An Anesthesiologist's Journey to Sacre Coeur hospital in Milot, Haiti

Some great links

2010-06-06T09:34:00.001-05:00

It's been a while since I've posted so I apologize!

I just had to share these links.

The husband of one of the anesthesiologists I worked with is a film producer/editor and he put together a fantastic video about the volunteers. Here is his link:

http://dpcrow.smugmug.com/Other/Haiti-Movie/11994337_Fdpqk#849960455_sPyYo

The other link is a compendium of all the photos taken by the Duke-Raleigh crew:

http://dpcrow.smugmug.com/Other/Milot/11291961_wQCbe#792720883_4iVrG

There are quite a few pics in here!

Enjoy!

An Interview with 100 beds for Haiti

2010-03-15T14:16:00.002-05:00

I was interviewed by Cassidy Flanagan from the organization 100 beds for Haiti

http://100bedsforhaiti.com/

They are trying to give Sacre Coeur hospital 100 new hospital beds for their patients.

Please visit their website and get involved! Thanks!

1) You're an anesthesiologist working at York Hospital in Southern Maine; what brought you to CRUDEM and Hopital Sacre Coeur (HSC)?

I have always been interested in travel to developing countries and international medicine. I have travelled extensively in Mexico, Costa Rica and Turkey. I was evaluating several places to go for my next Medical volunteer trip when the Haitian earthquake happened. I knew right away that I had to offer my services to the Haitians. For a disaster of that magnitude to happen to a country with no existing infrastructure? What a catastrophe. I saw all the news clips coming in and the suffering I observed in the Haitian people really affected me on a professional and on a human level.

I was connected with CRUDEM/Sacre Coeur through a connection at the American Society of Anesthesiologists (ASA). I felt like my skills would be particularly useful there because they had operating rooms that were up and running. Thus, I could do clinical anesthesia and spread out their workload a little bit. I was able to get 2 weeks off from work thanks to my colleagues and I went down.

2) Have you ever done humanitarian or disaster relief work before?

I spent 5 weeks traveling around rural Turkey about ten years ago as an ER physician. I helped teach the Turkish residents and Medical Students in eight or so different hospitals. It was a great experience.

I have never done disaster relief on the scale that I found in Haiti. I’m not sure many medical providers have!

3) What were some of your first impressions when you arrived in Milot and HSC?

Milot was actually much smaller than I expected. It was a very tight-knit, “homey” sort of community. Everyone was very welcoming in Milot. It was much cleaner than Cap Haitien, the city I flew into. Milot actually had some paved streets, a rarity in Haiti.

The first thing that really struck me about HSC when I arrived was how ORGANIZED the place was! I was expecting chaos. After all, they had to expand from 65 beds to 400+ in two weeks! The OR area had been converted from 3 to 5 working OR/procedure areas. I was expecting I would be doing surgeries outside in tents! The tents for patients had already been set up. The volunteer area had been expanded to hold all the extra volunteers. It was very impressive. It was a real, functional hospital in the middle of the poorest country in the Western Hemisphere.

4) Before you left for Haiti you set up your own blog,
http://brewdocinhaiti.blogspot.com, reporting on your own experiences and observations working at HSC. It was really moving to read your different entries starting a few days before you left to your return back to the U.S. You also took quite a few photos of different patients both recovering and in during surgery. What was it like to document your own experience on the ground?

Thanks! I really enjoyed writing the blog. It helped me decompress after the long, stressful days away from my family. I wanted to share my own experiences down there to give people a sense about what it was really like to work there. Most of what people see of Haiti on CNN or the other news channels definitely has a “spin” on it. The news networks are in the business of attracting viewers so they are going to find the most shocking or awe-inspiring stories to report on. They aren’t going to talk about the different types of rice and beans the volunteers share with the patients and such... or the roosters that keep the volunteers up all night (laughing).

The kids loved having their pictures taken. Most of the pictures I took of the kids were with cards that my kids’ classes made for them. They LOVED those cards! Even the teens. They were SO into those cards!

5) On average, how many patients did you see a day and about how many surgeries were able to be performed each day?

Wow. That’s hard to figure but I would say in an average day I personally did between five and eight cases. The OR was doing at least 30 cases a day. I was there late February and they had done upwards of 800 cases for 2010. Last year they did 1200 cases in the entire year.

6) As a doctor working in a hospital in the U.S. with access to some pretty advanced technology, how were you able to adept to technology you had available to you at HSC? What were some of the most challenging aspect of diagnosing patients?

In anesthesiology, the main concern was safety. We tried to keep the anesthetics as safe as possible for the patients. Since we did not have access to the most modern anesthesia machines, we tried to do regional anesthesia (spinals and nerve blocks) as much as possible. Regional is pretty “low-tech” : although one of the Duke/Raleigh anesthesiologists that came down brought his own ultrasound for nerve blocks. That was pretty slick! (laughing)

The thing I found the most challenging was not being able to get ( or find) lab results on my patients. I knew they were ordered, but I couldn’t ever, for the life of me, find them. That tends to make things challenging. Your patient is hypotensive and tachycardic. Is it a result of the spinal or is it because their Hemoglobin is 4? (Normal is 15)

7) You mention that Phillips Electronic donated a "fluoroscopy unit for 'real-time' X-rays in the operating room". What did this mean for the OR?

That was huge. We had the only fluoroscopy machine in all of Haiti! A fluoroscopy machine lets the surgeon see immediate X-ray images intra-operatively. When all the original, emergency repairs took place this was not available to the surgeons. As a result, the orthopedists were taking their “best educated guesses” as to how the bones would line up best.

Once they got the fluoro machine they could re-do the repairs with much better fixation and alignment for long term recovery. We were getting 4-5 patients flown in daily from all over Haiti to have their fracture fixations revised. The orthopedic team was absolutely pummeled when I was there.

8) You describe one patient, a 17-year old boy who among other injuries had a fractured skull with parts of the skull effectively dead from infection, and needed to be removed to prevent an even more serious infection like meningitis. The decision to operate was a complicated one because this particular piece of the skull rested over a large vein that drains blood from the brain (so any sort of tear could cause immediate death) and you had only one unit of blood that you were unable to test for HIV. How did you and your team evaluate this case, including the mitigating circumstances, and chose to operate?

Yeah, that was a tough one. He was the nicest kid too. He was an orphan but had such a great attitude about everything.

With him it came down to: without the surgery, he was certainly going to die from an extension on the infection intra-cerebrally. There was a much smaller risk of tearing his sagittal sinus and an even smaller risk of contracting HIV from the blood transfusion. So, even though the surgery and transfusion would entail some risk, “gonna die” trumps “slight risk of dying” to put it bluntly. So we elected to proceed. Luckily, he did fine and there were no complications.

9) Haiti has one of the world's highest HIV rates, did you find this to be an added challenge when treating patients?

We practice universal precautions with all our patients and assume “everyone could have HIV” in the US. So it didn’t feel any different in Haiti, although I must confess I was I bit more wary down there. The diseases I was more concerned about were malaria and tuberculosis (TB). Several volunteers I talked with contracted malaria on previous visits. That didn’t sound the least bit fun.

TB runs rampant in Haiti and it is, in fact, one of the leading infectious causes of death in Haiti. We took care of numerous patients with TB and probably many more that are undiagnosed. HIV is relatively hard to catch, TB is relatively easy to catch.

10) One passage from your blog struck me as particularly moving--and in keeping with our 100 Beds for Haiti Campaign, I found extremely relevant:

“It is now 10 PM and having just transported our last patient of the day on an army stretcher, across the dirt road, in the rain, to his current home in Tent #5 where he will spend the night with 50 other patients, I’m going to pass out on my own cot. zzzzzzzzzzzzz”

HSC has about 73 patient hospital beds, and is treating well over 300 patients. Many of these patients are recovering in the Tent City set up across the road from the hospital, sleeping on cots; and, even you were sleeping on your own cot! Can you describe your response to the condition you were working and living in?

Ha ha. Yeah, I was pretty tired when I wrote that. We all realized that when we were heading down there, it was not going to be “Club-Med” and our accommodations were going to be somewhat spartan. We weren’t getting the best sleep in the world but none of us were complaining. We knew it was as bad if not worse for the patients. That patient that I described just had a revision of his lower leg external fixation device. So Sam, a medical student and I carried him across the street in the pouring rain and we were all soaked. The patient plopped himself down on his cot, KAPHLUMPHH!! He and his family thanked us profusely. All the other patients were peering out from their sheets to see what all the commotion was. I couldn’t help think, “I have absolutely nothing to complain about”. But, I really think he would have benefitted from a real hospital bed. The cots are far from the least comfortable thing to sleep on ( that prize goes to the luggage compartment floor in a Czech second class train) but post fracture fixation patients do require a bit of malleability in their resting quarters. They really need their fractures elevated and such.

11) Haiti has a long way to go on its own road to recovery but from your own experience and observations what does an increase in support and donations from professionals volunteering their time and skills to monetary donations mean in terms of immediate positive changes?

Haiti is totally dependent, at this point, on foreign aid and organizations. Sadly, the Haitian government has not figured out how to truly help the people of Haiti themselves yet. If there is a silver lining to this earthquake, I hope it is that the Haitian government can begin to honestly work with foreign governments and aid organizations to re-invent Haiti’s infrastructure, schooling system and health care delivery. The will to help in Haiti is definitely there! In the meantime, Haiti will continue to benefit from people generous enough to donate their time and resources to help them rebuild their country. Aid is the only way things are going to improve at this point. The people of Haiti are phenomenal; kind, generous, friendly, caring. I’m already planning my next trip back there! I love it!

Reflections and Re-entry

2010-03-07T19:16:00.000-05:00

My last few days in Cap Haitien were spent walking through the city and striking up conversations with the 12-14 year old teens who would predictably latch onto me. The chats were mostly light-hearted, talking about Haitian music

“ I love reggae! Who’s your favorite Haitian reggae artist?”

“Bob Marley!”

“Bob Marley is not Haitian, he’s Jamaican!”

“No he’s NOT!!”

But the question often came up, why weren’t they in school?

“ My family can’t afford it..”

“I don’t have enough money...”

“I live on the street, they won’t let me go...”

The replies were as endless as the kids on the street. I was floored.

“ But you need to learn to speak English or French. You need to learn math. ”

“YOU can teach me!”

Clearly their truancy was not from a lack of interest or a lack of eagerness to learn. They wanted to be in school. Sadly, the system made it difficult for them to attend.

In Haiti, there is a tuition to cover the expenses of school. It amounts to a fairly nominal $200 or so, however this exceeds the annual income of many Haitian families. Add to this the cost of a mandatory school uniform and remember that Haitian families with more than six children are not uncommon and the problem is clear. Families in Haiti simply can’t afford to educate their children.

In the vicinity of Port-Au-Prince the problem is compounded by the fact that there aren’t any schools. Nearly all of them were destroyed in the earthquake. Some opportunistic schools have taken to having outdoor lectures under tarps, but these appear to be the exception, not the standard.

It is my opinion that the one change that could improve Haitian society more that any other would be an improvement of their education system. Observe countries such as China, India or most of the “Asian Tiger” countries. Thirty years ago their development indices were on par with Haiti’s. Recently these countries have made great strides in development and are no longer referred to as “frontier” or “third-world”. Their common denominator is that they put great emphasis on education and their educational systems.

I believe that if Haiti started to take its education system seriously and could allow all of its citizens to attain a quality education, it too would rise from its current depressed state. Haiti could finally be freed from the bondage of foreign aid by the talents and technology of its own citizens.

I have had a few days to reflect on taking care of the victims of the worst natural disaster of this century to date. I don’t need to reiterate what wonderful people the Haitians are and what a horrible tragedy this was for them.

The following, however, are points that do seem to keep sticking in my mind......

I completely underestimated the physical and mental exhaustion I would experience working with disaster victims.
Disaster work attracts truly unique individuals. I was fortunate to be able to work with such a flexible, resourceful, adaptable and talented team of individuals.
It is incredible, even in society’s darkest hours, how humans can retain the ability to smile, joke, sing, dance and aid one another.
Even though this may sound cliché, sometimes it takes an experience such as mine in Haiti, to realize the relative insignificance of some of the things we get riled up about in our society.

As I write this, I am already planning when I can return to Haiti. Haiti is an incredible place that needs a chance of a fair educational system for all and an uncorrupt government to help it get on its feet.

Bon chans Ayiti!

Back to Cap Haitien Again.

2010-03-03T08:15:00.002-05:00

I ended up leaving Sacre Coeur a day early to relish the American comforts of an air conditioned room, a soft bed and no midnight roosters before heading back to the USA. I’m staying at a charming little hotel in Cap Haitien called Mont Joli. I highly recommend it to anyone who is coming down this way. My wife asked me to describe Cap Haitien, the (I believe ) second largest city in Haiti.

Cap Haitien Harbor

Cap Haitien, is very, very dirty. Piles of trash line the streets as well as the drainage ditches which run alongside the streets. The drainage ditches have become backed up from all the trash obstructing them filling them with a gooey, mossy, green sludge. The roads are unpaved and very dusty. Dog feces, flies and mosquitoes are everywhere. It is very loud. Humans unashamedly relieve themselves right in the middle of the street. Most of the buildings are crumbling and disintegrating.

Everywhere you walk 4 or 5 guys tag along beside you and tell you how hungry they are . They ask why can’t you just spare a few dollars for them. I had two young men follow me all the way up to the hotel entrance before the staff shooed them off. Not that I blame them, after all, the average Haitian wage amounts to about $20 a month!

I haven’t been able to take many pictures because if you take your camera out on the streets here, you might as well put a big, red bullseye on your chest.

That being said, for reasons I can’t explain, I really like it here! There is so much color and personality! There is a vibrancy you just don’t see in US cities!

People who have worked in Africa tell me this area is a lot like Nigeria. They also say most of Africa has much better sanitation than Haiti does. Although that does surprise me, I suppose it would not be hard to do! Sanitation is clearly, as I see it, the major challenge for this country.

Tomorrow I head home. I will be very excited to see my family, but I will miss it here. For all its shortcomings, Haiti really grew on me. I have never met a tougher, more resilient people in all my years of traveling. I never once heard a Haitian complain about anything during my time here.

It will be a few days before my next post. It will take a few days to reflect and ingest this whole experience. I do wish to send a thank you to York Hospital. Hundreds of dollars of drugs and equipment were donated by the hospital and my colleagues were quick to cover my calls and late-shifts in my absence. THANK YOU!

Kreyòl Ayitien

2010-03-02T20:05:00.001-05:00

"Creole is a language whose body is French but whose soul is African."

-Aimé Césaire

Most people assume that Haitians speak French. French, after all, is the official language of government and higher education in Haiti so it would make perfect sense to assume that to be the case. In fact, only a small number of educated Haitians are able to hold a conversation in French. The language of the people is called Haitian Creole or Kreyòl Ayitien. To anyone who has heard Kreyòl, at first it sounds like a dialect of French spoken extremely fast. But it doesn’t take long to realize that Kreyòl is certainly not French. Most native French speakers admit they can’t understand hardly a word of Kreyòl . So how did this language evolve to be the real national language of Haiti?

In the 18th century, large numbers of slaves were brought to Haiti by the French. Most came from Western Africa, from what is present day Nigeria, Togo, Benin, Burkina Faso, Ghana, Ivory Coast and Cameroon. The main tribes that were selected to bring to Haiti included the Yoruba, Igbo, Ewe, Bakongo and Fon tribes . The slaves from these tribes heard the French that was spoken by their masters and tried to assimilate the words and syntax into their own languages. Gradually, a unique language evolved with a vocabulary that was mainly derived from French, but a grammatical structure, or syntax, that was distinctly African.

Over the decades Kreyòl solidified its identity and became the language of the people. For centuries it was solely a spoken language as most of the citizens of Haiti were illiterate. It was only in the latter half of the 20th Century that written Kreyòl became standardized. An interesting side note is that Haitian Creole is very closely related to the French Creole of Louisiana and other creoles of the Caribbean.

Kreyòl has had a difficult path to establish itself as one of the national languages of Haiti. Ever since the revolution, French has enjoyed much higher prestige in Haiti. French has always been considered to be the language of the educated and of the elite in Haiti. Over the years, lawmakers have consistently dismissed Kreyòl as a direct link and reminder to the days in which Haitians lived in bondage. Kreyòl was not accepted as a literary language and until the mid- 20th Century there was no literature written in Kreyòl. To this day all Haitian school instruction is mandated to be conducted in French. This, despite the fact that most of the teachers are unable to speak proper French themselves.

I was able to teach myself a fair amount of Kreyòl in the few weeks before I left. I am able to fairly adequately express my needs in Kreyòl...understanding the reply, however, is a different story. Kreyòl does tend to be fairly easy for English speakers thanks to the vocabulary ( 50% of English words have a French origin) and the mercifully simple grammar.

For example, nouns have no gender, and their plural is formed simply by adding yo after the word. The term for “a” or “an” is placed before the noun, the term for “the” is placed after the noun. There are only five pronouns that do not decline based on their function (eg: mwen can mean: I, me, to me, from me, my or mine) To form the negative, just put pa in front of the verb. Possession is shown by placing the person or thing possessed before the possessor (eg: kay mwen : my house, kay ou : your house).

Good morning! Bonjou!

Good evening! Bonswa!

How are you? Kijan ou ye?

Not bad. M' Pa pi mal.

And yourself? E ou menm?

Great! Anfòm!

I’m getting along. M' ap kenbe.

Hang in there! Kenbe, pa lage!

Have a good trip! Bon vwayaj!

Bye-bye. Babay.

See you (God willing). N a wè pi ta (si Dye vle).

It has been great fun attempting to communicate with the Haitians in Kreyòl. They are very enthusiastic teachers and when I attempt to speak Kreyòl with them the response is always the same. Eske ou menm pale Kreyòl?? Do you really speak Creole??

For more information, please visit:

http://www.indiana.edu/~creole/creolenatllangofhaiti.html

Food and Ethics in a Disaster Zone

2010-03-02T08:35:00.002-05:00

Did I mention we have a goat?

One of the best things about our compound is undoubtedly the food. I had never had Haitian food before and had no idea what to expect. We have a cooking staff of five or six who go out of their way to make sure we eat well.

Breakfast is simple with some sweet grapefruit, toast and eggs or Haitian oatmeal called avwàn. Avwàn is more like gruel or porridge than what we would think of as oatmeal. It is creamy, salted and has a touch of cinnamon. It is a bit of an acquired taste, but I love it.

Lunch always consists of some sort of diri ak pwa and vegetables. diri ak pwa is rice and beans cooked in a large pot. I have had at least four different kinds of beans since I have been here and they are all delicious. The vegetables are usually green beans, beets, cabbage, potatoes or carrots. There is also some sort of meat. Chicken (we see them delivered live on Saturdays, talk about fresh!), meatballs or stewed meat. We think the meat is goat but we aren’t really sure. It’s good nevertheless.

It is said that wherever the French have left their footprint, one can be assured there is good bread. Haiti is no exception. For dinner there is always great, crusty bread and salad with the most amazing dressing I’ve ever had. It is served in a large enameled cooking pot and is made with ( I believe ) lemon, shallot, peppers, oil and vinegar. It is sweet, salty, spicy and sour all at once. My friend commented, “ You could put that dressing on (insert expletive of your choice here) and it would taste good!” They also make an “American Classic” with a Haitian spin. We have had Shepherd’s Pie, Baked Macaroni, Pizza and Spaghetti to name a few with flavors that are distinctively Haitian.

That's a lot 'o beans!

One can’t help feel guilty about eating so well in a country where the population receives only half the recommended daily calorie intake by the UN. Starvation and sever malnutrition runs rampant. People constantly approach us on the street crying “grangou” , “I’m hungry”. We try to justify it by acknowledging that we are providing a valuable service to the people and need our strength and energy. We only take small portions and don’t leave any waste. Justified or not, we still feel incredibly guilty.

It's always good to befriend the chefs!

Medical ethical decisions are difficult enough in the developed world. One can only imagine how much more difficult these ethical decisions are to make in a disaster zone. Much of this has been well publicized in the international media. For example, the decisions to amputate limbs of children which may have been able to be saved in a developed country in a non-disaster situation etc. The questions that need to be answered at our hospital are a bit more subtle.

Cardiac surgery Haiti style

For example, in my previous post I referred to the difficult decision whether to convert the medical tents into a refugee camp. The benefit would be a sense of community for the traumatized people and assurance of proper shelter and nutrition for them. The disadvantage would be that valuable medical beds will no longer be available in a country where there are only five major hospitals (as far as I know). Haiti has only one doctor for every 4,500 people which is among the worst in the world. It goes without saying that facilities such as Sacre Coeur are extremely valuable in Haiti.

Dr. Crow and a friend

I also referred in a previous post about the child with severe hydrocephalus ( increased fluid accumulation within the ventricles of the brain) who is going to die without treatment. The week before I arrived there was a rumor that a neurosurgeon was offering to come down to place a ventriculo-peritoneal (VP) shunt to drain off the water surrounding the child’s brain. The issues here were,

Would placement of the shunt kill him? There is a good chance that in such an advanced case, a sudden draining of the fluid would cause herniation of the brain and immediate death.
VP shunts require an immense amount of maintenance and follow up care afterwards. They often require revisions as well. How would this happen in a country without a permanent neurosurgeon and one doctor for every 4,500 people?
There were still thousands of patients needing urgent medical care and surgery as a result of the earthquake. Would a case like this suck up valuable resources that could otherwise help a trauma victim with a much better chance of recovery?

It is a very sad case, but the decision was made not to aggressively treat him. Eventually he will be sent to the Haitian equivalent of hospice-care.

In this case the person I feel the most sad for is his grandmother. The boy’s parents left last week and Grandma has been at his side ever since. The other day I was in the pediatric ward handing out cards from my kids’ classes and taking their pictures. After I was finished his grandmother came up to me and asked if I would take his picture. I did and showed it to her afterwards. She beamed and looked as proud as any grandmother I’ve seen looking at a picture of a grandchild. It was clear to me that she didn’t see the baby as "deformed" or a “really interesting medical case", but as her wonderful grandchild. I almost broke down crying.

The last case which made me stop to ponder happened yesterday. The patient was a seventeen year-old boy. He lost his entire family in the earthquake and was being treated alone, as an orphan in Milot. In addition to other assorted fractures, he suffered a depressed skull fracture on the crown of his head which had become severely infected. Antibiotics had failed to improve the wound and now it was clear that a large portion of his skull had become necrotic with infection surrounding the mass. If this could not be removed soon he surely would develop meningitis and/or encephalitis and die.

The issue was that the bone lied directly over the sagittal sinus, the major blood drainage from the brain. There was concern that unroofing this bone could tear the sinus resulting in sudden, massive blood loss, venous air emboli and sudden death. We were able to secure one unit of blood for him, however, there was no way to screen it for HIV. The questions this raised were

If we need to transfuse the blood, what is the risk of transmitting HIV in untested blood?
Is one unit of blood adequate? If the sinus is torn he would need dozens of units of blood to replace the blood loss. So would we be better off letting him die and using the blood for someone with a better chance of survival?
If, God forbid, he did not survive the surgery, would he be better off? He has just lost his entire family, has no place to live, no job, no education and a long painful recovery ahead of him.

Neurosurgery Haiti Style

Thankfully, he did survive the surgery and did great. We did not have to give him any blood and the infected bone lifted off relatively easily as it was completely surrounded by an abscess cavity. I hope he recovers well and things start to look up for him.

On a lighter note, this guy felt this phone call couldn't wait until after his hand surgery!

Konbit!

2010-03-01T15:13:00.001-05:00

3/01/2010

I have been here a week now and have seen several groups come and go. Each night at eight we have a meeting and “debriefing session” of the day’s events. This also gives the new volunteers a chance to introduce themselves and ask questions. It’s amusing because the arrival of each group brings the same questions.

They ask about taking pictures and have to be reminded that most Haitians are very superstitious about photos. Haitians believe that each time they have a photograph taken of them, a part of their soul is given away. One can only imagine what they feel when people arrive and start non-discretely shooting pictures of them in their tents as if they were some sort of freak show. Sad to say, some journalists have shown up unannounced and have done exactly this. It is for this reason that I have chosen not to photograph any patients in the medical tents.

On the other hand, I have found that if one asks “M’kab fe yon foto ou?” (May I take your picture?) the response is an enthusiastic “WI!” the majority of the time. Kids especially love to be photographed here. The only condition is that they can see their image in the LCD screen when finished (which invariably results in wild laughter). I finally figured this out the other day. These are kids that have never been photographed before and certainly haven’t ever seen their own picture. Compare this to the US where most kids have hundreds if not thousands of pictures taken of them before their fifth birthday. The kids are certainly not camera-shy here.

The other issue that invariably arises on the first night is, “There seem to be a lot of patients in the tents that don’t really need to be here”. They would be technically correct as the wounds and illnesses of many patients have improved and they don’t need to be in a hospital per se. An interesting thing, however, has happened in the tents over the past six weeks.

In traditional, rural Haitian society, the work typically consists of subsistence farming and hard, manual labor. It would be unrealistic for a family to expect to do all the labor by themselves. What has developed as a result of this is the “Konbit”. The closest word I can think of in English for this would be “Co-op”. Essentially it is a village cooperative where the work is divided up amongst all the community members in exchange for the goods produced.

Each tent, over the past several weeks, has established within itself its own community, its own konbit! Walking past a tent one sees patients and their families washing each others’ hair, bringing in provisions for each other, walking patients, playing cards, etc. The nurses have acknowleged that breaking up these little mini-communities would be devastating. Besides, as I noted before, the patients have absolutely nothing to return to.

There is some talk, as it becomes less medically necessary, to turn the tents into a sort of “refugee camp” to allow the people more time to either assimilate into the community of Milot or relocate elsewhere. This, obviously, is a controversial issue in Milot and with Sacre Coeur Hospital. I have not heard the verdict yet on the issue. There is no “Hospital Social Work” here and no way to simultaneously help so many people re-acclimate after the disaster.

An amusing side-note. I took care of a man from the Dominican Republic the other night in the medical clinic because I was the only one who spoke Spanish. The following morning he returned demanding to see the Department of Social Work so they could pay for a bus back to the Dominican Republic for him. When I told him no such thing existed he gasped

“ Well! In the Dominican Republic each hospital has a Department of Social Work and they can take care of this for people like me!”

“ Buddy, in case you haven’t noticed, this ’aint the Dominican Republic!”

On a sadder note, the work is really starting to drain me physically and mentally. There just dosn’t seem to be enough hours in the day for all the cases that need to be done. My sleep has been sub-par for the past week in the un-airconditioned military style cots accompanied by rooster operettas through the night. But most of all, the sad stories of the patients have caught up with me mentally. Every day I have had at least one patient who has lost both parents in the quake. Several patients have lost all family members altogether. I’ve tried to stay positive but eventually everyone here reaches a point where they become simply exasperated and overwhelmed.

A night out in Milot

2010-02-27T18:36:00.001-05:00

2/26/2010

We have seen many medical conditions that we never would have seen in the States here. I have seen two cases of spinal tuberculosis, a sad case of a child with metastatic Ewing’s sarcoma (a treatable condition in the US but terminal for this boy) and a child with severe, massive hydrocephalus ( again terminal here). A Georgetown cardiologist here told me in his first day here he has seen more cases of critical rheumatic heart disease than he has seen in all his years practicing back home. It can be explained by the severe lack of health services in this country. Patients that need to be seen here often need to walk extreme distances over strenuous terrain and endure very long waits; and this is the premier tertiary care center in the country. “The Mayo of Milot”.

There are other slight differences. Before I came people advised me to bring “high test DEET” for the mosquitoes. I had assumed they meant to bring it for walks and outside activities. No, they meant to use it in the OR. I was completely bombarded the other day. It was frustrating because there were large “no fly zone” placards on the OR doors but people kept leaving them wide open. On one occasion I saw ten flies come in. Nonetheless, after an aggressive spraying in the ORs, it seems much better.

Kristen in our PACU

Sam, Med Student extraordinaire in charge of the PACU

This evening a medical student, “Sam” and I walked around downtown Milot. We were a little apprehensive going out at first but Edeline, an ex-pat Haitian nurse told me “Relax, all you need to do is smile and say ‘Bonswa’ and people will smile and reply back. People here are very friendly, they don’t cause problems”.

A friend at the hospital entrance

We headed out into the darkness as there are no streetlights here. The curbs were illuminated by the fires of the “banan” stands. They are fried plantains with a sour/spicy sauce on top and better than any bar food I have ever had. We carried our banans, munching heartily into the darkness and sure enough everyone we greeted with a “bonswa” replied with a huge smile. A group of young men offered me Haitian citizenship in exchange for my US citizenship. I told him, unfortunately, that I didn’t have the authority to do that... People were great and quite amused that these two “blans” cared enough to venture out and get to know them on a Friday night.

Anesthesiologists from Duke/Raleigh showing us the real way to do ultrasound guided nerve blocks

The stereotype in the US seems to be that neighborhoods of the low income and underprivileged tend to be magnets for crime, drugs and lascivious activity. Thus, our fellow volunteers thought we were crazy to walk through this area at night. What we found was the contrary; a wonderful night-scape of a relaxed, caring people seemingly a world apart from the tragedy that tore them apart a month earlier. I love the people here. Their smiles and laid-back nature are infectious.

The walk across the street from the OR to the tents

The UN's frequent presence around town

A local banan stand at night

Carefree on a Friday night

Milot town

First week photos and experiences.

2010-02-26T17:10:00.001-05:00

Here are a few pics from the first week

We are all looking forward to Coq Au Vin...

the Tap-Tap, the main mode of transport in Haiti

The cases to get done today and Pierre, the hardest working man in Milot.

Our compound backyard.

OR room #2

2/25/2010

It is now my fourth day here and I think I’m starting to acclimate a bit. I’m sleeping through the dogs fighting and roosters crowing throughout the night much better. Our compound, however, now has a goat. He clearly did not appreciate the dogs and emitted some of the most horrendous noises I’ve heard come from an animal last night. He did seem to be alright this morning though.

Things continue to be quite busy here. Phillips Electronic donated a fluoroscopy unit for “real-time” X-rays in the OR. As a result we are able to see just how bad some of the patients’ fractures are. Our days now filled with revisions of patients’ original emergent repairs. It has been both a satisfying and frustrating experience. Satisfying in that we are able to give the people a better chance of functional recovery, but frustrating in that the procedures are taking 3-4 times longer than they would in the US. As a result there just aren’t enough workable hours to take care of everyone (and remain sane). Our hospital currently has the most advanced technology in all of Haiti even though it would not be considered remotely adequate in a Western country. As a result we have seen an influx of Port-Au-Prince residents helicoptered in daily for treatment.

All the patients coming through, it seems, have heart-wrenching stories to tell about the earthquake. Most have lost at least one, if not all of their family members. The majority do continue to be, for the most part, upbeat. Sadly, there is not much I can tell them other than “m’regret” ( “I’m sorry” in Haitian Creole) as my Kreyol is not so good. A nurse told me of a patient who was being flown back to Port-Au-Prince who started crying. She asked why and the patient replied she had absolutely nothing to go back to.

I am a bit apprehensive that once the media finds more interesting stories to move onto, they will cease coverage of the plight here in Haiti. As a result, the influx of third-party and foreign aid will diminish. This country is highly dependent on foreign aid for its survival and the support of its people. Without this aid, the continued rehabilitation of its earthquake victims and reconstruction of its largest city may all but disappear.

It is now 10 PM and having just transported our last patient of the day on an army stretcher, across the dirt road, in the rain, to his current home in Tent #5 where he will spend the night with 50 other patients, I’m going to pass out on my own cot. zzzzzzzzzzzzz

My First Day Experience Here

2010-02-25T18:57:00.002-05:00

This is a delayed post from my 1st day here.

2/23/10

We arrived yesterday afternoon into Cap Hatien. Our plane descended into a beautiful green landscape, quite mountainous and filled with sundry plots of farmland. From there we were taken into town by our Haitian porter, Delnatice, to try and find some electrical supplies for our hospital engineer.

While “OKap” was described in travel guides as a “sleepy, little town”, I found it anything but. People everywhere, on the move, in every direction. On bikes, scooters and on foot people were scurrying about with an urgency I would more likely associate with New York than Haiti. A volunteer explained it to me. “They are all living for today. Tomorrow is so uncertain that every day they do as much as they can everyday. It has become more pronounced since the earthquake”

We visited several hardware, contracting and electrical stores, but none of them had the basic supplies we needed. So up the mountain to Milot. It was a wild, bumpy ride on a dirt road, dodging potholes the size of Volkswagens. Finally we arrived at Sacre Coeur Hospital and it was pretty amazing.

The compound spanned over several blocks. A volunteer compound that had previously existed needed to be rapidly expanded to handle the sudden influx of volunteers. Tents had been constructed and the rooms which formerly held 1-2 volunteers now held four. Another anesthesiologist described the experience as “the most challenging camping trip I’ve ever been on”.

The hospital itself now spilled over into several military tents known as “tent city”. The sicker, acute patients stayed in the hospital building. The bulk of the patients however stayed in the tents. As we were walking to visit the operating rooms, there was a band playing. It sounded like a slow New Orleans jazz band. My colleague commented,

“ You know what that is, dont you? That’s a Haitian funeral procession. You’re gonna hear that a lot here...”

A Very Quick Post

2010-02-24T07:14:00.004-05:00

Wednesday 2/24/10

It has been pretty exhausting so far. Very hot (low 90s). The patients and some staff are staying in military style tents. The OR is working well into the night. There are so many cases to do. We have done mainly fracture revisions, debridements of infected wounds, and yesterday we took care of a guy with a chemical explosion in his face. Burned off his ear and half of his scalp and neck.

Apparently there was a story in the Wall St Journal yesterday about us. We were taking care of a baby Doe and they found her parents in Port Au Prince! There was a 4.5 Aftershock in Port Au Prince yesterday. Nobody will go in buildings because they are so frightened.

There is not time to be sad because it is so busy there is no time to reflect on it all. The people (Haitians) are so nice and appreciative. I woke up at midnight and the roosters were already crowing?!?! I thought they were morning birds?!?!

The Duke Anesthesia folks that are here are really great. I am learning a ton from them. One of them wrote the textbook on Regional Anesthesia. I'm going to miss them when they leave Saturday.

I will write a more detailed account if time allows.

Why Haiti?

2010-02-21T12:27:00.002-05:00

One of my main motivations for traveling to Haiti was to better understand the country and its people. The statistics on Haiti are absolutely mind-boggling for a country in the Western Hemisphere.

Haiti was "discovered" by Columbus in 1492. The native Taino tribe reportedly welcomed him initially with open arms, only to be completely annihilated by the Spanish over the next 2 decades. The western third of Hispanola was ceded to the French in 1697 at which point the country of "Haiti" was born. Haiti became the jewel in the crown of the French colonies. It was the most lucrative of the colonies thanks to the sugar and wood industries. Sadly, the French wealth depended upon the exploitation of slaves imported from West Africa. The conditions were deplorable, which eventually led to a massive slave revolt under the command of Toussaint L'Overture in 1804. The result was Haiti's independence and the formation of history's first black republic.

Over the past two centuries the people of Haiti have endured an endless succession of coups, dictatorships and military violence against its people. Reports of political corruption have been much publicized and Haiti has been historically vilified has being one of the most corrupt countries in the world. In 2006 Haiti finally democratically elected their own president and Parliament although their response to the recent earthquake has been much criticized by Haiti's people.

Haiti is only a few hundred miles from the United States but is truly a world apart.

Life expectancy in Haiti is 59 years which is among the lowest in the world surpassed only by countries in Sub-Saharan Africa.
The prevalence of HIV is 2.3% which ranks Haiti as 28th worst in the world.
nearly 20% of children will die before their 5th birthday
Its literacy rate is just over 50%
Its unemployment rate is 80%
80% of Haiti's people live in abject poverty
Haiti is now 97% deforested which severely has affected not only land fertility, but also has created a serious land erosion problem
Its GDP ranks 203rd out of 228 countries worldwide

   These factors have resulted in a complete lack of infrastructure in Haiti. Most people live without electricity or plumbing and survive by subsistence farming. Haiti has also been unfortunate enough to be situated right in the path of 4 major hurricanes since 2006 and also lies on a major fault line.

   Despite this, the Haitian people have been described as very kind, generally happy and as possessing an "optimistic fatalism" by Haitian Creole professor Bryant Freeman.

   Their characteristic response to adversity is "Si Dye Vle!" which roughly translates as "It is God's wish".

   This rugged-stoicism in the face of centuries of severe hardships made me want to assist the Haitians all the more!

Si Dye Vle!!

pictures courtesy of traveljournals.net
facts courtesy of the CIA factbook

All set to head off for Haiti!

2010-02-17T18:18:00.001-05:00

This weekend I will set off for the small town of Milot in the Northern mountains of Haiti to assist the organization CRUDEM with the medical support of thousands that have been affected by January's horrible earthquake.

CRUDEM has been in Milot since 1968 and serves the 225,000 people living in the Milot region of northern Haiti. The village of Milot itself has a population of about 25,000, and an additional 200,000 people live within a 12-mile radius. The area is made up of many small hamlets and rural communities, situated on rough terrain consisting of mountains and plains.

Sacre Coeur Hospital is one of the few hospitals in Haiti which was not damaged by the earthquake. As a result, they have grown from a maximum capacity of 73 beds to well over 300! There have been makeshift wards constructed in the adjacent missions and schools. The town is literally bursting at the seams with local townsfolk opening up their homes for families of the patients. I humbly hope there will be enough time and space to help all those in need...

( Images and data from the CRUDEM website. Be sure to visit at www.crudem.org)