Due credit

Well, Ruth, Beth and I are all back from Haiti General Hospital where we gave a unit each so Fidel (not his real name) can have his surgery tomorrow. It was an interesting experience. Adventiste is fairly close to being back to normal now, but there was a time early on when there was a mini-tent city out on the grounds, and indoors there were lots of patients who had to sleep on cots out in the hallways. We may have thought that was a little inconvenient for the patients - until today when we saw patients on cots out on the sidewalk at the General. Again, somone's always got it worse. So we get our blood pressure and hemoglobin checked, and fill out the standard questionnaire you fill out anywhere when you give blood. We all must be a little dehydrated cause Beth's hemoglobin is 12 and mine is 16, both of which are high for our normal values. Unfortunately we forget to bring the crossmatch sample of our patient's blood so we can donate for him but we can't pick up his units until tomorrow when we come back with the sample. One of those things you take for granted back home, because it's someone's job to do that, and a whole sequence of events automatically happens when you write "type and crossmatch 2 units of blood" and "transfuse 2 units of blood." Here, you do it all yourself and it gives you newfound appreciation for systems and the people that make up those systems back home. We're all a little nervous about giving blood in Haiti but the whole process actually goes really, really smoothly and by the books. We make sure to let them know we're there to give blood for Fidel (not his real name) so he gets credit for 3 units of blood. My tech was really good about sterile technique and gracious enough to pose for a photo op. The three of us are in and out within an hour. Unfortunately, Randy's a bit late with our ride back so we wait about an hour. At dinner a few nights ago somene had talked about the five languages of love. Well, tonight we learn about Ruth's seven levels of annoyance. When applied to a situation like this when you're waiting for someone, this scale would range from a very mild level I (Someone's late picking you up, but you're at home - annoying, but at least you're at home so you can go to the bathroom and watch TV) to the absolute maximum, level VII. We figure that waiting for a ride for an hour on a street curb with a random dude peeing on a wall in front of you and you don't speak the local laguage and you're a tad dizzy from just having given blood and being a little dehydrated might not be a level VII, but is a bit past level I. At any rate Randy shows up, we're very thankful for the ride, Fidel (not his real name!) gets to have blood ready for his surgery tomorrow, and it's all good!

It's been good having Pat Ebeling here cause there's enough to do to keep two docs busy. For example, today before we left to go give blood we got to run clinic and OR simultaneously. Normally, any normal orthopaedic surgeon would rather be in the OR than clinic, but today I feel like I dodged a bullet as the first case turns out to be what Jeff Brewer from HCMC (self-described "just a low-life tech") likes to call a Horrendo-plasty. It's four or five hours of rebuilding this kid's foot. The plan changes a bit right before surgery since most of these cases were booked a few weeks ago by other docs and they keep getting pushed back to the following week because OR's are always being overbooked because there's just so much to do. But the foot looks great by the end of the case, as I see when I poke my head in on a 5-minute break from clinic. Speaking of clinic, today in clinic I had a lot of fun. It was super busy, always go go go, people lined up in the hallway all waiting to see you, a bit chaotic, sometimes with two people trying to edge their way through the door at the same time. Most of them have been there since 7am since it's first come, first served. But everyone's super polite, really appreciative, well-dressed, and very understanding of having to wait for up to seven hours. I also get to meet the oldest person I've met in Haiti, a 101-year-old lady with left hip pain who fell last week but luckily didn't break anything. Must be made of some pretty strong stuff!

Tonight we get a call from Charlene, who's left Adventiste for Bernard Mevs / Project Medishare hospital. They have a poor chap there who broke his hip about 4 weeks ago and was seen at one of the MSF hospitals. Unfortunately they don't havethe means to fix him there so they're wondering if they can transfer him to us tomorrow. Of course we can take him, and in general the sooner the better with this sort of thing, except for two factors: (1) the roads here are bad enough and dangerous enough during the day that getting someone to us at night is probably a bad idea, and (2) it's already been a month since he broke it. So he's coming down tomorrow. We got a full slate of surgeries already, but this is something you just gotta do and take care of, and somehow we'll make it work.

Making it happen

Things have been hopping this week here at Haiti Adventist Hospital. The new team is working out just great. Pat Ebeling and I are the orthopods, Paige Saunders and Chris Kline are the anesthetists, Beth Bard is our fourth-year med student from the U of M (that's the Twin Cities, not Ann Arbor, for you Michganders), and Ruth Bowen is a medical device rep. Right now Beth and I are about to head out to the Red Cross in downtown Port-au-Prince. We're chock full of fluids and I just downed an Annie's mac n cheese so we don't how up hypotensive after being in the OR and clinic all day. Why are we going you ask? Well, there's this poor chap who's been hanging out for the past 8 months with a right femur (thigh bone) fracture and bone overlapping by a few inches. He had actually been put on the schedule for a rodding (with a SIGN nail), but we cancelled him last week because his hemoglobin was too low, and trying to put back together a femur that's 8 months out is a long, bloody process. So the way it works here is that the patient or the family have to donate blood to get blood from the Red Cross. Unfortunately this gent doesn't have any family around, so Beth, Ruth, and I are off downtown donate blood. Wish us luck!

Halfway there!

This morning discover that the little 3-year-old boy we added on the schedule for this morning didn't show up to have his external fixator removed and his leg casted. Perhaps it's just as well, since we soon find out that there are two C-sections the local docs have added on for this morning  that would have bumped us anyway. Funny how things work out. We make rounds.  The 9-year-old girl we fixed on Wednesday has already been up and about on crutches for the past few days. Not too shabby at all. The elderly lady with the hip fracture we fixed Friday afternoon has also been up and about. Not too shabby either. We note to ourselves how little pain people have here, or rather how little they let their pain prevent them from wanting to get better and get out of the hospital. The lady with the metatsatic tumor in her humerus that we put the Kuntscher nail in a few days ago is also looking up and up, especially now that she's had her first BM in many days. I'm sure that's gotta feel great!

Tom and Amy are leaving for the airport, and the other 4 of us - Beth, Kris, Paige, and myself - hop along for the ride to say bye and to get over to the Hotele Ibalola to meet a friend of mine, Al Ingersoll, and hang out and relax for the day. Al's a prosthetist, husband, father to two girls, father to an adopted son from Haiti who also happens to be a double amputee (above the knee and you'd never know if from watching him walk!), soon to be grandfather, and just all-around an amazing guy. Last summer he and his wife Deb sold their home in Minnesota and moved full-time to Haiti, where he is the country director for Healing Hands and she works with Catholic Relief Services. We have an amazing view of Port-au-Prince below us to the north. Again, the central highlands off in the distance to the northeast and the words of that Haitian proverb come to mind again. Something about overcoming osbstacles reveal the presence of more obstacles - or more opportunities.

Deb notes how many of the expats around us at the hotel - we're hanging out at the poolside having Prestiges and rum punches - are European or South American, and how few are American. This pretty much jives with her experience working in CRS for over the past year here. I swallow my Creole omelet and think to myself, we gotta get some more people down here to help out! After a thoroughly relaxing afternoon lounging around, enjoying the view, and cooling off with the mountain breezes, it's back to Adventiste where we meet up with Pat Ebeling, a buddy of mine I've known and kept in touch with since residency, an Ruth Bowen, a rep from Wright Medical, who've just arrived from the airport. It's a new team. The two of us who've been here since the week before are refreshed after a much needed break after working full steam ahead for the past week. We're ready to hit it again tomorrow morning!

Beads ... Now you see them, now you don't!

Friday began with Jameson (just like the Irish whiskey) pretending to kick ZJ in the butt with a BKA prosthesis in the chapel. Nothing like a little humor to jump start your day and kick you in the pants! Our goal after making morning rounds was to see everyone in clinic, and then try and tackle a few cases in the afternoon. And, of course, it's Friday? Which means MAC AND CHEESE for lunch! Amazing how the little things can really make a big difference. Like the light at the end of the tunnel, or the thought of a big swig of lukewarm Crystal Light after a long case, Mac and cheese on Fridays here at Adventiste motivates Tom and Amy as they do their dressing change rounds, and Beth and I as we slog through a busy morning clinc. Unfortunately the ortho clinic X-ray machine's been down all week so people either have to pay $20 to use the main hospital's X-ray machine, or we just go without, or if we absolutely need it we just pay for it ourselves. It really makes you think what X-rays you need and what you don't and it's a lesson I hope to carry home. Meanwhile, Tom and Amy spend some time with patients in the "White House" above and beyond what they're out there to do. An extra five minutes with each patient isn't really too much time to spend, but it makes a huge difference in these people's day. A smile here, a wink there, a few softly spoken words, and a clean dressing go a long way even if you don't speak Kreyol (what we'd call Haitian Creole). Amy and Tom then run over to the peds ward to do some more changes, visiting, and of course the all-important Sticker Therapy (yep, look it up, it's a valid medical treatment and it works better than 99% of the drugs we use on kids).

Lunchtime can't come soon enough. We get done with clinic and Tom and Amy get done with sticker therapy around the same time, about 2pm, and we all congregate on our cots upstairs to eat - no, inhale - our feast of mac 'n cheese. This tastes better, Tom swears, than any ribeye dinner from Manny's. We then burp contentedly and go downstairs to take care of the lady with the hip fracture who got cancelled last night. Normall this kind of fracture (called an intertrochanteric fracture) gets fixed on a fracture table back home in the States but here, our "Fracture Table" is Tom bent over the table pulling on the foot like a water skier trying to get up. Hopefully he doesn't throw out is back because then both he and the patient would be in a world of hurt! Beth graciously steps into the role of X-ray technician and does all of our C-arm pictures, and I take Dr. Francel Aleksei through the case. He does great, the patient's doing just fine, X-rays look good, and we're on to the next. This is an 82 year old woman who had a hemi-hip arthroplasty back in July.  Unfortunately her would became infected post operatively.  A previous surgeon placed cement beads impregnated with antibiotics in the wound, in attempts to clear up the infection.  This type of procedure is commonly done back in the United States.  Once Uno (Amy) performs her anesthesia wizardry, Beth (astutely) recommends we take a couple of X-rays, to make sure there are in fact beads present (this happened a few days prior, where there were supposed to beads removed from a patient, only to find out there were none...).  Kudos to Beth's idea, because once we fired up those X-rays, we come to find once again...the beads, we were supposed to see them, but now we don't.  PLEASE NOTE:  As Pat and I are typing this, we've heard four gunshots in the past hour, and...ummm...they appear to be getting closer.  So, things are back on track, however now it has come to our attention the woman's sutures had yet to be reomoved.  Given the length of time since her original surgery, Beth steps up to the challenge of removing all 30 stitches from a wound that is over 10 weeks old.  So, with the help of a headlamp, and some bacitracin to soften the incision scar up, Beth successfully removes all those little buggers, and our lady's wound is already looking 117% better than it had 30 minutes earlier.

Now our caseload has been completed, we decide it's in the best interest of everyone involved, that we make another trek to the Auberge de Quebec, for a tomato & onion pizza...oh yeah, and a few Prestiges too!  However this time, as we stretch our weary legs, and lick our dry lips, that there is no pizza this evening...not a single one.  Our hearts crushed, our stomachs screaming, we order french fries, and papaya juice (we'll get to that one later).  **more gunshots**  As we digress, we notice a young gentleman waling out of the interior of the restaurant carrying to pizzas to go...and five minutes later, yet another person leaves with not two but three boxes of pizza!!!  We look around at one another and laugh, we've come to expect this...and it's almost an edearing quality we've learned to love about this little oasis in a desert of rubble.  Let me preface this next little story by saying I "did not" order the papaya juice.  After being here for the fourth time, I've gotten more wise.  I watch Beth, Uno, and Pat each take a nice big pull from the straw of their juice...I look at their expressions, and all at once it's decided the papaya juice tastes like the way a room full of sweaty people would taste if you had the ability to bottle it up and drink it...we shortened it up by calling it 115/4...our own little nickname for papaya juice from here on out.

Saturday morning, today, we all wake up excited for our tradition of going back to the orphanage. We're excited to see the little kiddos, excited to give them stuff we've brought and see the smiles it brings to their faces. We're also really curious to see how they've grown and changed since we were last here in May. First we make our patient rounds in the hospital, and pack the bags for the orphanage with toys, shoes, leftover hand-me-down clothes from Tom's kid Cole, and little care packages courtesy of Jaewon Woo. As we walk into the orphanage, Tom is immediately bombarded by a horde of cute little tykes who surround him and jump all over him like football players on a fumble. We then find out that they've got a new nickname for him: Changez Movement, after the game we play with the kids every time we go, which is kind of like musical/dance version of Simon Says. Turns out the bubbles in the care packages are the hit of the party and the kids spend a lot of time blowing bubbles everywhere. After a few songs and dances, and after a lot of hugs and holding, the time to leave comes too soon and we're off. There are so many kids there each of us would love to take home if we could (think this little guy might fit into my carryon?), but we can't. The orphanage maintains a fairly steady number of 45 or so kids ... new kids come in, and older kids leave. Very few are adopted and we're not really sure where the others have ended up. One of the ones we saw back in May was a twelve-year-old boy who I played catch with, and who at the time reminded Paige of her son. He's no longer at the orphanage.

Afterwards we have lunch in Petionville at La Reserve, then it's off to Fort Jacques for some sightseeing. This is a 200-year-old fort the French built overlooking the city of Port-au-Prince from the south. You have a great view of the city to the north and on a clear day can see all the way to the beginning of the northern peninsula of the island. Off to the northeast, the massive central highlands are easily seen... one can't help but think, just beyond that is Cange where Paul Farmer and his Partners in Health have been working for decades. One can also imagine that mountains like these fading off into the distance were the same moutains that inspired the creation of the Haitian proverb "beyond mountains there are mountains."

Soon after we get back to Adventiste, Paige and Kris arrive. They're going to fill Amy's ample shoes in the role of the human painkillers - anesthesia. Tom and Amy get their things packed as they're leaving tomorrow morning. Beth and I are staying behind for another week along with Paige and Kris who've just arrived. We're all sitting around reflecting on the week that's past and the week that's coming up. All in all, it was a very rewarding week. Success isn't just measured in the number of cases done or the number of patients seen in clinic. These were tough cases that would have been hard to do under any circumstances, let alone in an OR with mosquitoes buzzing around, using batteries that die out in a few seconds, in less space than your mudroom at home, and on fractures that were sitting malreduced for days, weeks, months, and in a few cases years. Success was found in the satisfaction of a job well done no matter how tough the cirucmstances, in keeping our cool (for the most part!) despite the frustration involved, and in the poignancy of an orphan's smile when you sat down with him for a few hours, blowing bubbles, and drawing with crayons and paper.

Tom and Amy may be gone, but we hope to keep the positive vibe going for the coming week.

Promises

After a late night last night working past midnight, we're back up and at it for morning huddle with Amy who's standing in for Nathan today, and morning rounds on the ortho patients on the service. The first case on is a cute little tyke who needs a cast change. He's staying over in the "white house," which is a nice little euphemism for a one-room bungalow on the hospital grounds where long-term patients can go and stay if they've come from far away and need frequent trips to the OR or dressing changes that otherwise would have required them to travel a long way multiple times in a short period. I bring him back to the OR (if you want to start early or work late you bring the patients back yourself, which I suppose is only fair). The poor kid's an orphan but he's been staying here at Adventiste for the past few weeks all by himself. Patients like him are cared for by other patients or family members they share a room with. They share food, change bedpans (food and bedpans are family responsibilities here, not the nurses'), and generally keep an eye out for each other.I found this out when I had to run back to his room because I'd forgotten his chart. "Le dossier de l'enfant?" I ask the older gentleman in the bed next to the kid's. All at once everyone chimed in and almost in unison pointed out where they were keeping it for him. (You keep all your paperwork and xrays and carry them around with you, and that's the medical record system.) I also discovered this last night when I checked up on the last patient of the night, the one who got done at midnight. He couldn't have been in his room more than a few minutes, but as he was stable and it was a relatively small surgery, his father was already back to caring for an older gentleman who didn't have a family and was in the bed on the other side of the room. It's really touching to see. It gives you hope that with all the crap these folks have been through that because they stick together like this, this country will see a much brighter day in years to come.

Another highlight for me today was putting in a Kuntscher nail. Never done one before. Gerhard Kuntscher was a German surgeon charged who pioneered the technique of fixing tibia fractures (your lower leg bone) with intramedullary rods back in World War II. He'd get Luftwaffe pilots back up flying in a few weeks may not even have been healed enough to walk, but could push pedals well enough to fly. He performed this for American POW's, which prompted some people to call for trying Dr. Kuntscher on war crimes! Now, it's the standard of care for femur fractures that occur in the shaft (the long tubular part in the middle) and one of the mainstays of treatment for tibia fractures. Funny how times change. Anyway, you never see these things anymore back home in the States, unless it's on the x-ray of an older patient. They still have them here at Adventiste and they are stll commonly used in the developing world. They used them back in Uganda when I volunteered there a few years ago. We used one today to fix a pathologic humerus fracture in a poor lady's arm who's got skeletal metastases all over her body from cancer. Most of the time broken humeri heal pretty well but there are certain instances when you fix them, generally with plates and screws, or rods. I think hers is one of those instances. She's hurting a lot when I see her after surgery but all I can do is order pain medications and promise that things will get better tomorrow. And a little bit better that day after tomorrow.

The last case we were going to do tonight was another lady with a broken hip. Unfortunately there's a lady with a bowel obstruction who needs emergency surgery, and there's only one working anesthesia machine in the hospital right now and it won't get working again until they can fly in a technician from the States. So I go talk to her and let her know that she's waited all day without anything to eat or drink for nothing, with the promise that we will definitely, definitely get to her tomorrow. It's simply one more promise you end up making a lot here. You can only do your best to keep it.

Oh, there's no place like Foam

Sometimes it’s funny how things work out. The little things you do that end up making a huge difference. As she was getting ready before one of our cases yesterday, Amy was testing her anesthesia circuit. No problems. For some reason the thought came to her that maybe she ought to check it again. A little voice inside her head said, “You’re just freaking out, relax, it’ll be fine.” Nonetheless Amy tested her anesthesia circuit for the second time. Why, even now she couldn’t say exactly. As she did so a second time, a bunch of foamy bubbles spouted out from the machine into the tubes. Back home this would have essentially caused mass hysteria. That OR room would have shut down temporarily and all the cases booked for it would have gotten delayed or rerouted to other rooms while the anesthesia machine was cleaned out top to bottom. Here, we simply took some Q-tips & rubbing alcohol to the anesthesia machine…cleaned that puppy out real good, sent the circuit tubing back to get rinsed out again, and went on with business as usual. I mean, what else are you gonna do? It’s the only functioning anesthesia machine, and without it, well, no one would get operated on that day.

                During our first trip down in July 2010, about half the patients we saw in clinic and operated on in surgery were there because of the injuries caused by the January 12, 2010 earthquake, or because of complications thereof.  Over the next three trips, we’ve noticed successively fewer and fewer injuries related to the quake and more and more injuries that simply happen in the day to day life of a country of 9 million people and a city of a million. Kids falling while playing, people getting hit by cars and motorcycles. However, we have to remember that that earthquake killed about 250,000 people and injured another 250,000, though no one really knows how many, in a country with between 35 and 40 orthopaedic surgeons.. Let’s face it, for months, years, and probably decades to come, there are going to be a lot of people out there who’ve never gotten treatment. So it should really come as no surprise that a 63-year-old lady comes in with a left distal humerus fracture, her arm broken just above the elbow, never having seen a doctor since the injury. For the last year and 8 months she’s walked around with her arm flopping around completely uselessly.  She looks at me like I’m her knight in shining amour, because I’ve helped her into her wheelchair and into her bed a few times so far this week.  Despite her situation, she talks my ear off about this and that, holds my hand, and thanks me for adjusting her fan to keep her cool.  Let me take this time to remind all of you there is only A/C in the operating rooms (when the power is on), not in any of the patient rooms or wards.  Families tend to their own, providing them with food, drink, and in this case a fan.  This brings me to the long-term patient housing.  This is a separate building on the hospital grounds, having 5 beds, and a new armoire made of pine, for patients to keep their clothing.  In the bed closest to the door is Daphne, and 18 year old girl, who is cute and sweet as pie.  We took care of her heel the other day, and I went over to change her dressing.  Daphne’s bed is covered with soft floral print sheets, she has a new comforter, a silk pillow case with ruffles, stuffed animals, and an afghan all on her bed.  She’s wearing a nice nightgown, and is watching a movie on a portable DVD player.  The others are two men, each having on merely a pair of shorts, with a white hospital bed sheet.  It is apparent some have money, and some do not.  However, I was able to notice something in all three of these people, while Uno and I were there…without any of them speaking a word, I could see their appreciation, the gratitude in their eyes…the smile on each of their faces…a simple smile, letting me know each one was glad we were there.  That’s all we’re trying to do; make people smile.  Every now and then, I’m able to look down at the world, stretch out my legs, wiggle my toes and say to myself…”see Tom, life ain’t that bad, yer making people smile”.  Often life is conveyed as serious, complex, and difficult…but really, it can be so simple.  Make people smile.

I headed back to the main hospital, Uno in tow, and we slowly made our way upstairs to the volunteer area…beans & rice baby!  I saw Jay Leno (aka Nathan Lindsey) emerge from his room, where he’s been resting from being slightly ill, and having to see Pat and I for the fourth time in just over a year.  He reminds me of the hot sauce he’s got to kick the afternoon meal up a notch.  I would’ve accepted, however I had just taken my third breath, and well, the food was gone…breathe in, breathe out…breathe in, breathe out…food gone!

So I started drawing smiley faces on my mask, making balloons with faces out of exam gloves, to go along with the teeny Beanie Babies Beth’s sister gave her to bring down.  How much cuter can it get when a little one has a Beanie Baby in one hand, and chewing on a latex-free glove finger in the other…I’ve also taken a liking to room temperature Crystal Light it seems…when its 8pm, you’ve not had dinner yet, waiting for the next patient to be rolled on down, wearing a lead apron that’s at least 20 years old, and you’re sweating so much your arms are slipping off the keyboard…there’s nothing like putting some sweet 80 degree grape Crystal Light to your lips, and taking a big swig…heaven just arrived on earth…HEAVEN BABY! The only other thing that’s a little better, is when Pat steals some of Uno’s candy, and hides it in his backpack in the OR…then I eat all of it, but Pat still gets blamed for stealing…so much fun!

The end of peanut butter as we know it

Tuesday, 20 September 2011

                I think I would be shortchanging you if I neglected to tell you about the ant story from last night. During our last case, I felt these creepy crawly things all over my face. I thought to myself, Oh well, that kind of stuff just happens down here, I suppose, deal with it. I asked Bonhomme (who was our circulating Haitian nurse) to take care of it for me, and I just kept working. Problem solved, no more ant crawling around on my cheek. Until it happened again … and again … and again. These little suckers were crawling all over my head having a freakin’ picnic! My entire head and face were itching like crazy and Bonhomme had her hands full swatting my head with her hands killing ants.  I look back and think Holy cow, I was jumping around swatting my arms about like I’m crazy in the coconut, no wonder people were giving me funny looks. At the end of the case I took my headlamp off, opened up the battery case, and lo and behold, it was full of ants! Looks like the little buggers were making a little ant colony for themselves there. I kinda cringe when I think of putting that thing on my head. More than that I was relieved that it wasn’t all in my head – just on it.

                So we’re up and at it again at 6:30 this morning. We eat a yummy breakfast of energy bars while we check email, followed by morning huddle in the chapel. Nathan’s message today is about the two fish and five loaves of bread story that most of us are probably familiar with. The idea being that whether in abundance or in small subtler amounts, we’re provided for. I start thinking, I wish I was provided with an umbrella so the sweat off Tom’s forehead doesn’t drip all over me. But I also start thinking about healthcare. If you live in the States you’re like the guys with thousands of leftover fish and bread at the end of the day – more plastic surgeons, same-day appointment MRI scanners, and Lasik sweatshops than you can shake a stick at. If you live in Haiti you simply get volunteers like us, just enough flour and oil to make it to another day if you’re lucky. Five volunteers from Loma Linda, including Marq the “lifer” from Adventiste, and Heather, Sarah, and Vanessa  from Loma Linda are off to fly to Cap Haitien to run am outreach clinic there for a few days. Story is there’s 300 patients out there waiting to see them. I think, holy noodles, good luck with that! There’s also a full slate of surgery cases for us today. After rounds, surgery starts off with two bilateral clubfoot cast changes, and a knee manipulation under anesthesia. The knee manipulation kid previously had a 7cm limb length discrepancy and is being lengthened with an external fixator and the principle of distraction osteogenesis. This is basically where you break someone’s bone and stretch it out gradually with time, like a millimeter a day divided into four quarter-millimeter intervals, and new bone grows in the gap, Unfortunately this kid has lengthened about as far as he’s gonna get, at about 4cm (so he’s still 3cm short) as his knee is getting pretty stiff, hence the knee manipulation. Now the key with this is to push hard enough to move the stuck knee but not so hard you break his leg. That would obviously not make someone’s day, so after CJ and I nearly give ourselves hernias pushing on this lil’ tyke’s knee, caution wins out over making the knee move better and he’s unfortunately still stuck. A definite whomp, whomp moment.

                After a few more cases, the last case of the day is a 68-year-old woman with a broken hip. Believe it or not she actually comes in as a scheduled elective case for this, and has been at home for the past few days waiting for surgery.  Amy notes that this is the sweetest little old lady you’ve ever met and didn’t complain about one thing or say peep during the whole case. We lay her lateral decubitus, or on her right side, to perform a left hip hemiarthroplasty, or partial hip replacement. Once inside the hip it becomes apparent it looks like more than a few days old, more like a few weeks. After a lot of struggling we eventually get things done and things turn out just fine. As we’re getting the nice old lady off the table and back onto her gurney, Tom and I are undoing her “seat belt” which is strapping her securely on her side. Back home this is a real seat belt made of leather with metal buckles. Here it’s a roll of this semisticky stuff called Coban which is a 3M product (go Minnesota).  Now they’ve been known to reuse everything under the sun here (ventilator tubing, bloody laparotomy sponges, screws that come out of other patients) out of sheer necessity, so I ask Tom, “Do they reuse this stuff?” meaning the Coban which I’m about to unwrap. Tom pulls out his scissors and – Snip! – “Not this one!” Hahahaha!!

Besides thinking that everything’s funny, we’re all too pooped at 9:30 pm to do much else besides sit in a zombielike trance, eating food and sitting in puddles of our own catatonic drool. The danger with having jobs where you work ridiculously hard (this actually refers to memories I have of residency, not volunteering here at Adventiste – it’s too much fun here to be considered work) is that you feel entitled to eat whatever the heck you want to eat when you get home because you justify it and say, “Hey, I worked 118 hours last week, I deserve a whole bag of tortilla chips and a whole jar of salsa.” We all exemplify this rule as we spend the next hour sitting, mechanically shoveling food into our mouths.  I speciously justify my gluttony with the convenient argument above and eschew peanut butter (not having pb for the third night in a row, no way!) for some Annie’s mac ‘n cheese and half a box of Puffins … of course not to mention a few handfuls of Beth’s honey roasted almond mix. Sitting here kind of reminds me of the 60-hour stretch of continuously being awake I had early in my career. (You may wonder “Wait a minute, don’t they have that 80-hour work week and a 30-hour workday rule? – Nope, only for residency!)  After a while, you’re too punchy to really fall asleep. Everything becomes funnier. The vibe is similar here at Adventiste. We’re not nearly that overworked here, but we’re all truly working our tails off. We’re having fun  - meaning the work itself is fun, not that we’re goofing off. The camaraderie is great. We’re making cool friends from Haiti and other parts of the US. We socialize and laugh with our patients and try to make them feel comfortable. It’s fun down here because every single one of us down here – not just our group of 4, but the “lifers” Lynne and Marq and Brian and Nathan and Amy and CJ … and Heather and Sarah from Loma Linda … and our awesome Haitian friends like Jean Joel and Jeanty and Albert  and Aleksei  - are all here at Adventiste for the same reason, to help a brother out. Just cause we can.

Then to our surprise we run into Marq, Sarah, Heather, and Vanessa walking back into the hospital – they were supposed to be in Cap Haitien till Friday. You know the cliché about thinking your day being crappy until you hear about someone else’s misfortune? Turns out these five never made it to Cap Haitien. Rather, their plane actually made it, but after circling above the thunder and lightning for a while in a pattern, their Salsa Air pilot flew them back to Port-au-Prince. The pilot flying the Tortuga Air flight 5 minutes ahead of them wasn’t so cautious. He apparently tried to land his plane at Cap Haitien in the thunderstorm. Our friends were in a holding pattern in the air right above the other plane when this happened. The plane below them crashed and all three people aboard were killed.

Puffins - Not just for breaktast anymore!

Well, after a day like yesterday’s, no one really had too much of a problem sleeping last night, and we all wake up this morning refreshed and ready to hit the ground running. We start off with a hastily gulped breakfast of energy bars, coffee, oatmeal, etc., as we rush down to the traditional morning huddle led by our fearless leader Nathan (or should I say one-half of the fearless leader of a couple), and introduced by his warm-up act Lynne, a nurse from Loma Linda who’s here long-term. Or should we call her act the monologue? I could imagine her saying, “Well guys, we got a great team for you here today, they’ve come all the way from Minneapolis, Minnesota to fix broken bones, heal the sick, and contribute their pound of sweat … let’s give it up for Team Hennepin! And of course, the one you’ve all been waiting for … heeeeerrreee’s Nathan! Woohoo!” Alas, no.  But Lynne’s awesome and she’s kind of like the glue that holds the orthopaedic service here together, the link between successive groups, the institutional memory for a hospital that runs on lots of groups of volunteers. She also maintains our inpatient census which we refer to as we make rounds on all the orthopedic patients in the hospital after breakfast.

One patient we meet on rounds is a beautiful 20-year-old woman with a large thigh mass and a pathologic hip fracture and probably has a sarcoma. It turns out no one’s told her yet that a malignant bone tumor is one of the things we’re worried about so we try to break the possibility to her as gently as possible. She doesn’t cry or even miss a beat. She might be in denial, or it might just be one more load of bad news that life’s thrown at her and everyone else here, and the only way to survive is to shrug and deal with it. In her case, dealing with it may mean nothing more than simply pain medications. There’s no adjuvant chemotherapy here (chemotherapy after you remove someone’s tumor, assuming we could even do that), no neoadjuvant chemotherapy (chemotherapy before you remove someone’s tumor), and no radiation, even for palliative purposes.

Then it’s off to clinic for me and Beth and getting the OR set up for Tom and Amy. We find out that the xray machine in orthopedic clinic is down for the week. At first it might seem it would slow you down immensely. The only way to get xrays to have them go over to the main hospital, pay 500 goudes, 125 Haitian dollars, or about 20 US dollars over in the main hospital radiology department, which almost nobody here can afford. It actually turns out not to be so bad. You quickly learn to hone in on your physical exam skills and trust your senses. Clinic actually goes faster when you don’t sweat the xrays (uh, how about when you don’t have xrays). Kind of reminds me of the Calvin ‘n Hobbes cartoon where Calvin flips through the pages of his reading assignment in about 2 seconds and proudly declares “reading goes faster if you don’t sweat comprehension.” Not necessarily the most ideal situation if you had more resources, but you do what you can. There’s one patient who actually does need an xray emergently but can’t afford it, so the only thing to do of course is just pay the hospital for the xray out of our own pockets.

In the middle of clinic of course there’s the one meal the hospital gives us a day, a lunch of – you guessed it – rice and beans! We’ve actually been looking forward to it since the last time we were here, believe it or not! This gets wolfed down among the four of us in about 3.2 seconds. Tom’s never tasted anything so good that didn’t have meat in it! We supplement this with our own snacks we’ve brought from home, including some Puffins cereal I bought last minute in a shopping spree at Kowalski’s at about ten o’clock last Saturday night, or about eight hours before our departure Sunday morning. They’re surprisingly tasty for something that looks suspiciously like cardboard and comes out of a card board box without any cartoon characters on the front panel. They do the trick and are just fine in a pinch.

By the time clinic gets done Tom and Amy have gotten the OR all set up, Lynne nurse coordinator extraordinare has pre-opped our two patients we’ve added on the schedule for this afternoon (one woman whose heel wound was looking a little worse this morning on rounds, and one woman who’s scheduled antibiotic bead removal for tomorrow we moved up to today because tomorrow’s schedule is already shaping up to be a freaking NIGHTMARE), and Jean-Joel (that’s JJ to you and me) has brought the patients down. One goes very quickly, and the other takes forever. The lady with the beads has had about a jillion previous surgeries on her hip which all began with an infection. She’s unfortunately got no hip left, just a big wad of scar tissue the size of Alaska with a small string of 17 beads encased somewhere inside like a piece of spaghetti encased in a slab of Lucite the size of a small suitcase. Because it’d been so long since they were implanted, the string has partially dissolved and to our dismay breaks apart into multiple little strands, and here we go skipping through the forest excitedly hunting for loose beads very close to large arteries and nerves as we cheerfully sing songs, which is close enough to the truth as long as you substitute “spew out” for sing, and “colorful epithets not fit for publication” for songs. The mood is tense which is an odd juxtaposition with Vampire Weekend playing on Beth's iPad in the background. After a lot of singing we eventually locate a few beads behind the femur in the region of the sciatic nerve, a few beads way out in front, and a few beads juuuust a bit inside, just like a baseball pitch. As the 17th bead is found snugly tucked away in a little safe haven of pus we break out into cheer. Fortunately, our patient does well and we finish for the day.

And so we finally get a chance to sit down and have dinner at 10:30pm, about two hours ago, and just decompress and talk about the day. Bummer that this was supposed to be the light day before the poop really hits the fan tomorrow! Oh well. Realistically we know there’s no way we’re going to get through all the cases in the schedule, but … optimism is key. And, of course, a pair of kings wouldn’t be so bad either.  Cause you gotta play the hand you’re dealt, and do what you can.

"Welcome home!"

Those were the words Frantz Bastien, one of our translators, use to welcome us back to Adventiste. And indeed, as we shrugged off our backpacks and 50-lb. hockey bags full of medical supplies and subject Nathan and Amy to four sweaty hugs, it does feel like home.

Beth Bard, Amy Beer, Tom Slater, and I are here at Hopital Adventiste d'Haiti. It's the third trip for Beth, the second for Amy, and the fourth for Tom and I (in 14 months). We're down here for a 2-week stint to do orthopaedic surgery for indigent patients in Haiti. We feel excited to be back among old friends -Haitian and American - fortunate to have the opportunity to do what we love, tired after getting up this morning at 3am, and of course, despite the banter and lightheartedness, aware of why we're here, and how badly people down here really need a helping hand. Despite hundreds of millions of dollars in international aid and countless man- and woman-hours of human work, all it takes is a look around us in Port-au-Prince to realize that there's still a lot of rubble, a lot of people still living in tent cities, and a traffic system and infrastructure that still encourages a lot of road traffic accidents. We're here to work, to fix broken bones, to help some people out.

Our preparations for this trip began, as usual, with several months of collecting supplies. Tom's new job as Tissue Recovery Coordinator (TRC) at LifeSource has proved very helpful, as evidenced by the volume of spare/excess gowns, gloves, sterile OR packs, and prep kids, as well as by the low back pain we've all developed today schlepping this stuff around. We've also got to put in a great word for everyone back home at HCMC (Hennepin County Medical Center) who pitched into donate extra items from the OR. Speaking of Hennepin, this might be a good time to say that despite being "Hennepin to Haiti," until Paige and Chris join us next week, right now I'm the only one left from HCMC in the current group, although it remains the common factor among all 4 of us. Tom used to be surgical tech extraordinaire there until lured away by the promise of being a surgeon to the deceased (and a hope for the living); Amy rotated through here for a stint back when she was in anesthesia school but now works at Methodist; and Beth is a medical student at the University of Minnesota, and about to embark on a year studying and practicing medicine abroad! Haiti is simply her first step in a journey that will include Sweden, India, and Uganda. The next step was, as usual, a fundraiser. Previous themes were Help us Help you Help Us Help Haiti, Halloween for Haiti, 80's for Haiti, and for this trip, Haiti-Five-O. Most of you reading this were probably there and we do want to thank you for your moral support in showing up and having fun - yeah, I know it was hard - as well as your financial support, whether it be the loose change between your car seats as you frantically looked for something to donate, or whether it be the many generous large checks. (p.s. you can now write checks to Project Ortho and we're currently applying for 501c3 status.)

I almost didn't make it down here today. The ticketing agent at MSP apparently took issue with the "water damage" on my passport as evidenced by small blue dots, and instructed me to go to the local passport office tomorrow, get a new one, and get back on the first flight out on Tuesday (the day after tomorrow). Fortunately we run into a group of eight volunteers from Children's Surgery International, and a friend of mine, Peter Melchert, pep talks us into going back and at least getting down to Miami and if they won't accept my passport to get checked in there, well then deal with that then. Fortunately it all worked out! Turns out the "water damage" wasn't really that big of a deal, at least by the customs officials here ... though it apparently wouldn't hold water (hahaha) in Costa Rica or Bolivia.

As soon as we hit the ground in Port-au-Prince and step out of the arrival terminal to board the bus to the customs building (looks like a huge Costco warehouse btw), Tom and Beth immediately start engaging in an inadvertent Sweat-Off. The battle is still raging on but I've got $10 on Tom to out-sweat Beth by the end of round One. Luckily Tom's brought along 12 bandanas to stave off sweat, bugs, and spittle from excited co-workers.

One interesting change I've noticed this time is ... now hold onto your seats ... Tom's brought down absolutely NO beef jerky! Tom says it's in an effort to prevent the cankles we all got the last two trips by decreasing salt intake. I think that makes just perfect sense, so we'll see how that works ... though of course it doesn't explain him devouring - no, the word is punishing - a large serving of Chef-Boy-ar-dee Beef Ravioli. Just in case he goes thru Jack's Link withdrawls, I did bring him an emergency supply of two bags (see photo and the look of sheer pleasure on Tom's face).

At any rate, as we were talking about before, we all feel like we're kind of returning home here. Besides our fearless leaders Nathan and Amy, who are a couple from Loma Linda who've dedicated two years of their lives to running this place, we'refortunate to have many good friends here, both American and Haitian. We meet our luggage handler, Robert, at the airport, and are picked up by Richard, who's the driver for the hospital and welcomes us each with a warm (albeit sweaty, but no more so than we) embrace. After driving a half hour west to Carrefour, dodging potholes, stray dogs, and intrepid pedestrians scurrying away always just in the nick of time, we arrive at Adventiste. As we unload, bring our bags up to the converted patient ward where we sleep communally on army cots, amd unpack, we run the gauntlet of the long-term American volunteers, Haitian security personnel, and OR instrument room people downstairs. We finally plop down to rapidly stuff our faces with peanut butter sandwiches, instant ramen, mac 'n cheese, and of course Tom's ravioli, and unwind and talk about the day and prepare for hitting the ground running tomorrow. It's good to be back!