Beginning with a trip to Africa when Terry was a senior medical student, the Dietrichs have compiled an impressive resume of volunteer service. Over the past 40 years Terry and Jeannie have worked in numerous countries including longterm stints in Puerto Rico, the Dominican Republic and Haiti. Most volunteers do so at the beginning or end of their careers but the Dietrichs have managed to weave in a commitment to overseas missions while maintaining a thriving practice back home. Terry was asked to present their experience below at Loma Linda University’s recent symposium on Global Orthopedics. (In the photo above, Terry is helping an orthopedic surgery resident rod a tibia)
Our dirt poor little farm in North Dakota was the starting point . My dad was a farmer as were my grandparents. All of my uncles and cousins were farmers, laborers or petty criminals. That was my destiny as well. Well, hopefully not the criminal option. A book changed that destiny. The story of Dr Stanley Sturgis in the book “In the Valley of Seven Cities” captured my imagination. I would be a “missionary doctor” like Dr Sturgis. Nearly two decades later, my lovely wife and I embarked on the first phase of what for us has been an incredible journey. Our twelve years of full time mission work at Hospital Bella Vista in Puerto Rico were a wonderful experience both professionally and personally. Living in another culture, learning a new language all the while experiencing an orthopedic practice with amazing variety was unbelievably enriching for me and my family. It formed the basis for a skill set and comfort level that made all of the subsequent international experiences possible.
The SDA hospital in Puerto Rico initially was equipped with only outdated orthopedic equipment. Working with those somewhat primitive tools during the first 2 or 3 years gave me a much greater appreciation for nice, modern power equipment and imaging to manage the steady stream of ortho cases. Modernizing the orthopedic department was made possible by the addition of a well trained hospital administrator coupled with frequent requests to upgrade our equipment including C-arm acquisition. Nearly a decade later, I left Puerto Rico with the experience of several thousand cases of scoliosis correction, children’s deformity correction, total joint replacement, tumor and infection cases, fracture fixation and arthroscopy. The breadth of that practice would be virtually impossible to replicate.
The private orthopedic practice that I enjoyed for the next 16 years in the little town of Walla Walla, Washington was, needless to say, “tame” by comparison. The desire to continue with international work had not been extinguished. The opportunity to develop a quality orthopedic service in the Dominican Republic became available at a small Christian hospital. Nearly thirty week long trips over the next 15 years provided more opportunities to do many of the same types of orthopedic cases that a small town practice never sees. Ultimately, I had the great fortune to meet Scott Nelson. We were able to work together in the DR for several years. I even joined him for one of his short trips to Haiti. Scott’s legendary appetite for work became totally apparent during that week. More than 50 cases left me as exhausted as I’ve ever been and vowing to leave Haiti to him.
The disastrous earthquake struck Port au Prince and environs more than a year later. Scott was the first orthopedist to enter the country 48 hours later. In the milieu of near total catastrophe, he organized human resources and orthopedic equipment and developed an amazing program at Haiti Adventist Hospital. Synthes announced plans to send a corporate jet with $10 million of implants and equipment. Much of that donation found its way to HAH. Other organizations made major donations. More than 200 members of the AAOS volunteered in Haiti in the weeks after the disaster. Several helped Scott at HAH. I have been privileged to be part of that program.
It is nearly mind boggling to see what has been done in the poorest country in the Western hemisphere. Correction of unbelievably severe long standing deformities has become fairly routine. The TSF is a great example. To have such a powerful internet controlled tool to deal with these severe deformities in Haiti is almost unimaginable. Scott taught me the principles as well as surgical technique. I was able to follow his cases as well as use the device on a number of mine during the year I volunteered at HAH.
The arthroscopy program that we have is another important addition to the program. Now teaching Francel Alexis is a major focus. He has the potential to be the best arthroscopist in the country. He came to HAH to finish a fellowship in pediatric orthopedics during the middle of my year in Haiti. He remains there serving as the important bridge between teams of visiting orthopedists. He has become adept at placing the TSF and doing many other types of deformity correction especially in children. We believe he is the key to the future of the orthopedic program at HAH.
37 yeas of living and working full and part time in these two nonAmerican cultures has been a very interesting and satisfying experience. Learning another language is a byproduct of the situation. La lengua de Cervantes is considered by those with whom I lived and worked for many years to be la lengua del Cielo. I have also been privileged to meet and work with many other incredible orthopedic surgeons who dedicate much of their time and expertise to international orthopedic work. I think of Dr John Herzenberg, Dr Kaye Wilkins, and Dr Lew Zirkle. There are a host of others as well. An orthopedist doesn’t need to leave his own culture and “comfort zone” to find poor people with significant orthopedic needs, For me, it has been a special journey to be involved in other countries.
Stay tuned for the upcoming trip report from the Dietrich/Mulder/Gerke team who recently returned from another trip to Hopital Adventiste d’Haiti earlier this month. Please consider donating to the Dietrich Haiti Indigent Patient Fund’s goal to raise $500,000 for an endowment to facilitate the care of indigent patients at HAH.
Corey Burke Trip Report
Corey Burke is a 3rd year medical student from Loma Linda University with an interest in pursuing a career as an orthopedic surgeon. He recently returned from spending 2wks volunteering at Hopital Adventiste d’Haiti.
When I think about HAH, I see a young girl waiting in the pre-op room smiling at me. She can’t contain her enthusiasm over the hope she has been given by the hospital staff. She has never even met her surgeon before this week, yet she has complete trust in his ability to make her whole again. There were so many children like this. Although their lives are far from easy, their joyful and lighthearted spirits can’t help but inspire those around them.
With this being my first time on a medical mission trip in Haiti, I wasn’t exactly sure what to expect. I remember the excitement and apprehension I felt as I stepped off the plane onto Haitian soil a little over three weeks ago. Little did I realize then the immense impact that this trip was about to have on my vision for my life as a medical doctor.
I can’t even put into words the immeasurable amount of poverty I saw on a daily basis. Although I knew that Haiti was an impoverished nation, I didn’t anticipate being so affected by this reality. Large piles of garbage lay wherever I turned my head. The amount of pollution was shocking. There was evidence of poverty all around us.
Each day as we walked to the market, we would pass a man with only one leg who was crutching around the streets. Each day I wondered what his story was. How did he lose his leg? When did it happen? Could this ailment have been prevented if he received the proper care at the proper time? I found myself asking these questions time and time again. I still can’t wrap my mind around a boy we saw at another local hospital who had been inadequately treated for a tibia fracture and had been lying in a hospital bed for eleven months. Although no one at the hospital has said it yet, he will most likely need an amputation and not have the opportunity to grow up experiencing the vibrancy of young adulthood with both legs. Countless other patients lie in their hospital beds waiting to be treated, having no idea when or if they will be able to have the surgery they need. I found myself feeling incredibly thankful for the work of HAH. The country of Haiti is truly blessed to have HAH selflessly serving those in need. The work they have done and continue to complete is tremendous. But the need in this country remains remarkably great.
My Experience at HAH
I had the honor of working with a team that came from all different backgrounds, yet were unified as one for the common good of the people of Haiti. How neat it was to experience the genuine camaraderie of a group of profoundly talented individuals. Our surgical tech and head nurse, Elaine, did an extraordinary job of keeping everything moving quickly and in an orderly fashion. Her constant encouragement, phenomenal work ethic, and heart for service all stem from her love for Christ. Maria (anesthesiologist) and Lucia (nurse) traveled from the Dominican Republic to join us. Maria displayed her expertise and confidence with each case. Lucia worked tirelessly to care for our patients. The way they both worked with our patients made it evident how much they cared about them and wanted what was best for them. On the last night of our time together, our group went to the roof of the hospital and Lucia led us in prayer, lifting up the patients of HAH. She also shared about how she has a special place in her heart for the people of Haiti and how she prays for them daily.
What a humbling and valuable opportunity it was for me to work under such an exceptional team of orthopaedists: Dr. Nelson, Dr. Anderson, Dr. Mildren, & Dr. Alexis. Seeing the way they responded to the different cases and how they thoughtfully worked through each one is something I will take with me throughout my career and training no matter where I go.
There was one case in particular that I’ll remember for years to come. A young girl had been burned on the back of her leg by a motorcycle exhaust pipe a year ago and hadn’t been able to walk due to contracture of her leg. We performed an excision of the scar and casted her leg in extension. This was not a complicated surgery, yet this child had to endure a year of pain and difficulty not knowing if she would ever be able to walk again. How incredibly rewarding it is to know that a simple procedure will have lasting effects on her life.
Another case etched into my memory involved a teenage boy with tibia osteomyelitis. His infection had been worsening over the past year to the point where the old, dead bone was sticking out through his skin and new bone was growing in behind it. We were able to remove the dead bone and put in antibiotic beads so that it could begin to grow properly. This procedure was unlike any I’ve had the opportunity to assist with before.
Not only did I amass valuable knowledge of orthopaedics from the doctors I worked under, but I also learned about the importance of servant leadership. In order to keep matters running efficiently, our team spent time each day performing tasks around the hospital. This often meant preparing for surgeries, but also included a lot of organizing, cleaning, and even painting. Our team was up late into the night on one occasion finishing painting and preparing the new preop room. The following morning, a hospital worker approached me about how he could not believe that he saw Dr. Nelson, a respected surgeon, take the time to paint one of the rooms in the hospital. He said that it made him think, “If Dr. Nelson is willing to paint a room for the hospital, why can’t I? What else can I be doing to help?” This is merely one example of the many instances in which the team of orthopaedists took the time to serve in whatever capacity was needed in the hospital. It was truly a blessing to partner in their work for two weeks.
I have been to Africa, Central America, and South America on mission trips, but never did I realize the massive need in this small country of Haiti, a place in America’s backyard. The doctors, nurses, technicians, and patients I worked with at HAH have inspired me as I step into the remaining year of my medical school training and as I continue on into residency. My mind will never cease to remember the images of those men, women, and children at local hospitals lying in beds for weeks at a time waiting for treatment. This has served as a reminder of why I chose to enter the field of medicine and has given me a picture of what I am working towards. As I stepped on the plane to come home, I left with a renewed sense of purpose, motivation, and hope that I will have the opportunity to return to Haiti someday soon.
To Our Donors
The following is the seventh and final installment of Scott Nelson’s March, 2015 Trip Report Series.
The accomplishments and plans mentioned in the previous posts do not happen without the support of our generous donors. I would like to thank those who have contributed in a special way and remind you that your investment is making a difference for the people of Haiti. It is being used in a judicious and efficient fashion to rejuvenate the hospital physical plant in order to more adequately reflect the quality of medical work and the healing ministry of Jesus Christ that we represent. The permanence of physical plant restoration is satisfying but even more substantial is the lasting effects of the operations we perform on the lives of our patients. The physical burdens lifted by the operations we perform often make a lifetime of difference and even affect subsequent generations. In the cosmic scheme of life you could argue that these acts of kindness last forever, going well beyond the short span of our lives on this planet. We are especially grateful to the Foundation for Orthopaedic Trauma for their support of this trip and the operations that were made possible. Continued support is needed and again past support is appreciated.
The following is Part 6 of Scott Nelson’s March, 2015 Trip Report Series.
Since the loss of the US Embassy contract to provide history and physical exams for Haitians applying for a visa, the hospital has been in a severe financial crisis. This provided about $60,000US per month, which is around 60% of the hospital overhead. Soon after that, Mdme. Clotaire hospital CEO stepped down and Edward Martin assumed the position. His first 6 months in office have been fraught with many difficult challenges one of which is a major staff reduction. The financial viability of the hospital has continued to struggle and many workers have not been paid for months. The volunteer program has continued to attract patients who are unable to pay for services and further add to the deficits. Up until this point it has been difficult to use donor money to fund this program because of a lack of accountability and the natural tendency of these subsidies to only enable continued fiscal irresponsibility. A new Haitian CFO named Bob is changing this and Mr. Martin is steadily gaining control of the situation. Due to these recent changes we spent significant time on this trip designing a business plan that would enable the hospital to maximize their income from patients who have resources and also to develop a formula where an equitable subsidy can help patients that are unable to cover the direct costs of their care and prevent the institution from incurring further losses.
Estimates for the allocation of total hospital resources attributable to each orthopaedic operation performed at HAH are approximately $1500USD per operation. This includes administrative expense, generator fuel, facility maintenance etc. (indirect costs) As volume of operations increases the per case indirect costs decrease. However,direct costs, which make up a relatively minor portion of total costs remain relatively constant. These are expenses like dressings, medications, and additional anesthesiologist expenses relating to any given case. Our subsidy formula seeks to cover the direct costs of each operation which are approximately $300US for an average case. At the end of the year we know that this will come nowhere near the amount of income needed to economically sustain the hospital. The hope is that the volunteer program will enhance the reputation of the hospital, attract paying clientele, and encourage donations of materials and supplies and with a good business plan the hospital can become financially viable. Volunteers should understand that the hospital may charge some of the patients receiving operations. Donated supplies are brought to help offset hospital expenses and our spirit of charity must be intended to help build capacity of the institution and medical community and not only to give free operations to patients.
The indigent patient subsidies will be given with some criteria for the hospital to be accountable and also have a social work department in the business office to assess the economic needs of the patients and give discounts accordingly. All too often simple pricing schemes in Haiti are used to target upper or middle class paying patients and poor people are turned away. On the other hand if token prices are given and potential income is not collected then donors are subsidizing care for wealthy patients who could easily afford to pay. In addition resentment is created in the medical community when wealthy patients are given discount services as this undermines the income sources for other surgeons in the city.
Where will this money come from?
- Indigent patient endowment fund which has the potential to produce approximately $15,000 per year based on a principle of $300,000.This will be largely used to fund a portion of Dr. Alexis’ salary for the portion of his work attributable no nonpaying patients
- Volunteers – Surgical teams will be encouraged to donate sufficient funds to subsidize the operations they are performing.Operating 20 patients who pay nothing would require $6000 of subsidy, which would be the suggested donation for a typical volunteer team. Sometimes more or less patients will be operated, sometimes patients may be able to pay part or all of their direct costs. Although accounting will be kept, and year-end balances will be reviewed, these subsidies will be suggested tax-deductible donations.
- Patients themselves – even if a patient can pay $10 this will be collected and decrease the reliance on donor subsidy while also creating responsibility and commitment on the part of the patients.
No plan is perfect and in this environment where there is a large difference in affordability of services it is difficult to create an equitable system that serves the richest and the poorest as well as all of those in between. The general concept will be what I call the “American Airlines Model”. That is where all passengers arrive safely at their destination at the same time, but if you want a wider seat, warmed nuts, a washcloth and hot meal then you may be willing to pay 3x more for your ticket. Even in economy class people may pay different amounts for equivalent seats. At HAH we will not discriminate but if patients are willing to pay for premium rooms then let’s maximize our opportunity and provide first class service. If they want the cheapest economy rate then let’s give them a timely and safe operation – and maybe we can add a free orange juice and a handful of peanuts.
Update On Current Projects
The following is Part 5 of the March, 2015 Trip Report Series written by Scott Nelson.
Although our previous operating room was recently reported to me as being one of the best in Haiti, in reality it was not adequate for doing the quality and volume of work that we envision. A major renovation was started in January 2014 and continues at this time. The outcome of this project is beyond my highest hopes, the time and resources required for this have also exceeded my expectations. Things are progressing and although I hesitate to mention it, I have been told that by July 1st we should be able to move in. They actually said June 1st but in reality at the current rate I think July 1 is a much more realistic goal. The one thing for sure is that the attention to detail, quality of work, and improvement from the previous facility will not be a disappointment to anyone. Dan Brown who is managing the project is a perfectionist after my own heart…Dan’s well organized workshop is the feature image above. The lab is also in beautiful condition and as soon as some cabinetwork is completed the space will be inaugurated.
In our review of the facility a high priority has been placed on a cosmetic renovation of the main floor of the hospital. This will be a relatively simple update consisting of new electrical fixtures, some plumbing repairs, door and window repairs, air conditioning repairs and paint. The contractors who did the construction in the OR renovation have looked at the project and will be giving estimates of time and expense to complete this. There are several rooms which are uninhabitable at this time due to mold and mildew (I mean you can not even breathe in them). Many others have rotted doors, bare wires, broken lights and leaky plumbing fixtures. This will be a high profile improvement project that we will need to raise some funding for.
In recent years we have not had an organized space in which to place the patients being prepared for surgery. I have made multiple appeals to have a pre-op room and finally was granted the space. This is an important part of patient safety and OR efficiency. Patients have been waiting for surgery in the hallways and entrances of the hospital. Sometimes it is confusing to keep them straight, we are not able to effectively update them on when their operations will start, sometimes moms slip their hungry children bites of food and then don’t admit it knowing that their long awaited operation will be delayed or cancelled.
When I arrived this time the designated room was in a state of disrepair without immediate plan for inhabitance. Fortunately Chad became an expert painter last summer when he painted our house and was able to take over the job and execute a one-day makeover that met the approval of Dan’s quality expectations. Patients were moved in on Monday morning utilizing 6 new gurneys. IV’s were started, gowns placed and the day of surgery progressed with a new level of patient safety, efficiency and comfort.
Trip In A Nutshell
The following is Part 4 of the March, 2015 Trip Report Series written by Scott Nelson.
Patient care, administration, and organization were the 3 main areas of focus for this trip. Dr. Mark Mildren PGY4 ortho resident, Corey Burke 3rd year medical student, John Anderson MD orthopaedic surgeon LLUSM graduate year 2000 and our two Dominican essentials Lucia Hernandez RN and Maria Adrian MD anesthesia made up the team.
John’s family – Jeannette, Joshua, and Kaitlyn as well as my son Chad also joined us and devoted most of their time towards helping Jonathan Euler and the Beehive organization. Francel had many operations lined up for us as well as a couple of days of clinic. Due to John’s sports medicine expertise several arthroscopic surgeries were performed, we also operated on a spine fracture, and did a number of hip and lower extremity operations.
Elaine Lewis who is a surgical tech living at HAH for 6 months had the operating room nicely organized and clean. This was much different than the conditions that we have been faced with on earlier trips. She motivated us to organize all of our orthopaedic equipment and other supplies, which we spent a significant amount of time doing. Corey and Mark learned more about orthopaedic implants than they ever wanted to know. A big part of doing safe surgery is knowing what you have and where it is, perhaps this is even more important than quality lighting and the room that you are working in. Elaine had hoped that I would throw away a lot more than I did, but without a reliable supply chain I convinced her to hold on to some items that we will need in the future, but this came at the expense of her thinking I am a hoarder.
I spent a significant amount of time with Edward Martin the CEO developing a business plan and working out ways for the volunteer and orthopaedic program to continue in a sustainable fashion. More about that in subsequent report. We also spent an entire day with Dan Brown the facilities manager reviewing the entire facility and creating a coordinated plan for the future use of space and how various physical plant improvement projects will be prioritized. One notable aspect of this is the plan to remodel the upstairs area of the HIV clinic (building in front area of the property) for volunteer team housing. It is a pleasant space about 3x the size of the current quarters that has several large bedrooms and a common area.
The Importance of HAH
The following post was written by Scott Nelson who returned last Friday from another visit to Hopital Adventiste d’Haiti. This is Part 3 of the March, 2015 Trip Report Series.
A few blocks away from the Basilique Notre-Dame (still in ruins noted in image above) is a local hospital for which I will keep the name anonymous. I had a good idea of what the conditions were like but never having been there I asked Dr. Alexis if we could take a tour of the orthopaedic wards. The situation was even worse than expected. Patients languishing in crowded, oppressively hot, foul smelling rooms, some of which were only lit by tiny cell phone flashlights.
One horrible case after another, many of which would have been avoided with a simple well-performed operation at the appropriate time. In some cases expensive modern external fixators were seen carelessly applied with complete neglect for postoperative care. One patient had 10 inches of his tibia debrided after a relatively straightforward tibia fracture that got infected. Now he has been there for 11 months in bed. An emergent debridement and SIGN nail could have put him back on his feet. Now, an amputation is the only reasonable option, but no one wants to tell him that so he just hangs there. His Bible and Sabbath School quarterly are at bedside.
When we arrive back at HAH, our perception of dilapidation, disorder, and poor nursing care has changed. We feel like we have just walked in to the Hilton. But the knowledge of those patients at the government hospital, still suffering even as I write this report is motivation to continue our focus on treating the underserved. As we renovate our facility and improve the level of care we have an urgent need to create a communal ward where the poorest of patients can be economically cared for.
A few weeks ago Elaine Lewis met a man who brought in a patient who needed surgical care to Hopital Adventiste d’Haiti. As it turns out the gentleman is the coordinator for the Restavek Freedom ministry in Haiti. Restavek (restavec in French) is the name for child slaves in Haiti. Children who are desperately poor are taken in by families who promise to get them an education and a better life in exchange for servanthood. The reality is far different and amounts to 300,000 child slaves in this country. According to their website, Restavek Freedom’s mission is simple, to end child slavery in Haiti.
The following post was written a few days ago by Scott Nelson who is currently at HAH with son Chad, orthopedic surgeon John Anderson and family, orthopedic resident Mark Mildren and medical student Corey Burke. This is Part 2 of the March, 2015 Trip Report Series.
My life is not necessarily in balance. In fact, often the things we strive for most are the areas of our lives that are most lacking. Balancing priorities at home nearly eclipsed my plans for this trip and now that I am here it seems that a good part of my busyness at home is relatively unimportant. In many ways these trips help to keep me in better balance. They help me realize what is important in life and what is not. Due to my own lack of balance it is important for me to get to Haiti at least every three months. Most people do not require such rigorous travel schedules to stay sane, but I find myself getting restless unless I am able to leave the United States and come to such a place as this on a regular basis.
Our effectiveness as human beings, teachers, and leaders depends upon balance. We should not be satisfied with the status quo, but nor do we want to focus only on areas of needed improvement lest we become negative and critical. When looking at hospital economics, business plans, and the pace of operating room construction it is easy for me to get frustrated. These vexations need not be published here but perhaps it should be known that not everyday in the mission field ends in feelings of victory and accomplishment. In an attempt to not be overwhelmed by challenges, I have chosen to quit asking when the new operating room is going to be ready. Nor will I be able to answer that question for anyone else. The projected date is June 1, but realistically at the current pace it will be well beyond that. The good news is that progress is being made, the quality of workmanship is well beyond anything I have seen here, and the provisional operating room is now so well organized that we can safely perform just about any operation there.
The improvements and installations in the new operating room continue to impress me. The new operating accommodations are such high quality that future surgical volunteers will not be challenged as we have been in the past. Sometimes I wonder if they will even want to still come, as there will be less of a sense of adventure and the perception of local needs will be softened.
I continue to try and balance diplomacy with accomplishment, relationship with productivity, tolerance with perfection, optimism with reality, censure with appreciation, and rest with work. Fortunately after 6 days of work, a day of rest has arrived.
The following post was written by Scott Nelson when he first arrived with a team at Hopital Adventiste d’Haiti early last week. This is Part 1 of the March, 2015 Trip Report Series.
Due to the efforts of Elaine Lewis (surgical tech), Dan Brown (facilities manager) and Ed Martin (administrator) major progress is being made. When we arrived yesterday on campus there was a noticeable difference. The wires and tubes hanging all over the front of the building have been consolidated and cleaned up, the old ambulance parked in the backyard has been relocated, the nonfunctioning rusty water tank that was “gifted” to us after the earthquake has been removed, and the makeshift dilapidated kitchen built by The Supreme Masters in 2010 has been destroyed.
Thanks to Elaine the operating room is in impeccable condition. I have never seen it so organized. Not a single item is out of place in the sterilization room, the table is not piled up with a bunch of disorganized instruments, the sinks are clean and the shelves are labeled and neatly stacked. Although the new operating room is still awaiting some final touches the current operating area is more than adequate to accommodate whatever cases need to be done. A big part of doing safe surgery is being organized, having what you need when you need it, keeping equipment clean and in good working condition, and effectively using what you have. More important than Elaine’s organizational skills is her diplomacy. She has not done all this work herself. She has motivated the staff, built relationships, taught them what needs to be done and shown appreciation for quality work. They are now doing it on their own.
I have not yet seen the progress inside the new operating room but I expect that my report will be good. Two massive medical air/suction pumps have been installed downstairs as well as a huge circuit board. These pumps look large enough to run the 16 operating rooms at Loma Linda University much less the 3 at HAH. The front entrance to the operating rooms has been remodeled and looks modern and clean.
This week in addition to the cases that we have to operate we plan to accomplish some administrative goals regarding the sustainability of the orthopaedic program. Although all of us have the common goal of continuing to offer top quality services to all, it is challenging to find ways to increase revenues, make a budget, transact donations and continue to host volunteers without burdening the precarious financial situation of the hospital.