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!
Hi all! Our fourth year medical students (including me!) will be the first group departing for the 2018 trip on May 30, 2018.
In the meantime, please visit our old blog at https://emoryhaitialliance.wordpress.com/ to hear about our 2017 trip!