February 7, 1986 was the day that dictator “baby doc” Duvalier was overthrown in Haiti. To mark this occasion 33 years later and call for the resignation of Haiti’s current president the Haitian people have come out in force. Inflation continues to rise out of control (the gourde is now 82 up from 65 this time last year) and corruption plagues the government who has not been able to satisfactorily account for US$3 billion in the Petrocaribe deal. A call to action was made last Thursday where thousands of people protested on the streets of Port au Prince.
This paralyzed all transportation and most businesses. Our patient census is very low and patients are not showing up to clinic as there is no public transportation and it is impossible to safely travel even relatively short distances. On Friday there was a reticent return to normalcy. And Saturday, things seemed to start out relatively normal and then at midday, chaos erupted on the streets of Carrefour with fiery roadblocks and a large mob of angry citizens making their way towards central Port au Prince. Our hospital is located near the main road connecting the entire southern part of Haiti with Port au Prince. This thoroughfare is a favored area for disrupting commerce by creating roadblocks. Tension continues to mount. In spite of all the disruption PAP airport has remained open. This morning we had to make a trip to the airport. We went in the ambulance and I wore hospital scrubs and my badge. Most of the demonstrators kindly let us through, but on the way home at 7 am many more roadblocks had been created. These are made from any combination of rocks, tires, branches, furniture, trash, overturned cars and fire.
In spite of burning tires and the sound of gunshots in the distance no one should worry much about our personal safety or discomfort. Many people cannot get food and fuel because of the disruption. Delimart has been closed and barred up most of the time since Thursday with the Haitian militia protecting it. For those of you not familiar, Delimart is our local food source outside of the fresh food we buy from street vendors. The owner of the Delimart chain is thought to be a supporter of the president and thus it is particularly prone to looting and mass destruction unless proper measures are taken. If the market does not open up again soon I might be eating canned garbanzo beans for breakfast! But I doubt I will suffer any serious hunger. All petrol stations are still closed and motorcyclists are being stopped by gangsters to make mandatory donations of gasoline to fuel their fires. Our diesel reserves for running the hospital generator are down to the last day. (city power only arrives at night for a few hours) The maintenance crew was able to rally up a 55 gallon drum of diesel yesterday to keep things going at least until now. We have powered down air conditioners and are only running essential systems.
In spite of turmoil great things are also happening. Rozanie is a 57 year old lady who had a tumor removed from her right knee in 2011 at one of the best hospitals in Port au Prince. This was a giant cell tumor, this is benign but is known for its tendency to recurr. When she presented to me several weeks ago the tumor had recurred and totally destroyed her knee creating a large visible mass. I texted my friend Lee Zuckerman who is an ortho tumor specialist at LLU to ask if he thought amputation or fusion would be the best option. Of course he recommended a $25,000 total knee mega prosthesis! But unlike other first world advice that I sometimes get, he said he would get Onkos Surgical to donate the prosthesis and come down to do the case. That same day a couple hours later I met Wilthur a 2 year old who had a tumor (lipofibromatosis) removed from his forearm and it was now bigger than ever. I sent a photo to Dr. Z and we scheduled both cases for February 6. He flew in from Los Angeles the day before and left the day after. Both cases came quite close to cancelling after he arrived… which would have been tragic. Rozanie was anemic. We had ordered blood for her, but the situation with blood here is a long and complicated story. Her blood type is O Neg which is present in only 7% of the population. In spite of trying to get blood during the 2 weeks prior, the Red Cross was unable to accommodate. We did the calculations and promised ourselves not lose one drop over 600cc of blood, which gave us a small margin for safety. The case went perfect and she ended up only losing 300cc.
Dr. Zuckerman and Charlie the Onkos rep were able to catch the first flight out Thursday morning before the “manifestations” went into full effect. Subsequently Rozanie has recovered beautifully and is getting some extra rehab while waiting for the street scene to calm down.
Scott Nelson, MD
Just 2 months ago Marni and I arrived in Port au Prince. This time it was with one way tickets. This is both literal and figurative. It is not that we won’t be going back to the United States, in fact some voyages are already planned, but we now live in Haiti. We don’t have a home in California – it is rented out. Trips will now originate from PAP not LAX.
Living in Haiti is different than visiting. We won’t be going “home” in a week or two. The differences of another culture have to be accepted and embraced. Two more languages have to be learned. And administrative issues at the hospital cannot be ignored. I keep reminding myself that there are benefits of doing hard stuff. This is hard stuff. But even though it is hard, I still have it better than most people living in this city. To some it may seem a life of hardship and sacrifice but it really is not. Don’t feel sorry for us. Although the challenges are overwhelming, each one of these challenges presents an opportunity. A lot more on that in upcoming posts… But I can summarize by saying I am happy to be here, working with wonderful people, attempting to make a difference for our patients, our hospital and the country of Haiti🇭🇹.
Marni and I have now settled in to our 300 square foot cottage. That did not really take long. Basically it consisted of unpacking a couple of suitcases and putting sheets on the bed. Our place is about 100 feet from the door of the emergency room. Living so close has its pluses and minuses but for now they are mostly pluses. Commuting time is minimal, we have 24 hour water and electricity, there is security and we have a relatively large garden area around our house. There are several people that are living in small buildings within the same area.
Amongst other cases this week we took care of Michelot an 8 year old boy from Cite de Soleil (city of sun) one of the most impoverished slums in the western hemisphere. Appropriately named for the tropical sun that beats down on those toiling in the streets where all vegetation and signs of nature have been completely eradicated. Life is not easy especially when injuries or illness occur. Michelot developed a fever with pain and swelling in his right thigh earlier this year. He was seen at a local hospital where a very small incision was made to drain some pus from the thigh. The infection was seeded in his femur and progressed to the point where the bone integrity was compromised and fractured. He was placed in a cast which ended at the site of the fracture only making the situation worse. When it did not heal he was told he would probably need the cast for a couple more years. That was when someone found him and brought him to Hôpital Adventiste.
Osteomyelitis or bone infection is an amazing process when nature is allowed to run its course. This is a process rarely witnessed in developed countries where the first signs of infection are aggressively treated in order to avoid further destruction. In Michelot’s case the shaft was devascularized by the infection and walled off (sequestrum) and then new bone started growing around it (involucrum). The involucrum was not yet fully mature and a fracture had occurred preventing him from being able to walk. We were able to remove the sequestrum and stabilize the bone. At this point nature can resume its course and hopefully the newly growing bone will consolidate and become strong.
Early light is just starting to welcome in another day as I sit in the peace of the morning under the mango tree in front of our place. A few chickens and their babies are cackling as they are out here scouring the ground for insects. Yesterday Marni asked Jacques, the gardener to capture the rooster that roosted in the tree above our place and started cock-a-doodle-dooing at 4am every day, so the morning is a bit more peaceful than usual.
Scott Nelson, MD
This is one of those dates that reminds me of where I was at 4:53pm on this same afternoon in 2010. People in America and around the world remember with clarity where we were on the morning of 9-11-2001 when 2996 people lost their lives. Today the Haitians remember every terrifying detail of this same afternoon 9 years ago when more than 200,000 people lost their lives. Special mention was made at our church service today in Carrefour about this event. Praise was given to God for bringing the people through this event and blessing them over the past 9 years, knowing that He has special plans for each and every one of us. I was not here, but I did experience the earthquake on my way home from work that day in Santo Domingo. Every detail of the next 72 hours is well engraved in my mind as this was a significant change in direction for me. I had been here to Hôpital Adventiste d’Haiti several times before. At the time these experiences were less than inspirational and the hospital had largely lost the luster of its early years. It was operating on a shoestring budget and striving to cater only to those who had significant resources.
Before I arrived here in Port au Prince 48 hours after the earthquake I realized that in spite of the tragedy this may become an opportunity to recreate a mission hospital. The story is one that many of you have been part of. The deterioration of the hospital that had occurred in the years preceding the earthquake superseded any damages brought to the building which was the closest major hospital to the epicenter. With great gusto and lots of external support an orthopedic program was launched. I spent 6 months working here full time and then Terry Dietrich came with his wife for another whole year and was joined by Dr. Francel Alexis who has been the mainstay of our program here over the last 8+ years. We have had many victories and frustrations, but when looking back there have been many more victories than defeats.
This week we made a significant leap towards realizing our mission of providing hope and healing to people of all economic classes. We now have a designated office for financial counseling and social support that will help facilitate communication and financial support for patients without sufficient resources. Developing prices for surgeries is always tricky in mission hospitals. If we make it cheap enough that everyone can afford it, then balancing our budget and paying our employees is difficult or impossible. In addition other health care institutions would resent us for undermining them. If prices are too high then poor people get turned away. If they are in the middle then some of both problems will happen. This mandates some flexibility with pricing especially in situations regarding medical emergencies. Hopefully our new financial counseling office will help us to treat all of our patients with the highest level of dignity and respect.
Scott Nelson, MD
Bon Bagay means “Good Stuff” in Kreyol. If you say it a few times it becomes addicting. It is a fitting title for this week’s events. Team Sinai returned for their 7th trip to Hôpital Adventiste d’Haiti. This is a group led by John Herzenberg MD one of the most respected limb deformity surgeons in the world. His wife Merrill is the organizer of these trips which include a comprehensive team of people from 6 different countries many of whom speak French and Kreyol.
I first met Dr. Herzenberg in 2004 when I went to the Baltimore Limb Deformity Course as a young surgeon. He is the course chairman. This course really opened my eyes to a new world of surgical possibilities and taught me many surgical concepts I had never before known. I learned about limb alignment, bone lengthening and gradual correction of severe deformities. There is so much to learn that I decided to repeat the course two years later and at that time I asked if I could come and spend a summer in Baltimore at the International Center for Limb Lengthening. This was an amazing experience both for mentorship and learning. I never dreamed that these surgeons would all come down multiple times to work with me in Haiti and the Dominican Republic. Mothers in Europe, the Middle East, and Asia are Google searching for well-known clubfoot and limb deformity surgeons and find John Herzenberg, meanwhile, moms come across Port au Prince from some of the worst slums in the western hemisphere to Hôpital Adventiste to find the same guy. Bon Bagay!
We had a great week with the team which included a lot of operations as well as a Taylor Spatial Frame workshop. This consisted of 4 hours of lectures for local surgeons and residents and then another 4-hour laboratory session to teach hands-on application of the TSF (graduates pictured in banner image).
For those of you who are not familiar, TSF is a type of external fixator used for limb lengthening as well as gradual correction of various deformities. It is based on a mathematical theorem that allows you to correct all kinds of exotic deformities but requires some computer programming in order to do so.
Meanwhile, a lot of other Bon Bagay is occurring at the hospital. Last week a CT scanner arrived from Florida Hospital (see banner image). There are only 2 others to my knowledge in the country and one of them is usually broken down.
The installation for this is quite complex as it needs a 480V line, so if you have cancer please don’t stand by until we get this thing up and going, it could be a little while yet. Thankfully we have an electrical master, JT Haas on site who is getting the job done. Previously he was in charge of power distribution for the central coast for Pacific Gas and Electric. He recently retired and is giving his time and expertise to help us solve some major issues.
We were told these issues would cost about two or three hundred thousand dollars to fix, but by redistributing some of our power and working out some practical solutions JT is going to have the job done for less than $30,000. Bon Bagay!
Scott Nelson, MD
As I deplaned at MIA this morning, we were immediately directed towards an escalator leading to the Skytrain. I stepped on to the elevator and the young man about 25 years old right in front of me fell down and dogpiled with the man next to him on top of my bag as I tried to pad his fall. At that point, his feet were up and his head down as I struggled to lift him up. He looked like a young healthy man and did not seem to be drunk after this short morning flight. As I helped him up his friend explained to me that it was his “first time”. I said “welcome to the United States of America!”. I only know of one escalator in Haiti – it is in the arrivals hall at PAP. Out of the many times I have arrived there it has only been working once.
This experience gave perspective to some of the things we have been trying to accomplish at Hôpital Adventiste – commonplace endeavors to take us up to the next level sometimes end up in a dogpile at the bottom of the escalator as we tumble over each other trying to communicate, understand and stand up again.
One such endeavor is our new PACS system. Some of you may not know what that is, and the rest of us who do, still might not know what those letters stand for…Picture Archiving and Communication System. Virtually all hospitals in the United States now have such systems which electronically store radiographic images. This technology is to the traditional x-ray what digital cameras are to film cameras. The way it works is by the use of a 14×17” digital detector which is the size of a standard x-ray cassette. X-rays out of any old, new, portable or stationary machine can be beamed through the patient onto the DR detector and voila! The image shows up on an adjacent computer via Bluetooth. It is then labeled, edited as necessary, and archived onto our server using an Agfa PACS database program.
The benefits of a digital system especially at a mission hospital are many. Film x-rays often require about $20 US of film and chemical per study. Bypassing the need for film allows us to more easily afford x-rays for people who cannot pay and yields more profit for the folks that can. If a poorly performed x-ray is taken then it can either be edited for clarity or retaken without wasting materials.
Gone is the day that you could not get an x-ray because the patient could not afford it and you did not want to put your hospital further in the lurch! Now we are lowering our prices, creating more accessibility for the common man, woman and child with an even better quality of care than before.
The reality of this system occurred over a cup of coffee early one morning on my way to work at LLUMC last November. I met with a friend who told me to let him know if I needed some financial support for a project in Haiti. I presented him this idea thinking that he may be able to provide a small jumpstart for this $95,000 project. Halfway through our cappuccinos he had heard enough of my enthusiasm to reach his hand across the table and shake on a promise to fund the whole project! Mike Haman director of our PACS at LLUMC used his VIP status with Agfa Healthcare to strike a 70% discount on the software and then put the whole system together, travel to Port au Prince and spend a week for installation and training.
Entering good data with consistent attention to spelling and details is where we began to stumble at the bottom of the escalator. We soon discovered that there were at least 7 existing medical record numbering schemes, with many patients having duplicate numbers. Continuing with this database nightmare would create chaos and frustration when searching for patient images. Fortunately, Jere Chrispens, our CEO is a seasoned IT executive who was able to come to the rescue. An eighth medical record numbering system was created with a consistent 7 digits to supplant all previous systems. It seemed like a simple scheme but various complexities arose which created moments of frustration amidst the joys of our new system. This has now led us to create a demographic database in order to avoid duplicate record numbers, have the consistent spelling of names, and contact patients when needed. These concepts don’t intrinsically exist in Haiti. But by padding the falls, communicating, and helping to lift each other up we are standing on the escalator and moving to the next level. Welcome to HAH!
Scott Nelson, MD
At Loma Linda University’s 2015 Alumni Postgraduate Convention seminar on Global Orthopedics, Merrill Chaus gave both a disturbing and challenging presentation entitled, “The Dark Side Of Doing Good.” Disturbing because, as a veteran of several overseas mission trips, I knew that I had personally violated many of her recommendations – challenging in the sense that I vowed to try and improve my track record in the future.
Merrill is a registered nurse and team coordinator for Operation Rainbow, a nonprofit organization providing free pediatric orthopedic surgeries to indigent children in underserved countries, mainly South and Central America, Mexico and Haiti. She has participated in over 20 national and international medical missions including 4 trips to Hopital Adventiste with her husband Dr. John Herzenberg, Director of the International Center for Limb Lengthening in Baltimore, Maryland. Merrill’s preparatory skills for these trips are legendary and she is more than qualified to offer the following advice.
Before the mission
Do consider national and religious holidays and elections before committing to mission dates.
Do inform local surgeon of your team’s specialties before arriving. The local surgeon needs time to match appropriate skillsets to patients’ needs.
Do anticipate and pack all supplies and medicines needed for a week of clinic, OR, recovery and follow-up care. Don’t strain the limited local resources.
Do ask local staff what lectures topics to prepare. Don’t assume that you know what they want to learn. Do extend lecture invitations to local doctors and community healthcare workers. Invite local experts to share their expertise and experiences.
Do not pack expired medications. Most NGO policies clearly state: No meds less than 6 months from their expiration dates.
Do take the Stanford/Johns Hopkins online course: Ethical Challenges in Short-Term Global Health Training.
Do take the Cultural Competency Online Course by Unite For Sight.
Do learn basic phrases in the local language. Do recruit volunteers who speak the local language to prevent miscommunication and reliance on interpreters. Do prepare patient education materials in the local language.
Do ensure your team is competent and credentialed to prevent spreading false knowledge and harmful practices. Good teaching skills are a plus!
Do consider recruiting a biomedical engineer to train locals on equipment maintenance and IT specialist to maintain computer networks.
Do fundraise to offset fixed hospital costs your team incurs such as water, fuel, electricity, oxygen, x-rays and IV fluids. Volunteer’s use of operating rooms may prevent local doctors from operating for a period of time. The local hospital is likely to need help to pay staff wages due to increased manpower demands.
Do cover up tattoos. Tattoos are often sported by gangsters and thieves in the developing world and may be threatening to patients.
During the mission
Do dress conservatively.
Men: scrubs/lab coat. Please no earrings or shorts.
Females: scrubs/lab coat, no sleeveless shirts during work hours.
Don’t smoke or drink alcohol on the hospital premises.
Do coordinate/cooperate with the local team and respect their hospital rules.
Don’t ignore or work around local staff. Work with them. This promotes good will and safe, ethical care.
Do identify who will provide follow-up care and consider reimbursement for service rendered in the future.
Do provide teaching moments during morning report, bedside teaching and conferences. Do less surgery and more training – “leave skills, not just scars.” Education is key to improving surgical capacity and sustainable change. The local staff needs skills to care for patient complications after teams depart.
Do wear identification badges with name and job title written in the local language. Locals have a right to know who is administering care. ID badges prevent misidentification and demonstrate collaboration and respect.
Do practice kindness, patience and cultural sensitivity. Locals may be reserved and intimidated. Engage them gently and practice cultural humility. Do remember that local staff and patients are watching you. Don’t do in the field what you wouldn’t do at home.
Do maintain high standards of care. Patients trust incompetent volunteers more than competent staff. This undermines trusting relationships.
Do document patient charts in the local language so that staff can follow patient progress and administer safe follow-up care.
After the mission
Do obtain contact information of the local surgeon providing follow up care.
Do give your contact info to the local surgeon.
Do leave casts, medicines and supplies for patient follow up visits.
Do continue sustained communication with surgeon and hospital.
Do plan a return visit.
Do consider a long-term partnership/training program.
Do consider using evaluation forms for both volunteer team and hosts.