Thank you to all of those that followed us this past month on the blog! This will be our last post of the 2018 trip, so please follow along with us next year. And if what we have written about this summer resonated with you, please consider donating to our trip. We always have unexpected costs to reconcile when we come home, and we start planning for the next year's trip the day we come back! Absolutely any amount helps.
A contribution from MS4 Beth Carpenter:
A summer thunderstorm is rolling in when Dr. Pettitt, MS4 Uday Betarbet, and I make our slow progress up the long, steep driveway from our house to that of Dr. Guy Theodore, the founder and father of Hospital Bienfaisance de Pignon. The road is heavily shaded by the Caribbean jacardanda trees and palms, and as we approach the house we begin to see Dr. Theodore’s beloved birds wandering around: chickens, turkeys, ducks with chicks, geese (who have taken a nip at more than one of us), and his gorgeous peacocks. When he’s nowhere to be found, we start the descent down thinking we misunderstood and we must be meeting him at the hospital—corrected when we see his early 2000’s land cruiser headed our way.
“Our meeting is not until 1pm, no?” he cheekily asks. It is 1pm on the dot. We all climb in and head to his house, where he seats us on a beautiful cantaloupe-colored veranda overlooking the trees on his property. We are rather humorously joined by at least five different kinds of birds, who clearly follow Dr. Theodore.
To meet Dr. Theodore is to meet the soul of Hospital Bienfaisance, a dream since eleven years old in the 1950s when he lost a close friend. There was no medical provider at all in Pignon to come take care of his friend who fell sick and soon after died, and Dr. Theodore promised himself that if he could become a doctor he would come back to Pignon to serve.
He did well in primary and secondary school with high expectations from his family, who raised him to believe that intelligence is a gift from God and one must give to their country.
He went to medical school and completed his internship in New Jersey and surgical residency in New York at Kings County Hospital, afterwards serving in the US Air Force for seven years starting in 1977.
Every year during his vacation time, Dr. Theodore would come back to Pignon to help in the Catholic and Baptist clinics. During this time, he created a leadership group to whom he presented in 1978 his vision for a hospital.
“When you get the acceptance from the community, that is the biggest thing,” he told us. Because while the majority of the money to build the hospital was sent by Dr. Theodore (for the most part earned by moonlighting as a surgical resident in Arkansas), the community banded together to assist. In 1978, only one truck a week made the journey through Pignon on the way from Hinche to Cap Haitien and thus a truck was unavailable to assist in construction.
The community of Pignon organized a rotation among the different schools of the town to haul sand, water, and rock from the mountain themselves. “It is their hospital—they have the sweat in it, the contribution in it. The hospital of Pignon is not like the common missionary hospital where outsiders came. They did the whole thing, and then others joined,” Dr. Theodore explained.
The hospital was completed in 1981, and Dr. Theodore sought out a partner in the United States. He founded the Christian Mission of Pignon in Arkansas, but a name change was soon in order.
“It was a commitment that you made at eleven years old, and--they said—a promise made is a promise kept,” Dr. Theodore recalls. The organization Promise for Haiti continues to be the main partner of the hospital to this day.
Dr. Theodore retired from the USAF as a full-bird colonel in 1983. He could not advance any further without giving up his Haitian nationality, which he refused to do. Instead, he returned home to Pignon. The structure was there, but now he needed to build a hospital.
“If I’m being honest with you—I’m a surgeon, not a hospital administrator. That’s the reality! So I came and I made something kind of like a hospital,” he joked. He recruited nurses and techs from around Haiti. International groups such as ours from Emory soon started coming to assist in 1983, with the first group from Arkansas. But Dr. Theodore understood that sustainability was at stake with these strategies.
“Just like in the States, when you’re in a small community like Pignon it is hard to retain! But I want a system which will sustain itself.” He created a scholarship for the poor, sending children of Pignon to primary and secondary school to become nurses and lab technicians and doctors. Without naming any names, he told us that many of the faces we see in the hospital every day were once children in his scholarship program.
His life’s work is recognized internationally. Pignon was the site of the first rural rotary club in Haiti, and as the president of the rotary club of Pignon and later Governor of the districts of the Caribbean, Dr. Theodore traveled throughout the region. He was chosen in 1999 as “Man of the Week” by ABC news in the United States. He was honored by the American College of Surgeons in 2000 with the Humanitarian Award, and shortly after by USAID as an international leader. He will be celebrated at his upcoming 50-year medical school reunion this year in New York City.
Throughout our meeting, Dr. Theodore fondly recalls the evolution of medicine over the span of his career, citing the birth of the nurse practitioner and physician assistant. He experienced the development of surgical operations commonly performed today, such as the carotid endarterectomy, and the dawn of surgical specialties such as head and neck surgery and pediatric surgery. “When people talk about novelty in medicine today, sometimes I laugh!” he chuckled.
His sense of humor entertains us for the entirety of the meeting. When asked if there is a video tape of his 1999 interview by ABC, he quips that the footage is better found on YouTube. When a rooster begins getting a little too feisty, he yells as him to be nice and eventually expels the rooster from his presence for being too loud.
He explains that the hospital requires over $40,000 a month to run, and Promise for Haiti contributes only about $10,000 a month—so where must the rest of the money come from to keep the lights on if we don’t ask patients to contribute what they can for their medical care? Many of his words carry an undertone of the ethical principle of justice, which describes fair distribution amongst the many. In a world where it feels like we characterize the success of a surgical trip like ours by the sheer number of operative cases and the complexity of the care we deliver, can we truly state that we are helping the region when our case load may place the hospital generator and/or available hospital resources at risk? And as we've discussed before, our most valuable surgery to offer in Haiti may be the humble hernia repair, which can give a patient back his or her chance to provide for their family.
Perhaps we can redefine our idea of a job well done not by the number of cases, but rather by the strength of the partnership we build with our host institution, which will hopefully translate into many more lives and livelihoods saved.
On the very first day of our first week of operating this summer, Dr. Sharma stated rather colorfully that he didn’t care how many cases we did this year because that wasn’t how he wanted us to characterize the success of our mission here.
“Many come, but few return,” he stated one morning as we walked to the hospital.
We look forward to be among those that return.
She is here for her first follow-up appointment to have her sutures cut and the JP drain pulled, which is often placed at the end of an operation to drain excess fluid from healing tissue. Pulling a drain after 10 days is no comfortable affair, as the body has begun to heal and form adhesions to the drain. These adhesions do not break painlessly. As I turn back to face the patient, she clutches my scrub top with her arthritic right hand and winces in anticipation of what is to come. Des, our faithful translator, speaks calming words to her in Creole as I tighten my grip on the drain.
“Okay, now pull it and don’t stop,” Dr. Pettitt commands. In one fell swoop I pull the drain and place gauze over the wound it left behind. The patient yelps and gives a retaliatory yank to my scrub top. She pants her breaths and whispers “Merci, merci,” relief showing as the pain passes by.
It is moments like this encounter with a patient and her daughter that have struck me most during my first time here in Haiti. The daughter was her mother’s primary caretaker and was present for every step of her care with us. She had brought her mother to us to help alleviate her suffering. The patient and her daughter placed faith in us - people who do not look like them, do not act like them, and do not speak the same language as them. They trusted us to cut her open. They trusted we would do our best. And they have trusted us to take care of her after surgery. We are foreigners to this country and this city and have been granted an incredible trust by the people of Pignon that we will do unto them as we would unto ourselves, our mothers, our fathers, our siblings, and our families.
This thought caused me to ask a series of questions to myself over the next few days - how would I feel if a group of foreigners came to my hometown of Toccoa, Georgia, and were performing surgery on my own mother? How would I want them to treat her? How would I want them to act towards us? Would I wonder what their intentions were?
Dr. Paul Parker, an old warhorse pediatric surgeon who has frequented this trip, explained it best when he told me, “We don’t get excited for hernia repair back in the States, but here these people’s livelihood depends on their ability to perform manual labor, rendering the hernia repair of utmost importance.”
Most importantly, I would want them to work humbly, treating my family and my hometown with respect and dignity. For this thought I must give due credit to Dr. Carla Haack, an Emory acute care surgeon with whom I got to operate this week.
At the beginning of each case, she would end the call to order by saying, “and we are here to care for this person with as much love, dignity, and respect as we would our own family.” If someone were to perform surgery on myself or my family, I would undoubtedly hope that the surgeon would refocus the OR on this objective before the case begins.
Admittedly, I had hoped to come to Pignon to find answers, such as how to care for patients in low-resource settings and how to be a better student of surgery. But I found that I have left with more questions than I have found answers. How can I serve these people best? What improvements can be made to the care we provide, as myself and my student colleagues begin to plan next year’s trip? And most importantly, how can we best do unto others as we would have done to ourselves?
One year ago, he underwent an Indiana pouch, which is an extremely complex operation in this environment. His postoperative course was rocky to say the least. He developed an ileus and needed an NG tube for decompression—try managing a nasogastric tube without any wall suction available! Despite his difficult recovery, he got better and charmed the entire surgical team while he was at it. At his discharge we were all wrapped around his little finger. When the word came that he had seen a local physician who told him his operation had failed and that he needed dialysis, hearts broke on all sides of the Caribbean. Arrangements were made to see him in Clinic as soon as possible. He and his mother made the long, long journey from the island of LaGonave to Pignon to generously share the news, in person, that he was thriving! He’s doing well in school, and his biggest complaint is that mom won’t let him play soccer. His workup indicates intact kidney function. Perhaps we can make a difference, one case at a time.
This brings me to considering the aspect beyond humans- the environment. We are spoiled by our hosts this year- 24 hour power, toilets that flush, bottled water. Bottled water, while an incredible convenience, creates an unimaginable amount of waste in greater than 90 degree heat. Haiti struggles to manage basic needs, recycling is not an option locally- plastic gets burned. Yep- burned. That’s it. Well, this year, I am personally carrying all the recyclables we consumed back to Atlanta with me- a small portion of the waste generated by humans in their day to day lives. A minuscule, perhaps insignificant, dent in the amount of waste we dump into our Mother Earth every day, but I refuse to add to the problem if it within my power to do otherwise. I come to be part of the solution, not the problem.
Some of today's photos from Week 3!
Introduction from MS4 Beth Carpenter and contribution from Gasser Joseph (nurse):
Today was another great day in and out of the operating room—we completed several pediatric and adult hernia repairs, a pediatric circumcision, and the removal of a chronic ulcerating skin lesion on a patient's leg that required a full thickness skin graft. All in a day’s work! We’ve also had some down-time at night over the past few days for evening serenades, Coke, and enjoying the view from our beautiful roof. (See bottom of post for some fun Week 3 photos of all three of these!)
The unsung heroes of our trip are our nurses. Venecia, one of the nurses from Week 2, was actually dubbed the “PACU angel” by the medical students because she helped us so much in the recovery room. Not only do our nurses heavily coach us along the way when it comes to pre-oping and post-oping our patients (vitals, consents, IV access), in addition to their involvement in the operating room, but many of our nurses are Haitian themselves and have an extremely valuable perspective that they bring to our trip and have the grace to share with us along the way.
Gasser Joseph is one of our Week 3 nurses and was kind enough to write some thoughts on what initially brought him back to Haiti on our medical trip as a nurse, as well as what motivates him to keep coming back.
Some additional Week 3 photos taken so far!
A contribution from MS4 Beth Carpenter:
It doesn’t happen every day, but every so often you have a day that is for lack of a better word, a joy. And our first day of Week 3 with general and pediatric surgery was just that. Just look at this adorable video of MS4 Corinne and one of her patients today who is post-op from an inguinal hernia repair…
Life can be tough as a medical student on the usual clerkships back at home. You meet and work with new people every day and just when you get comfortable (and maybe even helpful) on a service you inevitably have to switch to learn something new. And every role in the hospital has its own niche who seem to rarely interact with one another—the nurses are with nurses, attendings with attendings, residents with residents (+/- a tag-along student), and the scrub techs with scrub techs. Sometimes when the going gets tough with a late night or a difficult case, tensions can flare and relationships amongst different roles in the operating room and the wards can seem strained. Sometimes it doesn’t feel like you’re all on the same team.
This brings me to one of my favorite things about our annual trip to Haiti—we are hands-down a team here. And it’s amazing how eating dinner together and debriefing every night about our days, and actually getting to know one another and understanding where everyone is coming from can make the difference for a great day in the hospital!
Getting our patients to the operating room anywhere is a team sport, but it feels especially intimate in Haiti because you know everyone who played a role along the way. Our workflow goes a little like this: a medical student and one of our wonderful translators see a patient in clinic and perform a history and physical. We then staff the patient with resident or attending surgeons and anesthesiologists and coordinate with the local hospital OR staff and administration to get labs, medical clearance, logistics, and finances arranged. On the day of surgery, the medical student works on consenting the patient, gaining IV access, ensuring our Emory charting and local Haitian charting is in order, and helping the patient back to the operating room. Nurse circulators, scrub techs, medical students, and our anesthesiology and surgery teams all assist in pre-op and during the case! The patient is taken to the recovery room after the operation with monitoring by the medical students and nurses and either discharged same-day or admitted to the hospital for further care.
Every single one of these roles is equally important when it comes to taking care of our patients and getting them home and healthy. And I think the mantra “it takes a village” has real meaning in Haiti where I see every one of our teammates play a part in the above process.
Today I had the privilege of seeing the operation from an entirely new perspective—as a scrub tech! Running two rooms today (a pediatric surgery and general surgery room) with only one official scrub tech—the incomparable Saiying!—one of the M4s was needed to help in the general surgery room. (Heavily supervised and assisted by Dr. Haack and Saiying, I should mention.)
Learning to anticipate is a huge tenant of surgery, where as a first assistant you try to be one step ahead of the surgeon you’re operating with. When they pick up the needle driver to start suturing, you get your scissors ready. If there is blood obscuring the field, you get a lap sponge to clear it for better visualization. If they shift their retractor, you shift yours for appropriate counter-traction. Anticipating has an entirely different meaning as a scrub tech where you have to think fifty steps ahead of the surgeon and have an intimate understanding of the operation to have everything in the room before the surgery even begins! From orienting the table perfectly to protecting the sterile field (let's be honest, usually from the gangly med student) to handing instruments so that the surgeon doesn’t even have to look up to have it properly in his or her hand... the list goes on.
And a scrub tech’s job doesn’t even end at the completion of the case, because our scrub techs in Haiti are also responsible for the washing and sterilization of all of our instruments between cases! I have such respect for all of our scrub techs on our team in Haiti who make due with the limited supplies we bring when their job usually centers on having the perfect supplies for a case.
To all of our amazing scrub techs so far on the trip: Curtis, Donny, Lauren, Manny, Greg, Toni, Saiying, thank you for teaching me just a little bit each week about an essential part of surgery I wouldn’t learn anywhere else! As I found out today, your job is REALLY hard.
A contribution from Dr. Rajdev (general surgery resident), Dr. Sullivan (anesthesiologist), Dr. Srinivasan (general surgeon):
A few days ago, Greg, one of our wonderful scrub RNs very innocently leaned up against a wall in the pre-op area. Except it wasn’t just an ordinary wall…it was our OR schedule for the day. One minute it was there and the next minute it was gone, the shadows of its memory merely a smear on Greg’s back. The med students, who had meticulously drawn up the schedule the evening before, were momentarily crestfallen. But in what has become classic fashion, the students were on their feet in an instant, redrawing the board in their four-color dry erase markers (because of course this group of med students had four-color dry erase markers). That’s what this team of students does: they adapt.
It’s not just the students. Our scrub nurses have figured out how to build OR trays for anything from a simple circumcision to a vesicovaginal fistula repair. Our PACU nurses, who are really ICU nurses at home, have brought their keen eye for patient care to a post-op area with limited monitors—they are our monitors. Our anesthesia team has managed to deliver world-class care while teaching both our team of med students as well as the HBP team of CRNA students. Our attendings, well not enough can be said about how much they have taught us about flexibility. “No weitlaner retractors? No problem.” “No oxygen from the wall? That is actually fine—we’ll hand bag the patient for this four-hour operation.” Most of all, our patients are extremely adaptable. They recover in wards without running water, in close quarters with other patients who have also had major procedures (such as open prostatectomies with continuous bladder irrigations), with nurses who are obviously extremely adept at managing a very large patient census, but can’t be expected to focus on our patients as closely as we can. And, of course, they are always willing to patiently work through our language barrier.
Week two has drawn to a close, and with that comes time for our trip veterans, Dr. Sullivan and Dr. Srinivasan, to leave us with a few parting words:
Notes from the Ether – Part III, by Dr. Sullivan
At the end of every trip I tend to reflect on the week and the bigger picture of working in a resource poor environment. It can be challenging, and even heartbreaking, to encounter another human who is either suffering or dying and try to weigh the benefit of performing surgery with the risk of literally (and I mean that) bankrupting a family and using precious OR time that could help two to three other patients. We, as US citizens, take for granted that health care is available for even the poorest through EMTALA laws. Healthcare workers rarely consider the cost of tests we order or procedures we perform. As physicians, we see a problem and we start fixing it. It’s expected of us by the public as well as ourselves.
We are forced to consider more here. We CANNOT just rush in if we see an emergency or get pulled aside by and begged for help. At L’Hopital Bienfaisance there is a process set up whereby they expect every patient to participate financially. Unfortunately, they run on an extremely tight budget (they paid their staff for the first time this year in April), and their experience is patients will say they can’t pay anything when asked. They want all patients to be seen by a Haitian physician for clearance and an administrator to decide how much they will be charged, even if it’s a nominal fee. So when we, as first-world intruders, rush in “doing something” it can be harmful. There is definitely a maturity that goes with doing this trip year after year: you stop seeing their policies via the Emory lens. You start appreciating the wisdom of having expectations of your patients. You still grieve when an easy fix in Atlanta becomes a guaranteed death sentence, but you stop pointing fingers when you remember just the workup for the surgery would deplete the radiology department of their entire stock of Isovue.
This is probably the greatest lesson I have learned in my decade coming down to Haiti. There is a need to learn judgment without judging. It is a valuable skill to bring back to the States, for there are times when we CAN operate, but maybe we shouldn’t.
Reflections on a Week Gone By, by Dr. Srinivasan
I’m constantly surprised at how rapidly one week goes by, whether I’m in the States or in Haiti. My mother once told me when I was 19 that time flies more rapidly the older you get. I’ve marveled over time how spot on those words were back then (I shouldn’t have because my mother is among the wiser people I know).
In this case, a full year’s worth of preparation and work goes into trying to make our time down in Haiti great not just for the patients and Hopital Bienfaisance, but for our Emory group. There is a part of me that is always sad to see the youthful exuberance of the students get replaced with the furrowed brows of concern over their patients. It’s as if we’ve robbed them of that happy naiveté of youth. Rounding at night with them, however, I’m struck by how every patient mentions that they’d have never made it through the night had they not had our students watching their vitals, checking their IVs, making sure they were not in pain, and providing them emotional comfort. We get to give the students an in the trenches exposure that pulls out of them their greatest depths of humanism. In fact, to watch this every year repeatedly redeems me from becoming entrenched in the cynicism that plagues so many of us when having to confront the day-to-day reality of our jobs.
So tomorrow morning our week 2 group heads back to Port-Au-Prince, leaving behind our fourth year medical students who will remain the entire month. After an excursion to the beach, which we do as an annual wind down for our week, we will rendezvous with the week 3 group lead by Emory faculty Carla Haack (general surgery), Paul Parker (pediatric surgery), Mark Caridi-Scheible (anesthesiology), and Barb Pettitt (pediatric surgery) so we can pass the torch to the next group.
I call myself an optimistic pessimist. Those of you like me will understand precisely what I mean and understand when I say I’m already looking forward to what we will accomplish in the future. We thank our annual partners at Hopital Bienfaisance, without whom all these efforts would be dead in the water.
A contribution from Dr. Rajdev (general surgery resident) and Dr. Srinivasan (general surgeon):
Day 14 of the 2018 Haiti Trip—Week Two is just about halfway over, and the M4 trip leaders are also halfway done with their month-long undertaking. A few of the med students made this realization as they calmly spiked their morning coffee with a) more coffee, b) Miralax, and c) enough sugar to make any endocrinologist squirm. The day that followed was, as one of our trip leaders put it, “like plowing through a concrete wall”—we made progress, but it was S L O W. After several stops and starts in the morning, we got into a good groove with three (!) prostatectomies, a circumcision, and a hydrocele. Long day, you say? Well, Dear Reader, we still managed to finish up by 5PM! Lots of props and kudos to our Scrub RNs, PACU RNs, Anesthetists, and student runners who made it all happen.
Plowing through a concrete wall is an apt, if not distressing analogy for global work. Many questions arise: why is this concrete wall so thick? Should we be plowing through this concrete wall? Why was this concrete wall built in the first place? Is this a lode-bearing concrete wall? Bureaucracy is a difficult obstacle anywhere in the world, but perhaps most difficult in another country where we are merely guests.
One of the best people to speak to this challenge is Dr. Srinivasan. She works tirelessly to help iron out the small hiccups, to placate the right people, to make sure our trip is here to help, not disrupt. As students and residents, we are like thirsty kids drinking from a fire hydrant—our teachers are everyone, our lessons are everywhere. And certainly all the veterans of this trip—Greg, Mannie, Toni, Bernard, Venecia, Dr. Sullivan, Dr. Carney, and Dr. Srinivasan—are mentors to all of us. We’ll round out tonight’s post with a few words from Dr. Srinivasan:
The quiet details of this trip are always the challenge. There is nothing that is actually effortless, although I suppose we strive to make it seem that way. I vow every year that I do this that perhaps I can find a way to just be the ‘laid back’ week of the trip. For some reason that seems to never be the case. The truth is, it takes a lot of work to make this trip run. We spend the better part of a year working day in and out with the best medical students Emory has to offer trying to make things run without a hitch. One tends to take it a bit personally when the hiccups that naturally occur with the day-in and out occur.
Today was rough. I had to balance our group’s natural inclination to do everything possible to heroically intervene in cases that won’t otherwise be able to be addressed with the reality that if we do not respect the process of the hospital in which we work as guests, we will never be able to truly build lasting relationships that create long term change over short term wins. Over the years though, I’ve definitely learned a lot about my own deficiencies in this process. I’m not always the most patient person, nor am I always the most tolerant. I can get exasperated with the fact that everyone wants a piece of me to fix the problems that occur, but then simultaneously annoyed when someone breaks off independently to ‘create a problem I have to fix’. When we gather together at the end of the day, however, every night I am happily reminded when I look around the room that every single person on the trip is doing their utmost to do the most they can for every patient. That’s not a bad way to spend your day.
A contribution from Dr. Rajdev (general surgery resident) and Dr. Sullivan (anesthesiologist):
Tonight, we'll be focusing on our patients—that is, the reason we are here in the first place. To recap, last Friday, our team was involved with a patient who presented to the ER after a several hundred-pound tree branch hit him over the right side of his face and neck. He underwent an emergent tracheostomy with ligation of a branch of the external carotid artery. Since that time, his facial swelling has greatly improved, one of his drains (intraoral) has been removed, and his tracheostomy balloon has been comfortably deflated. This morning, we walked into his room and to find him sitting up, wide awake, ready to get on with life! Tomorrow’s a big day for our patient: we will be downsizing his trach and performing a swallow study (in the OR, for safety). We will keep you posted on his progress.
Yesterday, we performed a palliative mastectomy on an elderly patient with an exquisitely tender, firm breast mass with clear axillary lymphadenopathy. In the US, our treatment plan might look a little different: palliative surgery may come sometime after palliative radiation or chemotherapy. But symptom relief is our top priority here, so we performed a “toilet” mastectomy, excising gross disease for pain control and to prevent the development of a fungating mass that could become superinfected. Our patient has done well post-operatively, with good pain control and minimal output from her drain.
Our third patient is a young woman with chronic lower abdominal pain and dysfunctional uterine bleeding. She was actually a patient of the HBP’s OB/GYN, Dr. Etienne. He allowed us to assist him in the case in order to utilize laparoscopic methods of diagnosis and treatment. A preoperative ultrasound had revealed a large ovarian cyst, with what appeared to be “simple” fluid (foreshadowing…). We began the case laparoscopically, which takes some advanced planning down here in Haiti. Indeed, our eventual goal is to have enough in-country surgeons trained to use the laparoscopic equipment for diagnostic procedures in lieu of having a CT scanner or ready access to other cross-sectional imaging. Diagnostic laparoscopy is particularly well-suited for unclear pelvic pathology (think ovarian cysts, endometriosis, torsion) as well as for other abdominal pathology of unclear etiology (small bowel obstructions, mesenteric masses, etc). Our case today was particularly interesting: we started out with an open Hasson technique, placed two 5 mm ports in the LLQ as we might for a lap appy, and focused on our pathology of interest, which was a large ovarian cyst that engulfed all normal ovarian tissue. We tried to drain the cyst, which again appeared to be “simple” on ultrasound, but quickly found that it was filled with very viscous material and debris, including, wait for it, hair! Yes, it was a teratoma. After making this diagnosis, we converted to open, making a small Pfannenstiel incision to deliver and resect the right ovary. It was an interesting and unique case for every single one of us in the room.
We also continued last week's teaching sessions with a lecture on the Trauma Registry, a project pioneered by four prior Emory medical students (two of whom are current PGY2 residents). The session was both informative and engaging. Our in-country colleagues were able to draw on their experiences with last Friday's trauma to correlate the ABCs of ATLS to real-world action. See below for a great, short video of the Q&A session.
We'll round out tonight's post with another missive from Dr. Sullivan--
Notes from the Ether
Dear Lord! Don’t look at the pictures. Why didn’t anyone tell me I had gotten old? I mean, you come down here for 10 years with the same people and you’d think someone would at least recommend I put on something like lipstick, or mascara, or rouge. (Purposeful use of the word “rouge”)
If you insist on glancing at the pictures, I want to point out that this year the integration of daily teaching for med students and Haitian personnel has continued to grow. Dr. Srinivasan performed an abdominal ultrasound on a liver failure patient with Dr. Wagner, Internist. That was after we did a diagnostic laparoscopy to remove an ovarian teratoma- teeth, hair, and all. Gross, but satisfying.
One of my sneaky goals is to take all these great med students and make them Anesthesiology converts. My plan includes letting them all do spinals, intubations, and leaving to go to the bathroom at any time during the case--crowd pleasers in the medical community.
This is not a long diatribe, but who wants to listen to me wax rhapsodic when there’s cool pictures to look at?
A contribution from Dr. Rajdev (general surgery resident), Dr. Sullivan (anesthesiologist), Dr. Srinivasan (general surgeon):
“If you want to go fast, go alone. If you want to go far, go together.” – African Proverb
Collaboration is the name of the game down here in Pignon. The planning for this trip starts one full year in advance, beginning with a few attendings and a solid team of senior medical students. The team branches out from there, extending to PAs, OR nurses, ICU nurses, translators. But that’s just the Emory team--our other collaborators include Childspring International and the amazing team of nurses and doctors down here in Pignon.
One of the dilemmas we face we pursue global surgery is the fleeting nature of many of these efforts. Our intentions are good, but after the trip is over, we are often left wondering about whether our impact was a) lasting and b) positive. For the Emory Haiti Alliance, the move to Pignon has truly helped us sort through some of these ethical questions: Dr. Moise, the medical director of the hospital, has been in close contact with Dr. Srinivasan, Dr. Sharma, and the M4 Trip Leaders, collaborating on an lecture series for us to give while we are here. Dr. Roser (OMFS) was able to collaborate with a large group of Haitian dentists and oral surgeons to gather several patients waiting on repairs of old mandible fractures, and was also able to hold a symposium on his last day here. We have also remained in touch with Dr. Painson, a general surgeon who operates here for a week every month, to collaborate on patients he has evaluated and would like us to work up for laparoscopic cholecystectomies. All in all, the team at HBP has been incredibly gracious and welcoming towards us, and we have been working to build a strong, collaborative, cohesive relationship.
In the spirit of collaboration, tonight’s blog will be a joint effort featuring two of our faculty trip leaders, Dr. Cinnamon Sullivan and Dr. Jahnavi Srinivasan.
Notes from the Ether, by Dr. Sullivan
Every year I come down to Haiti with the Emory group I expect for somethings to have improved and some to have worsened. What a pleasant surprise to have nothing but improvements so far. Not only do I have two excited, smart anesthetists - Jason Birn, A.A. and Ann Wobler, A.A., the roads between Hinche and Pignon are better, thereʼs an ultrasound available, the food is still good, and our Haiti partners are truly cooperative.
While my work crush, Dr. Painson, isnʼt here this week I did reconnect with Dr. Jean-Charles. She graduated from anesthesia residency and as an attending has brought two anesthetist students, Jennifer and Zina, for us to teach. They handed me a list of topics and we have already started working our way through them. They stand with Jason and Ann during cases which allows our people to become educators.
Speaking of learning new skills, Ann Wobler, A.A. did her first spinal today and it worked beautifully for the inguinal hernia repair. Sheʼs a natural. Meanwhile Jason tapped into his inner pediatric anesthetist, taking care of an eight-year-old having surgery under a spinal block. With a little propofol/ketamine sedation, anything is possible.
Pignon in Perspective, by Dr. Srinivasan
I don’t do social media. I don’t blog. I generally shy away from providing evidence on the internet of my day-to day going ons. As I figure it, people who need to know, well they know. I make this point first to set expectations that this may not be nearly as witty or entrancing as we’ve seen on this site already, but mostly to make the point that it takes a big deal for me to put this out there. But Haiti is a big deal.
The first time I ever did global surgical work was when I first came to Haiti in 2010, about six months after the earthquake that would devastate the country for years to come. We came to the most under-resourced part of a country that in and of itself is under-resourced. Our goal was a continuation of an effort started two years earlier by two of my colleagues at Emory- teaching simple prostatectomies to local surgeons so that men forced to live their lives with the discomfort of indwelling catheters from prostatic hypertrophy could resume life without. I was to lend support for any general surgical needs. We brought with us, in addition to the urologist and anesthesiologist, several native Haitians who worked as ICU and scrub techs in Atlanta.
My appreciation for the country and for the work was instantaneous. Most people who do global health work will tell you that superficially, there is an inherent romantic appeal to such efforts, but those who really dig in have their hearts stomped upon repeatedly. Initially, this felt true. Many individuals, particularly the grateful and wonderful patients, warmly embraced our team. But over the course of the next few years, as we tried to build a sustainable relationship, we seemed to find a sense of irritation at our presence from the local hospital staff. It was as if we were viewed as an invasive force that came to self-aggrandize and self-congratulate, but never truly integrate. After years of fundraising, countless numbers of lives impacted positively via surgical cures, and numerous students taught, our crew of anesthesiologists, urologists, general surgeons, and nurses seemed to ask the same question every year. “Are we making any long term impact, and if not, are we doing the right thing for Haiti?”
Every year we’d come back from our trip in July, take 3 weeks off, and return to fundraising in August to make the money to cover all our surgical supplies, personnel transport, and in country housing of our crew of medical professionals. This group of people was, and is, bonded by a common inclination toward humanism for those most in need. I could look at each of these individuals and see the best our species has to offer, but still come away empty with the thought that maybe we were acting more as invaders than colleagues.
Our one-month trip changed dramatically when we coupled with Hopital Bienfaisance in Pignon. The leadership of the hospital, in the person of Guy Theodore and Evelyn Moise, are dedicated to deliberate integration of teams of physicians from abroad with their hospital personnel. Their work with us feeds their long-term goal of providing infrastructure expansion to the hospital and education to employees who will remain in Haiti to take care of patients year round.
So now I find myself back in Haiti again for the eleventh time, at the end of a good day’s worth of work on the second week of the second year of our trip to Bienfaisance. Now, however, I know we work with people and not around them. Our week has planned ahead, outside of numerous more cases, an educational session on surgical nutrition, postoperative care and a laparoscopy referesher. We also are set to integrate a trauma registry we have already piloted at four other hospitals in Haiti in Pignon so we can continue to collect data on how to best improve the survival of trauma patients seen in ERs based on regional needs.
I’m happy to watch my baller anesthesia colleague Cinnamon Sullivan teach every Haitian student or anesthesia professional in her midst how to start the process of care with IV placement under ultrasound to spinal anesthesia with conscious sedation for hernias and urologic procedures. I’m amused to watch the nurses and techs who come with us every year kid one another like they are siblings while they embrace the local hospital staff in their antics spreading their humor and affection. I’m appreciative to watch my urology colleague Jeff Carney spread his passion for urologic care to the medical students without whom we could not run this trip. I’m gratified to watch my senior surgery resident Priya Rajdev no longer require my help in the OR and take the place of me in teaching those junior to her.
It’s obviously still hard work, and there’s a decent chance you’ve skipped through my laborious prose and determined that there it was a gift to humanity that I refrained from blogging. If I’ve managed to drag you to this point, thanks for your forbearance. I hope my ramblings give you some sense of our decade long effort to find a home in Haiti we believe gives the country as much as Haiti has given to us.
A contribution from Dr. Rajdev (general surgery resident):
Have you ever traveled to a different country and thought to yourself, man, I wish my twelve best friends could see all the amazing things I’m seeing? Well for the Week 2 Gang, our wishes have come true.
Say hello to Toni, Bernard, Greg, Mannie, Venecia, Bonnie, Amit, Jason, Ann, Priya, Dr. Carney, Dr. Sullivan, and Dr. Srinivasan. We’re joining the M4 ground crew (Stef, Corinne, Beth, Danielle, Lindsey, and Uday) and our stellar translators, Des and Edjour. We started our trip two days ago, so we’ll get you up to speed on our journey to home base in Pignon.
We started out just like the week one crew did in Port Au Prince. Flying into PAP is always an interesting experience—three hours of flying south into the heart of the Caribbean when all of a sudden, the turbulence starts, the clouds part, the Haitian coastline grabs you and boom, you’re there.
We met up with the Week 1 crew at the Marriot hotel to get the low-down on hospital logistics and to get the scoop on the cases the team was able to do. All told, with the help of Dr. Painson and Dr. Jean Charles (our Haitian surgical and anesthesia colleagues), the group was able to do 25 cases, the majority of which were inguinal hernia repairs and mandible plating. Just after the last case was complete on Friday, a facial/neck trauma arrived. See our last blog post for details—we’ll keep you all posted on our patient’s progress as we work towards getting him back to normal life.
On Sunday, we loaded up our vans and drove into the heart of the country towards Pignon. The ground crew seemed excited to see some new faces arrive at the house. It’s unclear if this excitement was genuine or if they’re slowly going mad with cabin fever. Regardless, we high-tailed it over to the hospital to replenish our supplies. As you’ll see from these pictures, Dr. Sullivan was a very agile monkey-in-the-middle. In spite of best her efforts to thwart them, the students got the supplies stocked up and ready to go for the week. This is the most orderly supply room we’ve seen to date—three cheers for shoe organizers!
After a quick rooftop workout session, the afternoon continued with a quick tour of the hospital and some PM rounds on some patients we are getting ready for surgery this week. We joined up with our Haitian colleagues, who include Dr. Mondestine (General Surgery), Dr. Jean Charles (Anesthesiology, pictured), and a group of CRNA students, and assessed several patients for prostatectomies and inguinal hernia repairs.
A substantial amount of our learning experience at Hopital Bienfesance for the past two years has been about understanding hospital and operating room processes. Indeed, we want our trip to add benefit without disrupting the flow of the hospital as it exists. In a future blog post, we will delve into the interesting history of the hospital that has so generously invited us to be here. But for now, suffice it to say that our stellar M4s have built on all their experiences and work here from over the past two years to keep us efficient and keep our inconveniences to a minimum. Just take a look at the OR board and patient work-up process:
Nothing tastes better than an ice-cold Coke at the end of the day, and no, we’re not just saying that because we’re Emory-bred (ok maybe we are *a little*—thank you, Whitehead family!). The team gathered for dinner, some brief introductions, and a high-yield teaching session with Dr. Carney in preparation for a cryptorchidism case on the schedule for Monday. As the night wound down, the unmistakable aroma of an approaching storm wafted through screen doors, filling up the house. And at last, we went to bed, listening to the pitter patter of raindrops as land on the sturdy leaves of the mango trees outside the dorm, dreaming of a productive week to come.
Stuart Hurst and Dr. Painson shaking hands at the end of the case, quickly joined by Dr. Sharma and Dr. Lynde.
Our team formally debriefed when we got home, led by Dr. Lynde.
A contribution from MS4 Beth Carpenter:
It's been a very busy week with over 25 cases (not counting my own splinterectomy by Dr. Roser). We promise we'll post the rest about our week later today or tomorrow, but in the meantime here are a few photos!
Teaching rounds with Dr. Roser (oral and maxillofacial surgery attending).
Danielle (MS4) closing after a epidermoid inclusion cyst excision with Corinne (MS4) at the head of the bed helping deliver anesthesia!
Stuart (general surgery chief resident) and Danielle (MS4) finishing up an inguinal hernia repair (closely supervised by Dr. Sharma, general surgery attending).
A completely candid photo of Stuart, Dr. Lynde (anesthesiology attending), and Dr. Sharma.
Curtis (scrub tech) being Curtis... He may or may not have yelled at me to bring him more suture prior to this photo being taken.
Jason (nurse) and some of the local Haitian OR staff, including one of our favorite head nurses Ms. Eveline, in between cases. (This may be the only photo I could ever snap of Jason....)
MS4 Stef and Stuart operating on a woman with a ventral hernia.
MS4 Lindsey helping Brian (OMFS chief resident) repair a mandible fracture. Dr. Roser watching in the background.
MS4 Corinne, Dr. Lynde, and the scrub cap of Adam (anesthesiology resident) delivering anesthesia during a general surgery case.
From left, Curtis, Dr. Sharma, Stuart, Louis (nurse), and Uday (MS4) after a fistulotomy and sphincterotomy.
A well-deserved break on Friday at 3pm to get to lunch which was ready at 11:30am.
A contribution from MS3 Ehab Nazzal and MS3 Kareem Al-Mulki:
For everyone reading this blog, this is the first blog post of the 2018 Haiti Trip from the M3's. For the OMFS week (06/02-06/10), the M3's are Ehab Nazzal and Kareem Al-Mulki. We're incredibly excited to be on the ground, and can't wait to see how we can help!
We arrived in Port Au Prince Saturday afternoon and went straight to the hotel to get some sleep. Sunday morning, we started our four-hour drive to Pignon, where we would be working at L'Hopital Bienfaisance de Pignon. We drove along the Haitian countryside, up the mountains, and were able to see many different cities along the way. Throughout our trip, we talked with Louis, a Grady nurse who was coming along for his sixth trip with Emory to Haiti! As a Haitian, he was able to give his personal experience about growing up in Haiti, and also talk about the positive impact that our team has had the past few years. Hearing that people were traveling hours to receive care from our team gave this trip a new meaning to us, and helped to put our trip into perspective.
Upon arrival to Pignon, we drove to a compound that was owned by one of the doctors that works in Pignon. We were greeted by Dr. Sharma, Dr. Lynde, Dr. Roser, and the M4's. Kareem and I are roommates, and our first plan of attack was to set up our mosquito nets, which was no easy task! After that, we were able to get a tour of the compound and see where we would be staying for the next week. Kareem and I took our medical supply bags to the hospital, which allowed us to walk through the city. The walk was only five minutes, but in that short time, we had many people come up and greet us, which was a refreshing thing that we don’t usually see in the states. My personal favorite part was how many animals were walking around the town. Dogs, peacocks, roosters, and goats all live together, and we saw them at every corner in the city.
The hospital sits between a hotel and a few small houses. It was established by Dr. Guy Theodore, an American-trained Haitian physician. There are two separate buildings, and each one has two floors. In one building, you have the clinic and the Emergency room on the bottom floor. The top floor has a few bedrooms for guests of the hospital, one of them being the place we would be staying for night call (I’m sure you’ll hear more about that later). In the other building, you have the main patient care area. The bottom floor is the wards, with rooms separated by curtains, and also a center for labs and radiographic imaging. The upstairs area has a conference room where we eat lunch, but also has about fifteen rooms private rooms for patients. Next to those rooms is the surgical site of the hospital. There’s a small pre-op area, a post-op area, and two OR’s. After visiting these areas, we concluded our tour of the hospital by talking with some of the patients in the courtyard, and then heading home.
Our first couple of days in Haiti have been an adjustment for sure. We won’t be having the luxuries that many of us are used to back home (so if we’re not responding to your texts, it’s not because we don’t love you, it’s just because we don’t have WiFi or cell service!). But, I think I can speak for Kareem and everyone else on the trip when I say that we feel blessed to be here, and are excited to be present and helping, while also learning about the culture and the people of Haiti. Stay tuned for more, and enjoy the pictures!