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Monday, March 29, 2010

Ashley Hurt's update from Haiti

Dr. Joel Hurt and his wife Ashley, champions of the Austin Medical Relief for Haiti efforts, are leaving PAP today to return to Austin. Here's an update from Ashley:

We are so sad that we are leaving today. It has been a full three days and flown by so fast. Life here is different and wonderful. Church was amazing! The singing is beautiful and the Haitian people really get into the music. Yesterday we oriented the team to the clinic and did a major overhaul on supplies. Trying to get organized and situated. There are A TON of supplies. A blessing and a curse. There is a cirus tent full of supplies that are spilling out of. The school house still has tons of supplies in it, a huge hoop barn that was set up for supplies is now half way full and we have central supply room in the clinic stocked with supplies. It is a daunting task and we will now staff people on our weekly teams just to be a head of it and master it. Supplies are expiring and now unable to use simply because we don't know what we have. What a waste.

AC and water pressure are two things I miss. Our shower drips and is often filled with cockroaches at night...ugh, gross. I kill them and then do an icky dance before I'm able to pick them up and flush them. Last night I was greeted by a mouse when I entered the room. EEK was truly my response. I couldn't see a hole in the wall so I'm pretty sure he slept in our mattress with us.

The sun rises at 5 am daily. By 530 it is bright! Sets around 630. This is pretty much unchanged year round. We went into a local city near MOH for lunch yesterday. It was good Haitian food and they people were lovely.

Yesterday we changed Job's dressing and found his skin graft on his orbit to be necrotic so we removed it. Poor guy has two skin graft sites on his thighs with nothing to so for it. This is the second failed graft. We decided to sedate him to do the procedure which was much easier on everyone. He left this morning for Dell in Austin. Smider the baby with hydrocephalus was on the same flight. We put a lock, IV, in Job yesterday so we could give him a sedative for the flight. I went down at 645 to check it. It's patent and working. His "mommy" was bathing him and getting him dressed in his church clothes. He looked so handsome and was so proud. He's never worn anything like this before. He had slacks and a long sleeve yellow shirt with shiney black shoes that were probably 2 sizes too big. He jumped down and did a little dance for us in his new shoes. All the kids from the orphanage came by to see him off. We took a picture. Please pray for his flight home. Two amazing men, middle aged, no medical training, will be flying with Job and Smider to Austin. They tried to get Joel and I on their flight but it was full. The mommies are so sad to see their babies go and asked to bring them new babies to care for. They loved Job and Smider but understand this is the best for them.

Sunday, March 28, 2010

3/28/10 - Team 10 is on the ground!

Team 10 is on the ground at MOH today!
Tom Jackson, MD - emergency physician - Austin
Ann Soo, MD - internal medicine, retired - Austin
Sara Khanzadeh, PT - wound care - Austin
Rosie Wustrack, MD - orthopedic surgery 4th yr resident - San Francisco

Joined by Mercy Ships team of nurses - Melody Phelps, Mary Cade, Denise Piper, and Judy Teague, paramedic Bonnie DiSalvo, physical therapist Helen Day (UK-week 2!).

This is Dr. Nathalie Fiset's (Canada) last week at MOH.

Bob Kertcher, paramedic with Halton Medics in Canada will join the team Tuesday.

Lastly, this weekend marks the first rotational weekend of our leadership physicians. Dr. Hurt and Ashley Hurt arrived at MOH this past Friday to assess current needs and help form the ongoing strategy for medical services at MOH. They will return to Austin tomorrow.

Monday, March 22, 2010

We Live in Good Times

Post provided by Barbara Bergin, MD

It’s really amazing to see all the external fixators being used in Haiti. That surgical procedure has revolutionized the treatment of open fractures (broken bones which have penetrated through the skin or have had something penetrate the skin to contaminate them).
I can remember in my residency (early 1980s) we were treating open fractures in traction or with casts. We would cut big holes in the casts so we could have access to the wounds in order to clean them. We had to fashion little doors out of the cast material so we could get to them a couple of times a day. The little “doors” were needed because if you just left a hole in the cast, the injured skin and muscle would swell up into the hole, like rising bread, and then you’d have a bigger mess on your hands.

I can tell you that there were a lot less open fractures back then. We just didn’t see the number of high energy trauma cases we see now; motorcycles and high speed car accidents were not as common. We also did a lot more amputations! Without external fixators, we just couldn’t take care of the wounds like we can now! External fixators were in the making though. Orthopods are tinkerers and we would put big pencil-sized pins through the bones above and below the break and then hold them apart by making outriggers of twisted plaster over wire, or whatever interesting polymer we could find around the operating room or the mechanical room in the basement of the hospital.

While I did my rotations at the Veteran’s Administration hospital, I saw many veterans of WWII with chronically infected wounds they received while fighting in the European and Pacific fronts. Sometimes, instead of having amputations, they would opt to keep their legs, but the exposed bone would have become infected. If the bone healed, despite the infection (most of the time infected bones won’t heal) then they would just spend the rest of their lives with pus draining out of their leg. They would walk around with big dressings covering the hole in their leg in order to absorb all the liquid that poured out! It was really quite incredible. Our veterans were in their 60s then! Imagine young men suffering those wounds in their 20s and living with them that long. They would keep that leg along with all its problems, rather than have an amputation.
Then to add insult to injury, chronically infected wounds are susceptible to getting a form of skin cancer, so we always had to check them for that. By the 80s, those veterans had been walking around with their wounds for about 40 years!

Now just because we can put external fixators on the unfortunate folks in Haiti, it doesn’t mean they’re all going to get to keep their legs. Nor does it guarantee them to be free of the potential for infection, but it sure gives them a better chance than if we weren’t using them. We do live in good times.

3/21/10 - Team 9, Day 1

Update from Sheryl Lucier, PA:

Good evening from Team 9 MOH Haiti. We arrived late today, after getting in to San Juan at 3am!! But we were so glad to be at the mission. Lindsey gave us the tour of the compound at 3pm, so we are hoping for a good night sleep so we are ready for a busy clinic tomorrow. There seem to be an abundance of supplies….but a lot of organizing, inventorying needs to be done. There is no formulary, so we will just have to ask tomorrow to see what is available. There is a very small group here this week compared to past weeks…but more will arrive during the week.

The city of POP is much less congested as compared to before the earthquake, due to so many deaths, and people leaving the city to live in tents because they lost their homes or they are afraid to be inside them, or because that is where the food comes.

On Sunday afternoon the children from Hope House come to the guest compound to play ….so there are many children around tonight.

Sunday, March 21, 2010

3/21/10 - Team 9 is on the ground!

Team 9 marks a transition in Mission of Hope post-earthquake medical care. Going forward, our operative weeks will occur once per month, followed by a week of recovery for inpatient care and finishing the month with a focus on primary care and community health.

Team 9 volunteers arriving in Haiti include:
ER physician: Ashley Kumar, MD (Austin-Dell Children's)
Physician Assistant: Sheryl Lucier, PA (Georgetown-Dermatology)
Ann Parsons, RN (San Antonio-Home health)
Dawn Hallock, RN (Virginia-ER nurse)
Helen Day, PT (UK-coming with Mercy Ships)
Nicky Chovaz, paramedic (Canada-Halton Medics)
Dave Ryckman, paramedic (Canada-Halton Medics)

They are joined by Team 8 team members who are staying on at Mission of Hope for another week:
Nathalie Fiset, MD (Canada)
Bridget Russell, RN (Austin-St. David's NICU)

Friday, March 19, 2010

Refuge in the Haiti Hills

Poem by Maggie El-estwani, RN:

Early morning solitude in the hills -
earth browns, ochre reds, limestone white
and dotted with dusty shrub and grasses.

Cradling coffee mugs and
sitting in companionable silence and low voices at breakfast.
Some in prayer and meditative reading.

The bright sun rises over the hills.
The wind blows mimosa branches briskly
in the stone courtyard.

Through the quarter-open gate,
wilderness and a glimpse of the city and sea,
and our EMS ride Haiti One.

And I remember why we've come,
this Lent to join a mission of hope
to Haiti after the quake.

Intertwined white and fuchsia bougainvillea
are splayed over the simple wrought iron fence,
backdrop to aid worker tents.

Later in the morning the children will fly kites
and mount wild ponies
to scramble on the rocky paths;
And at the ward and clinic,
the women will break into song.

The hills join in chorus -
gather your strength, your inner joy and deep faith.
Morning breaks again.

-Tintayen, Haiti
March 2010

Thursday, March 18, 2010

Just How Do You Fix a Broken Bone?

Post provided by Scott Smith, MD

Orthopedic surgeons treat many types of problems with the human body. One of the most common is a fracture commonly known as a broken bone. In Haiti or any where else for that matter; when a rock house falls on a leg, bones are going to break. A large part of the work done by physicians in Haiti has been "fixing " these fractures. Well just how do you "fix" a fracture?

Bones have an inherent capacity to heal. Typically this occurs more predictably and faster if the fractures are stabilized or held still. The most effective pain relief for a broken bone is to prevent it from moving. There are many ways to do this. We all know about a cast. This is some sort of rigid material (plaster or fiberglass) wrapped around the arm or leg to provide the support needed. This works great for hand and foot or ankle fractures but not so great for thigh or arm fractures. Also if a bone is displaced or aligned incorrectly then it must be reduced or replaced and held there. Casts can't always do this. If the bone has broken through the skin, or if there is skin damage then a cast is less then ideal as it does not allow access to clean and care for the wound.

At this point frequently an external frame is assembled and used to stabilize the bones. Essentially the external fixation entails using large (5 milimeter) pins or screws and drilling them into the bone above and below the fracture. Then attaching a metal bar external or outside the skin to the pins. This frame acts as a new skeleton to stabilize the broken parts. It also allows the skin wounds to be cleaned and dressed without destabilizing the fracture. Another advantage is that no further "damage" is done to the soft tissues by actually cutting around the fractures to expose the bone for the placement of plates and screws directly on the bone also known as internal fixation. The advantage of internal fixation is the bones can be precisely aligned but open incisions must be made to do so. This is sometimes not advisable due to the risk of infection and problems with open wounds.

Another older technique is traction. Just like it sounds, traction is a method of fracture stabilization where a pin is placed through a bone and a weight is hung from the pin to provide a pull on the bone holding it "still". This is a rarely used technique in modern medicine, but still has its place in some injuries.

In Haiti, due to the type of injuries (crush) and difficult living conditions (high infection risk) many fractures were treated with external fixation. These frames will probably stay on for >3 months and then be removed. Hopefully with most of the fractures healed. If they have not healed, reconstructive surgery with bone grafting will be necessary.

Each fracture has its own personality. Each orthopedic surgeon has their own "style" or preference for fracture management. There is always more than one way to get the job done . God has designed a pretty good system for healing injuries so usually function can be restored by these techniques.
Picture: Drs. Hurt, Le, Smith and Joseph putting on an external fixator

3/14/10 - Team 8, Day 1 & Day 2

Update from Nathalie Fiset, MD:

Like it is so often the case, before I leave for a medical mission, all my patients wanted to have their babies before I got on my plane. As a result, I ended-up doing a full day of appointments and delivering 3 babies (the last one at 7:10 a.m. as I said I needed to leave at 7:00 for the airport) and have not slept at all. I am happy though that I got to be present for all my patients and I actually was able to change my seat and get a window on the plane so I will sleep.
At the airport, the clerk was nice enough not to mention anything nor overcharge me for my very heavy suitcases. Before landing in Haiti, I am inhabited by a sense of sadness by seeing all the devastation. Usually when you approach a city, you see the swimming pools from the air. Here what is apparent are the numerous blue tents next to most houses that are down in dust.

At the airport, there is no customs formality whatsoever and immigration asks nobody questions. Then, the chaos starts: there are no carrousel for the luggage so a few bellboys are doing their best to find the screaming crowd’s suitcases and boxes. The luggage also comes very slowly and is often broken or dirty. It gets even worst when we get outside as there is a screaming crowd and we have to work our way outside because the truck is stuck two streets away. I hold on tightly to my guides.

After getting in the truck, we basically are stuck in traffic as there are no roads and no traffic lights. We finally get moving after an hour and get on a dirt road. We pass in front of hills that smell very bad. I am told this is the burial ground for the people who perished in the earthquake. My guide tells me that more than 200 000 people died. I am overwhelmed by a sense of loss this nation has suffered. I set up my little tent and try to go to sleep but it is very hot and damp and my sleep is light.

Today I am scheduled to do consultation at the local clinic. The pace is very slow and after two hours, I still have not seen any patient. I am learning to take it easy. I see a teenager who is dehydrated, has a high fever and pneumonia. I am surprised to see that this clinic is so well equipped. They even have an ultrasound machine and labs. I am happy to see that most people understand my French and that I can guess Creole and communicate with people. My highlight of the day is when we had extra time and played with the cutest twins.

As we ask people how the earthquake affected them, some children mention that they are now afraid to be inside and would rather sleep in a tent as they saw buildings collapse and kill their friends and loved ones during the earthquake. This morning, one of the team affiliates brought his son Matthew, a Haitian little baby boy that he rescued from an orphanage a couple of months ago in a near death condition. He also mentioned that sadly, many of the clothing, food and toys donated to orphanages are either stolen or sold. People have to be very careful who they donate to and make sure that their donations make it to the ones who need it. After taking a nice shower I realize that all my make-up and my deodorant have completely melted. What do you know, it was hot today!

Update from Tammy:
The OR has not been too busy. Monday we did a 2 month old ankle fracture and an I&D of elbow and a wound change on Job. Tuesday no surgeries but myself and Joe, a cath lab nurse from California, spent the day cleaning, organizing and sterilizing. Basically seeing what there is to work with! Really pretty good. I hope we are making it better and easier for the next team coming in. Today we did 5 cases. 2 external fixator adjustments and 2 ex fix removals. 1 I&D. Have an early morning planned , a 7:00 am ankle fracture also an old injury. As before, I am totally impressed and in love with the people here. Their faith and spirit keep everyone happy to be here and really give everyone perspective. I feel blessed by being here.
Picture: Waiting to be seen at the MOH clinic

Monday, March 15, 2010

3/14/2010 - Team 8 is on the ground!

Team 8 members from Austin include:
Matt Roberts, MD, Capital Anesthesia
Nick Nunez, MD, emergency medicine
Doris Robitaille, MD, family practice
Jennifer Allen, PT, wound care, Seton
Tammy Noel, RN, Texas Orthopedics
Bridget Russell, RN, St. David's
Tomorrow Laureano, RN

Joined by other team members from N. America:
Orthopedic surgeon from New Hampshire and his daughter: Brad White, MD and Margo White

A team from The Grove Community Church in Riverside, CA:
Michael Lance, PA
Jackie Bowier, PA
Joe Giron, RN
Vickie Schlone, RN
Dan Lamy, EMT
Chris Galletta, paramedic
Pastor Mike Barnes

Canadian team members:
Nathalie Fiset, MD
Agnes Hyma, RN

Cheryl Hoover, RN with the Indiana Purdue team

Week 2 for Hannah Warren from the UK with Mercy Ships!

3/12/10 - Team 7, Day 6

Our brief visit draws to a close. Most of us just landed in Miami, tired, excited, our heads spinning. A handful of our nurses (Hannah, Sally, Agnes, and Lyn) are staying for a second week, so they will mind the patients in the ward today and through the night. Along with Brad, Grant, Lindsey, Dr. Cheryl and the rest of our new-found Haitian and Mission of Hope friends, a smooth and coordinated hand off of our patients to team 8 is assured. At least we won't fear for the well-being of that group of patients. They are in good hands at the Mission and will get the care they need. In fact, Dr. Glenn just told me that he gave report by phone on all the recovering cases to the oncoming Orthopedic Surgeon.

For our last full day on Friday, as with Thursday, the sun peeked over the hills across a nearly cloudless sky, and by 9 or 10 the heat was building. We had to remind ourselves to drink lots and lots of fluids, and even then, it was hard to keep up. The Team worked hard, with several very ill patients early in the day that made us a little slower than normal treating the more routine people. We had to transfer a young feverish man to a hospital over an hour away. He was most likely suffering from cerebral malaria. Another woman we sent to the local Obstetrics clinic. She was nearly due, had minimal, if any, prenatal care, and was having contractions. We were worried about her being in premature labor, complicated by severe anemia. We needed a bed for another elderly lady with congestive heart failure, whose lungs we're half full of fluid from chronic untreated hypertension, but she wasn't too uncomfortable sitting up in a chair, so that is where she stayed for treatment. We parked her next the bathroom after a large dose of diuretics. Thankfully, several visiting nurses from Wisconsin arrived and offered to help (I have no idea who they were but I do know they dropped in at just the right time, proverbial manna from heaven). One was kind enough to provide one-on-one care for several hours as the lady very slowly improved. Yesterday was our busiest OR day yet, and we ended the busiest operative week to date for the Mission. As a testament to the maturing capabilities at the Mission, most of the work is being referred from other hospitals in the surrounding area, including the University of Miami tent hospital in Port au Prince. Accordingly, the wards were filled with patients their families, translators, many of whom were operated on earlier in the week. One of our nurses, nurse Julie, gave her tent to one family to go away with. At least then they would have a home to take 'home' as they left, a shelter in which to care for their special needs child.

When Team 8 arrives, the members of the their team will need to look over as much of their work and supply areas as possible to quickly get an idea of what they have and where things are. When the doors open Monday morning, things will ramp up quickly! We are excited for them, for we know they will continue to provide much needed care. We now know, as prior teams have learned, and as future volunteers will as well, that we have received far more from the Haitians than they have from us. We know that the next team will come home wanting to go back. They will be reminded of how good it feels to bring together a large group of individuals, each with his or her own skills and gifts, for a common purpose, each one willing to focus only on the mission, the goal of helping just a few people who need our help. They will be reminded of how inspirational it is to be led by those who live their faith. And they will come home with hundreds of stories. Stories of horror and tragedy and struggle. And songs. So many songs. And they will see faith and resiliency and hope and love. In action. They will feel it and see it and smell it. And they, like us, will never forget, and will be forever grateful for being allowed to be part of this. Dr. Glenn and I were talking a few minutes ago, still trying to grasp the scale of it all. This afternoon, we drove for several hours through the streets of Port au Prince, a city of between 3 and 4 million people before January 12th, trying to make sense of whether our tiny efforts mattered.We remembered that we only saw 500 or so in the Clinic this week and only operated on about 30. Could this really amount to anything given the scale of the need? In the face of such obstacles? When what is needed is not just 21st century medical miracles eked out one at a time, but shelter, food, clean water, education, and opportunity? The answer is absolutely yes. If we do our part, and other teams do their parts, and the efforts continue, then after a year, 1500 will have had surgery, and twenty-five thousand seen, just in the Mission of Hope clinic. If 20 other missions and NGO's do what the Mission of Hope is doing, then after a year, 30,000 Haitians will have had surgery and half a million seen in the clinics. Together, each doing a little, we will have made a difference. Now is a good time to look at the calendar, and pick a week, and join this effort. Put your gifts into action. We are grateful we have, and look forward to having others join us when we return.

Friday, March 12, 2010

3/11/10 - Team 7, Day 5

Text from Glenn Speigler, MD:

It Is just so amazing that a group of strangers could become such a team. Each of us a piece of a puzzle. The whole far greater than the individuals. Have been doing 7 wk old cases with levels of complexity that until now I would have thought impossible.. To date no operative infections. We feel that in many cases the care is equal to the US. Another full OR today. Will be doing overflow on Saturday. Have begun scheduling for next weeks team. They will be operating. Have become the referral center for facilities much larger than us. Lives depend on future teams. Please please please keep them coming. With great appreciation and respect.

Update from James Dudley, MD:

Just as I hit 'send' last night, our team found out what it is like to have the only 24/7 hospital in this area of 'Ayiti'. An important security official from a nearby town showed up with several armed escorts at the compound's front gate, requesting entrance; he was suffering terribly from a "belly ache, belly ache, fever, terrible fever". The guards radioed up to the ward where Dave, the flight medic, and Amie, our nurse practitioner were on duty, passing on their request. They talked it over, (well, maybe for about 15 seconds!), and soon, they were evaluating the gentleman. The call came up to the Guest House a few minutes later; orders were given and treatments started, and in a few minutes, as the 'on-call' doctor, I was on my way down to the ward. At night, the local populations of ponies seem to graze more freely, closer to the roadside than during the day. But, they remain skittish. Even though I expect them to move away as I approach, when they finally do bolt, I can't help but feel my heart race. I couldn't help feeling a kid's sense of grand adventure, as I made my way down the hill. The stars to the south were spectacular with constellations we from the north rarely get to enjoy. I had asked Dave to place our newest charge away from the other patients, partly out of deference to his status in the community and partly out of concern that should he be contagious, it wouldn't compromise the other patients, most of whom are post-operative patients. The Mission of Hope Hospital has one of the cleanest Operating Rooms on this side of the country, and it has allowed our pair of Orthopedic Surgeons and our Plastic Surgeon to take on very complex, professionally satisfying, and meaningful work. They are giving significantly injured patients a wonderful chance to return to normal or near normal function, but it is essential that we be vigilant to prevent wound infections. Dave and Amie had come up with the perfect solution. The officer was appropriately placed at the far end of the ward's central hallway, away from the others, on a mattress with fresh linens. Along with the IV fluids and medications he had received, they had also done the hard work of reassuring him and his wife as well as his comrades. Our able, if sleepy, translator, along with the patient's high level of education and ability to give precise details about his illness made my job easy. We decided to allow him to rest in his relative privacy until one of our Haitian physician colleagues, Dr. Alix, could weigh in on the situation in the morning.

The waning crescent moon was just rising over the mountains as I made my way back toward the Guest House around 2 AM. However, another patient, a 5 year old trauma patient, came in around 5 AM. He was on a small motorcycle with his dad and another young man, headed to the clinic to have a rash on his hands evaluated when his bare foot slammed into a cinder block wall. A large cut on the inside of his ankle was just the tip of the iceberg. Again, Amie and Dave did all the right things. The IV Morphine eased his pain, and the first dose of IV antibiotics began infusing within an hour of his injury. They reported he never whimpered as the line was started. n the way down to check on him, as I rounded a curve and emerged from a clump of trees, I saw a small figure sitting on a boulder playing what looked like the guitar from a few nights earlier. Jean Marc, about 14-16 years old, sat facing east as the sun rose from behind the hills and lighted his face. There was no one within a hundred yards of him. Jean Marc is the daytime translator for us on the wards, and his shift hadn't yet started. We chatted as he strummed away and after a bit, I asked him if he sang or just played. "Oh, yes, I like to sing" and added his warm voice to the easy rhythm of the chords. he antibiotics were finished by the time I made it the ward. The boy with the injured ankle required not only orthopedic work, but the transfer of a nerve by Dr. Matt, our Plastic Surgeon. This nerve is to take the place of the nerve on the inside of the ankle that was avulsed by the wall. Without this nerve, sensation in the foot is lost, and in the harsh environment of Haiti, inevitably he would end up an amputee, probably after years of progressive disability.

The whole team is really coming together to make a difference here. As we share stories at day' s end, one concern we all have is who is going to step into our respective places once we leave. The need is not just now, it will be for years. Mission of Hope is working, as are many groups, to build this as a sustainable venture. This is the essence of the work we were all called to do when we set out on our careers. For any who are able, this is an opportunity of a lifetime.

Thursday, March 11, 2010

3/10/10 - Team 7, Day 4

Update from James Dudley, MD:

It is nearly midnight, and the camp-style singing, tonight a gift of our college colleagues, continued until nearly 10. I don't know if the guitar lives here, awaiting the next player, or if one of the others brought it. It definitely seems that college aged men and women definitely have more energy this time of day compared to some of us middle aged doctors and nurses. They have probably done a lot more hard physical work today than we doctors and nurses, but most of our group has turned in while many of them are still giggly. Ah, to be so carefree. Mission of Hope-Haiti lies above the northern shore of a large horse-shoe shaped bay that is also ringed by mountains on the south and east. The opening of the bay faces west, and the south eastern edge of Cuba lies fewer than a hundred miles away. The Mission property sits on the foothills, no more than a few miles from shore, probably about five hundred feet above sea level. Its views of the Caribbean are spectacular. The 70 acres are basically a large narrow rectangular of land with the long borders running more or less in a south to north direction, up the hillsides. The gates of the compound are at the downhill, southern edge, and it is there, at the gates, where the queue forms each morning. The Guest House, where we stay, lies well up the hillside, probably a half mile up from the gates. The rocky road winds up the eastern side of the property. As one travels north, up from the gates, the large church, which holds hundreds of worshipers, sits to the left, or west. It has a large low-pitched A-framed roof and only posts hold up the roof and its trusses; its walls are open. Beyond the church is the cafeteria for the schools and to its west, a substantial concrete two-story rectangular High School. Each floor has a long central hall with classrooms on each side. After the earthquake, the school was needed for medical purposes and now it houses a hospital ward. There, our nurses, two at a time, around the clock, staff the downstairs ward, where patients are arranged up to four in a room. Family members stay with each patient. Tons of supplies are packed into the upstairs classrooms, but these temporary quarters have to find a new home soon, since the Haitian government expects school to reopen in April. In one of the store rooms is a box labeled "Tents for discharged patients". A hundred yards up the hill from the ward is the Clinic, and as the doctors and the day shift nurses walk down for rounds and change of shift in the morning, the gates open and several hundred people of all ages, a few at a time, wind their way up the hill. It is a sight to behold, a quarter mile line of people, hurrying as best they can the first in line.The Operating Room team heads directly to the clinic, and finishes their last minute preparations. As the patients gather outside the clinic one of nurses greets those assembled and matter of factly leads them in song. This morning's hymn was a beautiful Creole version of "Praise God from Whom All Blessings Flow". The conviction the Haitians expressed as they embraced the message in those words left me shaky. Following the hymn was a prayer. The rhythm seemed vaguely familiar as the phrases, some long, others shorter, rolled into the clinic from the waiting area, but its Creole words were lost on my untrained ear. The nurse told me later it was the 23rd Psalm, about walking through the valley of death. We have no time to dwell on those moments as the pace of the day's work overtakes us. Each person has a story to tell, or a hundred stories, and we each gather bits and pieces as we do our respective work. The team comes together a little more smoothly each day. The medics transport patients up from the ward to Pre-Op then triage the masses. The ER fills and treatments begin on the sickest of the group. The exam rooms fill and we move as many as we can as fast as we can, trying not miss those who are truly acutely sick, and not simply exhausted, hungry, burdened by parasites or lingering grief. Then, as before, almost suddenly, they are gone except for the late OR cases, and those awakening from surgery. In some ways, we all struggle to regain our bearings. So, at the end of the day, to share food and stories and music, brings peace and closure and allows us to drift off without worry.

Wednesday, March 10, 2010

3/9/10 - Team 7, Day 3

Update from James Dudley, MD:

Good evening from the Mission of Hope. The crickets are chirping the team to sleep in their respective bunks and tents, as things wind down on Tuesday evening. The evening after dinner brought lots of pleasant conversation and excitement about the work done today and the challenges facing us tomorrow. One of the highlights today was the work of the orthopedists. The team did a very difficult repair of an unstable fracture of the tibial plateau - the broad top of the shin bone. The fracture had been set at the time of the earthquake but was still unstable even though some bone repair had started. They were able to put the fragments back in good position, using a plate and screws to stabilize everything. The patient has an excellent chance of regaining full use of his leg. Each morning, there is along line winding its way up the hill to the clinic. By the time the gates open, many have already been in the queue for several hours. Our Paramedics triage the sickest to go to our small 3-bed Emergency Room for giving IV fluids, and monitoring. Three other doctors and their translators work steadily to see the many others Meanwhile, our Physical Therapist stays very busy, between therapy sessions with the orthopedic patients on the hospital ward, and wound care in the clinic. One of the interesting cultural aspects we have noticed is that when a Haitian undergoes surgery or a serious injury, it is common for them to stay in bed, waiting to get well. It requires significant education and encouragement to convince them of the benefit of early and sustained mobilization following surgery. Even in the few days on site, we are seeing them make gains from those efforts.Today's musical moments we're varied and mostly spontaneous. Anyone, anywhere is liable to break into song, and although the words are in Creole, the hopefulness conveys in a universal language. And when one starts, others join in. The Haitians seem to express themselves in song as easily as in conversation. The singing starts early in the morning, on rounds in the wards and in the waiting area outside the clinic, and goes well into the evening. Around sundown today, the large open-walled church was full of worshipers, singing full force, sending echoes several hundred yards up the hill to the hospital wards. There, patients and their families, who stay with those hospitalized to feed and help care for them, heard the singing. Within a few notes of hearing each new song, they have joined the chorus. And it feels like real healing is taking place.

Tuesday, March 9, 2010

3/8/10 - Team 7, Day 2

Update from James Dudley, MD:

Hello from Titanyen, Haiti! It was a beautiful day here, warm but breezy. It feels tropical and the pace of life seems like what one would expect in the islands. As many know, the length day in the tropics doesn't vary much with the seasons, and so sun-up is a few minutes after 6 in the morning, and sunset 12 hours later. Haiti is very mountainous and our compound is situated on the southwestern slopes of a mountain range, so the sunrise is delayed just a few minutes more. Most people in the area where we are seem to rise and set with the sun.

Last night was breezy and quite comfortable and it was easy to get going this morning. After rounds on the 6 orthopedic patients in the hospital, we walked up the hill to the clinic. It was about 8:30 and there were at least two hundred people in the queue, some with minor issues, some more serious. We met Dr. Jennifer and later Dr. Alix, our Haitian hosts who staff the clinic on a regular basis and to whom we could run anytime when we had questions about local practices and more importantly, the spectrum of disease we were facing. We worked as fast as we could to take care of all the patients, sort out the really sick from the not so sick, the acutely ill from the chronically ill, or malnourished. The range of needs, medical and social and spiritual was significant; challenging and exciting. In some ways, I felt like a medical student on the first day in the wards. Almost without warning, the mad rush was over. I went to find Dr. Jennifer, my new-found mentor, but she had gone. Early in the morning, she and I had talked about Wigans, the young man we had worked on feverishly just we hours earlier. Dr. Jennifer had been his primary doctor for the last two years and she had made huge efforts to care for him, even traveling to Cuba to arrange medical care for him, and staying with him at Christmas last year, acting as physician and mother for him during another hospitalization. His death overnight hit her especially hard, as it did many of those who work in the clinic. They all knew Wigans and knew the struggles that had been made for him. This evening, as grace was said before dinner, a prayer was made to bring healing to those suffering in the wake of his passing. It helped ease the pain, as did the wonderful music after dinner. There are two groups of college students here, about two dozen in all, and they provided a beautiful chorus for the pastor who played the guitar and sang with clear rich tenor. A good night's rest will bring a renewal of energy for the work tomorrow.

All are well here and send their love and greetings to family and friends back home.

Monday, March 8, 2010

3/7/10 - Team 7, Day 1

Update from James Dudley, MD:

Today, we have tried get oriented, organized, and ready for tomorrow, when our real work was supposed to begin. Unfortunately, just as we were finishing our inventory of supplies a young man was brought, sweaty, pale, and clammy. His family brought his medications; a small Walmart bag with five cardiac meds. He had undergone cardiac surgery in Indiana a year ago and was fragile even before he became ill yesterday with a fever, diarrhea and abdominal pain. He was critically ill, probably with sepsis. He required vigorous resuscitation, including a central line and intubation, as well as transfer to the field hospital near the airport that has been set up by the University of Miami. There they have ventilators and Intensive Care Units, all in tents. If anyone is looking for an adventure, ride in the back of ambulance, lights and sirens blasting, through the unlit streets of Port au Prince at night, crowded with tens of thousands of people on foot and bicycles. So our real real work starts in the morning.

Sunday, March 7, 2010

3/7/10 - Team 7 is on the ground!

Team 7 members from Texas include:

Stan Rice, DO - Team Leader - ER (Brackenridge & Dell Children's ER)
Kurt Knauth MD - anesthesia (Capital Anesthesia-Brackenridge)
Maggie El-estwani, RN - OR (Austin)
James Grant, PT (Encompass Home Health)
Julia Chang, RN (Seton)
David Krussow, RN (Austin, Star Flight)
Kathy Bremer, RN (Austin Area OB/GYN)
Pam Rizo, paramedic (San Antonio, W-I10 Fire Dept)

Joining the team from other areas of the WORLD!
Glen Spiegler MD - orthopedic surgeon (Virginia)
Mike Mara, MD - orthopedic surgeon (Oregon)
Matt Shambaugh, MD - plastic surgeon (Indiana)

James Dudley, MD -FP/ER (Virginia)
Greg Schmitt, MD (Indiana)
Peg Kiester, RN-OR (Indiana)
Hannah Warren, RN-Mercy Ships (England)
Sally Greenway, RN (Canada)
Sandi Brock, RN (Georgia)
Agnes Hyma, RN (Canada)
Amie Mock, FNP (Virginia)
Suzanne Tolson CC-EMT (Virginia)
Lyn Westman-Mental Health, Mercy Ships

Saturday, March 6, 2010

3/5/10 - Team 6, Day 6

Update from Heidi Walker, RN:

It rained today! This is wonderful considering it has been sticky and hot all week. There is actually a nice chill in the air tonight.

The day started with two women going into labor at the clinic. Unfortunately, MOH is not allowed to deliver babies and therefore we loaded them up in the ambulance and took them into Port Au Prince. The two labor and delivery nurses were excited and ready to deliver the babies, but they did not get to show us their skills.

The surgeries went much better today. Each surgery we do should be a lot easier than they have been, but with the lack of vital equiptment and these adverse conditions, we have had to work a lot harder . With passing time, these older injuries are getting more difficult to treat. Thankfully we were able to fix a bad tibial plateau fracture, an acute gunshot wound to the hand, a fractured and dislocated elbow, and of course a debridement of an infected wound (we have seen a lot of infected wounds). We were going to wrap up the OR team tonight, but we decided to leave Haiti with a bang with one last above the knee amputation tomorrow. Dr. Brad will be losing his scrub partner, Dr. Greg, tomorrow to a flight back to Indiana, so he has asked Kristen to be his assistant in surgery.

The ER was hopping today as usual. There were all sorts of people in there, which is much like it is in the states. We saw a 17 month old baby only weighing about 10 pounds who was severely malnourished. Of course this baby pulled at all of our heart strings and we did everything we could to get some fluid down. We eventually shipped her out to a hospital in Port Au Prince. We can only pray that someone else will care as much as we do and will nurse her back to health. We also had a patient come in yesterday who fell out of a building or tree depending on who you ask (no one is sure of the exact story because things get lost in translation). Dr. Jon was able to diagnose a C4-C5 cervical fracture and we immobilized him and sent him to stay the night in our ward. We were supposed to have a helicopter come into the mission today to transport him to a hospital that takes 10 hours by car, but they cancelled because of the weather. A helicopter around these parts sounds pretty unbelievable to me, so I will have to see it to believe it. Hopefully tomorrow’s weather will be better and the helicopter will come for him. Rick, the Canadian paramedic, made him a short back board to travel on so that his flight will be as comfortable as possible.

All of the people on this team have been amazing. It’s such an eclectic group, but everyone has had something amazing to offer. It’s great to see people working until exhausted for the same common goal of helping these people. We forget how lucky we are sometimes and thank God for allowing us these experiences to remind us. Our team will be disbanding slowly over the next 3 days and I think we are all feeling it. We wish we could keep the team together forever, but we are also looking forward to getting back to our family and friends. There really is no place like home!

Thursday, March 4, 2010

3/3/10 - Team 6, Day 4

Update from Team 6:

The most exciting thing about today is the fact that Dr. Brad did the first ever, as we know of, hip hemiarthroplasty in Haiti. Actually, he did two! Way to go surgery team! And rumor also has it that there is a 19 y/o from the Dominican Rebublic who is wanting to come to the mission for his hip to be fixed as well, but there is no word on that yet. We are hoping to go international here at the mission by the end of the week!

It was a long day today as we were in surgery until almost 7 pm. As a matter of fact, I haven’t seen the recovery nurse yet so my guess is she isn’t back yet from the clinic. I think tomorrow might be another long day as well because we already have 2 femur fractures and 1 tibia fracture to fix as well as several wound debridement’s on our schedule and there is always a possibility of add-ons. We are going to sleep good tonight!

There was also some excitement on the ward with a pt that was dropped off yesterday for fever, nausea, and vomiting. His condition worsened today and it was determined that he probably had a ruptured appendix. Dr. Greg said he would have preferred not to take out his appendix in our OR, but he was standing there ready with scalpel in hand. Luckily we were able to transfer him to a place that the paramedics said looked pretty clean. I believe that he was taken to the OR for an appendectomy, but I’m not for sure on this.

Kim says nothing much happening in triage right now except that there are a lot of people coming through. Coincidentally, everyone in triage has the same complaints of fever, cough, n/v, and abdominal pain which they say have been present since the earthquake. Maybe it’s nerves. These people really have been through a lot.

Dr. Jon, the ER physician from Chapel, had a patient come in on Monday with a heart attack in progress. We treated him as much as we could and then sent him on to the University of Miami hospital. We have since then learned from his son that he passed away today. May God bless him and his family at this time.

From Dr. Greg: “I have had the distinguished honor of assisting one of the most brilliant orthopedic surgeons in the world doing the toughest arthroplasty that I have ever seen under extremely adverse conditions. In fact, one could say he was operating under the jaws of death.”

Text updates from Dr Parker via Chris Merrell:

Pts seen today:
2 hip replacements
hip spica on a 10 month old
2 endo prosthesis
debreided stump wounds
"lots of action"

Haitian orthos are up and running again

Still many malaigned fractures from earth quake

2 femurs and tibia tomorrow.
Lots of wound care surgery.
2 surgeries lined up for next week.

Still need RN's. Dr Parker feels ward will be full the next week.

Update from Haiti and our prosthetics team:"Chase just texted me that the meeting he had with the government, WHO/ICRC and Helping Hands went incredible!! The Government has not only give us a big green light, but they have asked Chase and MOH to help make the Prosthetics Standards for the NATION!!! WOW." So exciting!! Our prothestics clinic is scheduled to open April 3rd.

Wednesday, March 3, 2010

3/2/2010 - Team 6, Day 3

Update compiled by Kristen Damery, PT from Team 6 members:

Our communication has been sparse secondary to a spotty connection with email and phones. We are all safe and busy! We are all going to contribute tonight!

Anesthesia system is pretty complete and we are able to take care of everything we need.
-Dr. Dave, Anesthesiologist

Ambulance needs some air conditioning! To his family, he misses you and is safe. Everyone is really great and a really good bunch of people to work with. I just hope my wife doesn’t have too much snow to shovel!
-Rick, medic

-Experience of a lifetime. Misses her family but not the snow.
-Denise, nurse

Can’t believe how great the OR team is. Met Dr. Greg, a retired thoracic surgeon, still demonstrating great surgical skills, a tremendous help. Have a new X-ray tech named Wicky (Haitian). Injuries are bad, we are able to help some but not all. Tomorrow morning we are doing wound cases and Haiti 1 is going to pick up fractures for tomorrow afternoon.
-Dr. Brad, orthopedic surgeon

Haiti one had a mishap in route yesterday, apparently the local population doesn’t recognize an ambulance.
-Pauline, medic

Very unique and rewarding experience. We have a great team that gets along together and works well except there are too many Texans. Haven’t been able to do any coronary bypasses yet, the TSA wouldn’t let me bring my bypass pump on the plane!
-Dr. Greg (cardiovascular surgeon form Chapel team)

Finally finding where everything is at in the OR. Have dish pan hands from washing instruments.
-Jeff, orthopedic tech

I really enjoyed working with Dawn from the Chapel team in post-op today. She is great to work with and we are thankful for the teams from Indiana and Canada (although we try not to talk about recent international hockey games). Despite searching very hard for a fax machine I was unable to locate one to fax the order to the pharmacy prior to giving meds. This was a huge bummer…NOT. Actually it is great to focus on patient care and being with the people here, they are very grateful and fun to be around. I also enjoy the random turkeys and goats that walk by the clinic. One baby goat actually walked in the clinic but we could not see anything medically wrong with it so we shooed it away.
-Eric, nurse

Today was a slower day for wound care so I was able to assist a little while in other areas which were fun to experience. Yesterday was madness, a steady stream of patients for wound care coming in all day. The Haitians were all so grateful. They are beautiful people. Our team is working well together, everyday is better than the day before. The patients are all so diverse; some are still recovering from wounds secondary to the quake. Their stories are unbelievable. They have experienced things that we can not comprehend. Miss everyone. Good things are happening here in Haiti.
-Kristen, PT

Melissa is currently working nights at the ward! What a blessing she is to the patients, unfortunately she is not here to contribute. She is an angel.
-Heidi, nurse

We had a new team from Austin today. Very happy to have them here. They are working on setting up a prosthetics clinic. When up and running many, many people will benefit from this service.

Tuesday, March 2, 2010

More on Amputations

Post provided by Barbara Bergin, MD

We’ve all been talking a lot about amputations. It’s an operation that doesn’t get much attention in this country. It’s not very glamorous and it’s certainly not cutting-edge technology. We’ve been doing amputations pretty much the same way for a hundred years. In the United States about 40,000 below knee amputations (BKA) and 35,000 above knee amputations (AKA) are done every year! About 70% of those amputations are due to disease, the main culprit being diabetes. About 20% are due to trauma. Those statistics have been gradually changing over the past several decades because of advanced technology with regard to treatment of traumatic injuries of the lower extremities. We learned a lot about the importance of cleaning contaminated wounds in Viet Nam. Just getting a contaminated broken bone cleaned and temporarily stabilized with an external fixator (like the ones you see in the pictures from Haiti) has made dramatic increases in the number of limbs we save here in the U.S. and in other industrialized countries. But again, in Third World countries, amputation remains the mainstay of treatment for these kinds of injuries.

Now an amputation isn’t a simple operation. If not done properly, with adequate bone coverage and just the right amount of muscle padding, fitting and ultimate use of a prosthetic limb can be a problem. So a lot of planning goes into the performance of this operation. And when there is adequate, healthy skin and muscle, this can be done with a relatively predictable outcome.
But traumatic amputations are a whole different ball game. A limb smashing into pavement from a motorcycle accident or being crushed by a collapsed building, such as thousands suffered in Haiti, almost never gives the surgeon an opportunity to perform a textbook amputation. There is always some degree of contamination, torn muscle, stripped skin and exposed bone. This can leave the patient with thin skin and a poorly padded stump, which then can be difficult to fit into a prosthesis and will almost always result in some functional disability and pain. Surgeons want to make every effort to give a patient a BKA because of the energy requirements it takes to function with an AKA (see Dr. DeHart’s blog from 2/22/10). We will often do skin grafts and muscle transfers to cover a little stump of bone in order to give a patient a BKA.

This is doubly important in Haiti, where a BKA instead of an AKA could make the difference in a patient’s ability to work and support him/herself. Many patients are refusing to have second and third operations in order to make improvements to their stump. I can’t blame them. It’s a huge pill to swallow even under ideal circumstances.

Barbara Bergin, MD
Texas Orthopedics

3/1/10 - Team 6, Day 2

Update from Brad Parker, MD:

Just got email. Things going great. Busy today and more people learning about MOH. Surgery working well. Massive thigh I&D, revision wound vac, fem nail revision, open shoulder for chronic dislocation.

Orbit debride on Job was difficult for all. Previous surgery failed for the little guy. Tomorrow, open tib fib, then osteo with questionable septic knee. Tell all that there were a large number of follow ups and I thought the previous surgical work was excellent.

Picture: Job traveling to USS Comfort

2/28/10 - Team 6, Day 1

Update from Brad Parker, MD:

Internet has been down. First and mainly to let all the loved ones know everyone is doing great, no issues at present.

Quick Notes:
-uneventful day
-4-5 OR cases scheduled tomorrow-General wasn't aware there was another OR team coming this week so some pts got sent home. They plan to do more PR to get these pts to MOH this week.

Update from Dave Bryant, MD:

The greatest part of our long day of traveling was the flight from Miami to Haiti. On board was a native Haitian, King Wa Wa, that was returning home after being in the states for 10 years. He so happens to be a fantastic musician and had the whole plane singing as he played in the aisle! Unreal! Once we arrived in Haiti we hit the ground running. The Canadian nurses worked all night in the ward and this morning we began sorting through the supplies that people have so generously donated. We explored where all the supplies are kept and are ready to begin bright and early tomorrow morning. Dr. Parker got to travel on Haiti 1, our ambulance, with Pauline and Rick, our medics. We have our first case lined up for the morning but when he found out he was coming here to have surgery he turned up missing. So…an I & D of a thigh abscess that came from General will be our first case tomorrow and several more are set to come. It has been very hot today, lots of water and lots of sweat. I think we might have even gotten a sun burn. Haiti is beautiful. The people are beautiful and loving and most importantly grateful. We are surrounded by mountains and you can see the ocean from the mission. The resiliency of the Haitian people is amazing considering the stories we have heard just from the people here at the mission. Eric arrived today from Miami. We are so grateful to finally have the whole team together. Some of our team went into the city today and told us about the chaos of the living conditions. The streets are lined with tent cities and the roads are clogged with everything you can imagine. We just finished up with mac and cheese and hot dogs for dinner and the mosquitoes are out. You better believe we have gotten an ear full from the Canadians about their team winning. We are all looking forward to tomorrow and hope all is well there.
Picture: Kristen, King Wa Wa, and Heidi