Situation Report 14 May 2015

 (no pictures due to poor network connection)

Life is not back to normal after Tuesday’s earthquake.  Yesterday morning people were visibly tense and in somewhat of a daze as they were walking around reading newspapers and many shops remained closed.  Bricks were scattered around the streets and many stores remained closed.  Even today many people remain in tents and under tarps in front of their homes and stores.

The workload continues.  Four thoracolumbar fractures were on our operating schedule today.  Dr. Shrestha the Chief of Orthopaedics at Kathmandu University Hospital is a young and very talented surgeon.  He and I have been operating simultaneous spine fractures in two operating theatres for the last several days.  After we finish the spine injuries we will operate on a severely displaced acetabular fracture this evening.

Given the limited economic resources in this country the quality of surgical care is very impressive.  The operating theatre is a beehive of activity.  Cheerful nurses move quickly to turn rooms over and the simplicity of the system allows for efficiencies that we are not accustomed to in the United States.  All the implant choices that we have at home are not available, but there are many economic alternatives that come from India.  We implanted $40 Indian pedicle screws in our last case instead of the $900 screws that we use at Loma Linda.  There is a noticeable difference in the feel of the instrumentation but the job got done.

The generous donation of spinal instrumentation from DepuySynthes turned out to be the single most important tray of instruments and implants that I brought on this trip and I used this set on the majority of the spine fractures that I operated.  The positive impact that we have made here is the result of many generous donors, hard working people at LLU Global Health Institute, our partners who had to rearrange schedules, and those that work in our offices.  This is truly a team effort and gratitude is owed to many.

The people of Nepal continue to suffer, hospitals are overcrowded, and the recovery process will be long and difficult. Thankfully very few patients required amputations after this disaster however we have seen a variety of orthopaedic injuries that will result in permanent disability, the most severe of which are patients who suffered spinal cord injuries.  Many of these occurred from jumping out of buildings that were on the verge of collapsing during the violent tremors.

For a first hand account of Tuesday’s earthquake see http://ireport.cnn.com/docs/DOC-1241256

Before and After

This is a 28 year old girl who had great difficulty walking due to a severe case of Blount's disease.  She has lived with this disability since early childhood.  We performed her operation in September 2014 and recently removed her external fixator.  Due to the severity of her deformity it was necessary to perform a gradual correction.  Once corrected a period of time is necessary to allow bone consolidation and then the fixator is removed.  We are very thankful to Dr. Alexis for his assistance with this case and for his management of her postoperative care.

Latest news from Port au Prince

On our last day we visited the ruins of the Basilique Notre-Dame.  You can walk in under the large chunks of concrete that dangle from rebar like chandeliers gently swaying in the breeze.  We walked up to the top floor where the rubble still stands as a solemn reminder of death and destruction.

Basilique Notre-Dame

Basilique Notre-Dame

The Importance of What We Do

A few blocks away from the Basilique is a local hospital for which I will keep the name anonymous.  I had a good idea of what the conditions were like but never having been there I asked Dr. Alexis if we could take a tour of the orthopaedic wards.  The situation was even worse than expected.  Patients languishing in crowded, oppressively hot, foul smelling rooms, some of which were only lit by tiny cell phone flashlights.  One horrible case after another, many of which would have been avoided with a simple well-performed operation at the appropriate time.  In some cases expensive modern external fixators were seen carelessly applied with complete neglect for postoperative care.  One patient had 10 inches of his tibia debrided after a relatively straightforward tibia fracture that got infected.  Now he has been there for 11 months in bed.  An emergent debridement and SIGN nail could have put him back on his feet. Now, an amputation is the only reasonable option, but no one wants to tell him that so he just hangs there.  His Bible and Sabbath School quarterly are at bedside.

Emergency Room HUEH during power failure

11 months and deteriorating 

When we arrive back at HAH, our perception of dilapidation, disorder, and poor nursing care has changed.  We feel like we have just walked in to the Hilton.  But the knowledge of those patients at the government hospital, still suffering even as I write this report is motivation to continue our focus on treating the underserved.  As we renovate our facility and improve the level of care we have an urgent need to create a communal ward where the poorest of patients can be economically cared for.

Hôpital Adventiste

The Trip in a Nutshell

Patient care, administration, and organization were the 3 main areas of focus for this trip.  Dr. Mark Mildren PGY4 ortho resident, Corey Burke 3^rd year medical student, John Anderson MD orthopaedic surgeon LLUSM graduate year 2000 and our two Dominican essentials Lucia Hernandez RN and Maria Adrian MD anesthesia made up the team.  John’s family - Jeannette, Joshua, and Kaitlyn as well as my son Chad also joined us and devoted most of their time towards helping Jonathan Euler and the Beehive organization.  Francel had many operations lined up for us as well as a couple of days of clinic.  Due to John’s sports medicine expertise several arthroscopic surgeries were performed, we also operated on a spine fracture, and did a number of hip and lower extremity operations.

Dra. Maria Adrian transporting patient into operating room

Mark Mildren transports patient after surgery

Mark sets up radiolucent table for spine surgery

Francel Alexis, Mark Mildren and Corey Burke start spine surgery

Elaine back table

Bone loss from infection

After extensive transport and reconstruction bone is consolidating with good alignment and increased length

Tibia nonunion 2 years after motorcycle accident

Nonunion repair and leg lengthening

Elaine Lewis who is a surgical tech living at HAH for 6 months had the operating room nicely organized and clean.  This was much different than the conditions that we have been faced with on earlier trips.  She motivated us to organize all of our orthopaedic equipment and other supplies, which we spent a significant amount of time doing.  Corey and Mark learned more about orthopaedic implants than they ever wanted to know.  A big part of doing safe surgery is knowing what you have and where it is, perhaps this is even more important than quality lighting and the room that you are working in.  Elaine had hoped that I would throw away a lot more than I did, but without a reliable supply chain I convinced her to hold on to some items that we will need in the future, but this came at the expense of her thinking I am a hoarder.

Hoarded orthopaedic arsenal

Organized stock

I spent a significant amount of time with Edward Martin the CEO developing a business plan and working out ways for the volunteer and orthopaedic program to continue in a sustainable fashion.  More about that in subsequent report.  We also spent an entire day with Dan Brown the facilities manager reviewing the entire facility and creating a coordinated plan for the future use of space and how various physical plant improvement projects will be prioritized.  One notable aspect of this is the plan to remodel the upstairs area of the HIV clinic (building in front area of the property) for volunteer team housing.  It is a pleasant space about 3x the size of the current quarters that has several large bedrooms and a common area.

Edward Martin CEO

Future volunteer team housing (upstairs)

Dr. Alexis giving lecture at HAAOT national Haiti orthopedic conference

Update on Current Projects

Although our previous operating room was recently reported to me as being one of the best in Haiti, in reality it was not adequate for doing the quality and volume of work that we envision.  A major renovation was started in January 2014 and continues at this time.  The outcome of this project is beyond my highest hopes, the time and resources required for this have also exceeded my expectations.  Things are progressing and although I hesitate to mention it, I have been told that by July 1^st we should be able to move in.  They actually said June 1^st but in reality at the current rate I think July 1 is a much more realistic goal.  The one thing for sure is that the attention to detail, quality of work, and improvement from the previous facility will not be a disappointment to anyone.  Dan Brown who is managing the project is a perfectionist after my own heart.  The lab is also in beautiful condition and as soon as some cabinetwork is completed the space will be inaugurated.

New OR HAH

New Lab

OR front doors countersunk into wall

Dan's well organized tool shop

Dan Brown and helper refurbish SS sink

Medical Gases installed with US standards using silver welding and nitrogen flushing

In our review of the facility a high priority has been placed on a cosmetic renovation of the main floor of the hospital.  This will be a relatively simple update consisting of new electrical fixtures, some plumbing repairs, door and window repairs, air conditioning repairs and paint.  The contractors who did the construction in the OR renovation have looked at the project and will be giving estimates of time and expense to complete this.  There are several rooms which are uninhabitable at this time due to mold and mildew (I mean you can not even breathe in them).  Many others have rotted doors, bare wires, broken lights and leaky plumbing fixtures.  This will be a high profile improvement project that we will need to raise some funding for.

Some of the many fixtures needing attention 

In recent years we have not had an organized space in which to place the patients being prepared for surgery.  I have made multiple appeals to have a pre-op room and finally was granted the space.  This is an important part of patient safety and OR efficiency.  Patients have been waiting for surgery in the hallways and entrances of the hospital.  Sometimes it is confusing to keep them straight, we are not able to effectively update them on when their operations will start, sometimes moms slip their hungry children bites of food and then don’t admit it knowing that their long awaited operation will be delayed or cancelled.  When I arrived this time the designated room was in a state of disrepair without immediate plan for inhabitance.  Fortunately Chad became an expert painter last summer when he painted our house and was able to take over the job and execute a one-day makeover that met the approval of Dan’s quality expectations.  Patients were moved in on Monday morning utilizing 6 new gurneys.  IV’s were started, gowns placed and the day of surgery progressed with a new level of patient safety, efficiency and comfort.

Dan inspects Chad's work in the Pre Op room

First patient getting IV started in Pre Op room

Future Plans

Alex Coutsompos MD was a 4^th year medical student who came to volunteer in 2010 after the earthquake.  He is now finishing his general surgery residency at Loma Linda University and has made a commitment to live in Port au Prince with his wife and new baby and work at HAH for the next five years.  Also some classmates of his Joseph Kim MD (ER physician) and his wife (pediatrician) have made a long-term commitment to living and working at HAH.  This will revolutionize the current collaboration and quality of services at HAH and will be the largest dose of adrenaline given in the resuscitation of this hospital to date.

John Anderson MD and his family who were with us on this trip came not only as short-term volunteers, but, with the intention of learning about how they can perhaps be involved on a long-term basis.  They have positioned themselves to be free to answer God’s calling and if it so be, would consider a full-time relocation to Port au Prince.  The synergy that this could create for our orthopaedic program would be unprecedented, and as much as I would like to see this happen I mention it not to commit them but that we all keep this in a spirit of prayer as to what God has in mind for their family and the future of our orthopaedic department at HAH.

Donors Note

The accomplishments and plans mentioned above do not happen without the support of our generous donors.  I would like to thank those who have contributed in a special way and remind you that your investment is making a difference for the people of Haiti.  It is being used in a judicious and efficient fashion to rejuvenate the hospital physical plant in order to more adequately reflect the quality of medical work and the healing ministry of Jesus Christ that we represent.  The permanence of physical plant restoration is satisfying but even more substantial is the lasting effects of the operations we perform on the lives of our patients.  The physical burdens lifted by the operations we perform often make a lifetime of difference and even affect subsequent generations.  In the cosmic scheme of life you could argue that these acts of kindness last forever, going well beyond the short span of our lives on this planet.   We are especially grateful to Foundation for Orthopaedic Trauma for their support of this trip and the operations that were made possible.   Continued support is needed and again past support is appreciated.

Hospital Economics

Since the loss of the US Embassy contract to provide history and physical exams for Haitians applying for a visa, the hospital has been in a severe financial crisis.  This provided about $60,000US per month, which is around 60% of the hospital overhead.  Soon after that, Mdme. Clotaire hospital CEO stepped down and Edward Martin assumed the position.  His first 6 months in office have been fraught with many difficult challenges one of which is a major staff reduction.  The financial viability of the hospital has continued to struggle and many workers have not been paid for months.  The volunteer program has continued to attract patients who are unable to pay for services and further add to the deficits.  Up until this point it has been difficult to use donor money to fund this program because of a lack of accountability and the natural tendency of these subsidies to only enable continued fiscal irresponsibility.  A new Haitian CFO named Bob is changing this and Mr. Martin is steadily gaining control of the situation.  Due to these recent changes we spent significant time on this trip designing a business plan that would enable the hospital to maximize their income from patients who have resources and also to develop a formula where an equitable subsidy can help patients that are unable to cover the direct costs of their care and prevent the institution from incurring further losses.

Estimates for the allocation of total hospital resources attributable to each orthopaedic operation performed at HAH are approximately $1500USD per operation.  This includes administrative expense, generator fuel, facility maintenance etc. (indirect costs)  As volume of operations increases the per case indirect costs decrease.  However, direct costs, which make up a relatively minor portion of total costs remain relatively constant.  These are expenses like dressings, medications, and additional anesthesiologist expenses relating to any given case.  Our subsidy formula seeks to cover the direct costs of each operation which are approximately $300US for an average case.   At the end of the year we know that this will come nowhere near the amount of income needed to economically sustain the hospital.  The hope is that the volunteer program will enhance the reputation of the hospital, attract paying clientele, and encourage donations of materials and supplies and with a good business plan the hospital can become financially viable.  Volunteers should understand that the hospital may charge some of the patients receiving operations.  Donated supplies are brought to help offset hospital expenses and our spirit of charity must be intended to help build capacity of the institution and medical community and not only to give free operations to patients.

The indigent patient subsidies will be given with some criteria for the hospital to be accountable and also have a social work department in the business office to assess the economic needs of the patients and give discounts accordingly.  All too often simple pricing schemes in Haiti are used to target upper or middle class paying patients and poor people are turned away.  On the other hand if token prices are given and potential income is not collected then donors are subsidizing care for wealthy patients who could easily afford to pay.  In addition resentment is created in the medical community when wealthy patients are given discount services as this undermines the income sources for other surgeons in the city. 

Subsidies for Indigent Care

Where will this money come from?

·      Indigent patient endowment fund which has the potential to produce approximately $15,000 per year based on a principle of $300,000.  This will be largely used to fund a portion of Dr. Alexis’ salary for the portion of his work attributable no nonpaying patients

·      Volunteers – Surgical teams will be encouraged to donate sufficient funds to subsidize the operations they are performing.  Operating 20 patients who pay nothing would require $6000 of subsidy, which would be the suggested donation for a typical volunteer team.  Sometimes more or less patients will be operated, sometimes patients may be able to pay part or all of their direct costs.  Although accounting will be kept, and year-end balances will be reviewed, these subsidies will be suggested tax-deductible donations.

·      Patients themselves – even if a patient can pay $10 this will be collected and decrease the reliance on donor subsidy while also creating responsibility and commitment on the part of the patients.

Business Plan

No plan is perfect and in this environment where there is a large difference in affordability of services it is difficult to create an equitable system that serves the richest and the poorest as well as all of those in between.  The general concept will be what I call the “American Airlines Model”.  That is where all passengers arrive safely at their destination at the same time, but if you want a wider seat, warmed nuts, a washcloth and hot meal then you may be willing to pay 3x more for your ticket.  Even in economy class people may pay different amounts for equivalent seats.  At HAH we will not discriminate but if patients are willing to pay for premium rooms then let’s maximize our opportunity and provide first class service.  If they want the cheapest economy rate then let’s give them a timely and safe operation – and maybe we can add a free orange juice and bag of peanuts.

Balance

Elaine, Dr. Alexis, Dr. Mildren PGY4, and Corey Burke MS3

My life is not necessarily in balance.  In fact, often the things we strive for most are the areas of our lives that are most lacking.  Balancing priorities at home nearly eclipsed my plans for this trip and now that I am here it seems that a good part of my busyness at home is relatively unimportant.  In many ways these trips help to keep me in better balance.  They help me realize what is important in life and what is not.  Due to my own lack of balance it is important for me to get to Haiti at least every three months.  Most people do not require such rigorous travel schedules to stay sane, but I find myself getting restless unless I am able to leave the United States and come to such a place as this on a regular basis.

More evidence of Elaine's supervision

Dr. Adrian opens a new bottle of Sevo ($200USD)

Our effectiveness as human beings, teachers, and leaders depends upon balance.  We should not be satisfied with the status quo, but nor do we want to focus only on areas of needed improvement lest we become negative and critical.  When looking at hospital economics, business plans, and the pace of operating room construction it is easy for me to get frustrated.  These vexations need not be published here but perhaps it should be known that not everyday in the mission field ends in feelings of victory and accomplishment.  In an attempt to not be overwhelmed by challenges, I have chosen to quit asking when the new operating room is going to be ready.  Nor will I be able to answer that question for anyone else.  The projected date is June 1, but realistically at the current pace it will be well beyond that.  The good news is that progress is being made, the quality of workmanship is well beyond anything I have seen here, and the provisional operating room is now so well organized that we can safely perform just about any operation there. 

The improvements and installations in the new operating room continue to impress me.  The new operating accommodations are such high quality that future surgical volunteers will not be challenged as we have been in the past.  Sometimes I wonder if they will even want to still come, as there will be less of a sense of adventure and the perception of local needs will be softened.

I continue to try and balance diplomacy with accomplishment, relationship with productivity, tolerance with perfection, optimism with reality, censure with appreciation, and rest with work.  Fortunately after 6 days of work, a day of rest has arrived.

New Haitian arrives

Mark returns patient to recovery room after operation

Chad paints pre op room with his supervisor

Mark gets morning nap as required by ACGME