06
Jul

Here’s looking at you, Hinche

Today we will finish post-op clinic and leave Hinche for Port-au-Prince.

This week has been more relaxed than the past two, but we still have kept busy running post-op clinic, organizing the supplies we plan to donate to Hospital St. Therese, discharging the remaining couple of patients on the wards, calling post-op patients from 2014 and 2015 who didn’t already return to clinic and laboriously completing all documentation (some things you can’t escape). Because Hospital St. Therese has no functioning electronic medical record system or wifi available in the hospital, we have used paper charts to document all aspects of patient care. Amazingly, we have managed to keep track of all of the patient charts!

One of our greatest accomplishments this year has been reaching patients for follow-up from previous years. We had 19 patients that returned to our clinic from previous years and we were able to reach several more over the phone. It has been rewarding to see these patients return to clinic–some from hours away–fully recovered and grateful for the care they received.

Until next time, Hinche!

 

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eating dinner with Dr Rony, our in country director for Project Medishare

eating dinner with Dr Rony, our in country director for Project Medishare

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with a follow-up patient from last year

with a follow-up patient from last year

saying goodbye to our fantastic translators for the past month: Des, Zombie and Jean Mitial

saying goodbye to our fantastic translators for the past month: Des, Zombie and Jean Mitial

 

Hinche Cherie

Hinche Cherie

03
Jul

“Bondye bon” (Whatever God does is for the best)

We completed our second OR week both at Hospital St. Therese and Hospital Bienfaisance on Friday. Over the past two weeks, we completed 63 cases and saw 111 patients in clinic. Our second operative team left Hinche today. The M4s and Dr. Pettitt will continue post-op clinic for patients this upcoming week.

There have been many challenges these past two weeks ranging from dehydration to language barriers to limited equipment and supplies to working in an unfamiliar healthcare system. But, both of our teams did a great job rising to meet these challenges in order to provide our patients with the best care possible.

There are four patient stories in particular that highlight some of the difficulties we have faced these past two weeks in providing patient care.

One patient was finally discharged on Saturday, eight days after his prostatectomy for one of the largest prostates both Dr. Carney and Dr. Osiris have ever seen. This patient presented with an indwelling foley catheter present for the past ten years because he has been unable to urinate due to the large size of his prostate. During his surgery, he suffered a large amount of blood loss which we were only partially able to resuscitate with blood transfusion as the Red Cross blood bank had a limited supply of blood available. Fortunately, we were able to fully resuscitate him in the ICU with epinephrine and crystalloid for several hours post-operatively. Throughout the week following his surgery as we helped him fully recover, he continued to express his gratitude for our help and that he believed God would bless us.

Another patient returned this week for a bilateral orchiectomy after we diagnosed presumed prostate cancer based on clinical history and physical exam. There is no pathology service available at Hospital St. Therese, and patients must take their specimens with them to other hospitals in order to receive pathologic analysis, often for a fee if they take it to a private hospital. This patient had been hesitant about his orchiectomy last week but stated that he indeed wanted to have surgery to enable him to eventually remove the SP tube that had been placed for urinary retention a few months prior. After a lengthy discussion regarding the risks and benefits of an orchiectomy with him, it was ultimately decided by the patient and the team that an orchiectomy was not the best decision for him. Given the language barrier and the limited health literacy of our patients, it can often be difficult to help them make informed decisions about their operations.

An infant was referred to us this past week from hours away with bladder exstrophy, a condition in which the bladder mucosa is exposed to the outer skin. The mother drove many miles to see if we could help only to receive a devastating diagnosis that few if any people in Haiti can probably fix. Her condition would require a series of operations to not only place her bladder back inside her abdomen but to also reconstruct her bladder, pelvis and genitalia. Even if she were to receive these operations, she would most likely require significant follow-up that also may not be available to her. Her condition is not life-threatening, but is significantly debilitating to her future quality of life. It was difficult to tell her family that we could not help her with the resources available to us.

On the flip side, we were able to gather the necessary supplies this week to operate on a patient who presented to clinic with hypospadias last week. Although we gathered all the necessary supplies to perform the operation, we were worried about the child’s follow-up care and the ability of the family to take care of the patient post-operatively to ensure success of the operation. Our fears were completely assuaged however after talking with the mother on the wards. She has asked questions every step of the way and has learned how to give her child medications and change his dressing after we leave.

These are just a few of the stories from this past week that not only highlight our challenges to provide patients with the care we want to give them but that also highlight the strength and determination of our patients. The most rewarding and humbling part of this experience has been interacting with our patients and their families. They travel sometimes from hours away, bring everything necessary for their stay in the hospital including bedpans, sheets, water and food, and sleep in open-air wards (the family members often on the floor) with minimal privacy and rats. But, without fail, they thank us profusely every time we check on them on the wards or see them in clinic.

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M2s

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Our well-taken care of hypospadias patient and his mother

Our well-taken care of hypospadias patient in his bed tent with his mother

Dr. Caridi-Scheible teaching us about ultrasound technique

Dr. Caridi-Scheible teaching us about ultrasound technique

Our prostatectomy patient at discharge

Our prostatectomy patient at discharge

03
Jul

The return of Wifi

Dear followers,

Very sorry for our absence during the second week! We were very productive, yet unable to recount our triumphs due to lack of internet! We now have access again and will do our best to catch you up over the next few posts on all that we’ve done this past week.

-M4s

28
Jun

Lending a Hand in Hinche

An M2 Perspective:

Having a dog bite on your right palm should mean that assisting a surgeon in an OR is off the table right? How was I going to learn about being a surgeon now? Lending me a hand, Dr. Srinivasan found a way to get me scrubbed into a patient case and actively participate in the surgery. Though I felt very lucky that I could assist in a left inguinal hernia repair, I only really started to understand the bond that a surgeon and patient share outside the OR.  My first patient was a lively older gentleman, who laughed at my broken medical creole, trusted me to listen to his concerns, followed my guidance to help him get back to on his feet. As soon as the surgery was over, we both became immediately dependent upon each other. I needed him to let me know almost every thing that was going on in his life. From him passing gas to knowing his eating idiosyncrasies, I needed any information I could get to make sure he went home safe as soon as possible. I had not previously realized how bi-directional the relationship between a surgeon and a patient is until the patient is discharged. This point was made very clear when dealing with my first pediatric patient. I was assigned to manage the care of a very irritable four year old boy who needed a simple but very immediately necessary urologic procedure. To help get the boy to the operating room and home safely, I was totally dependent on his cooperation to get his vitals and conduct a physical exam. It seemed like a nightmare at first to even find the pulse on a screaming child. With a developing patience, I learned how to work with him and learned how I could give has as much to my relationship with his sick child as I could. After getting very close with both my older and younger patient throughout the day, I felt I was really starting to learn what it meant to be a surgeon taking care of a patient. I can’t wait to help discharge these patients, knowing that I aided in patient care from beginning to end!

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Uday

27
Jun

Hitting the Ground Running

Today marks the first operative day of our second week here at Hospital St. Therese.

After a weekend with a little more sleep and bolstered by our new bright-eyed and well-rested compadres, we took on the new week in strides. The day started with a tour of the compound, the OR, and our supplies. By 9am the clinic was in full swing again and by 10am our anesthesiology team was putting our first patient to sleep. Throughout the day we shifted our schedule over the typical hurdles with much more ease and completed four major cases and one minor procedure.

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No lights, but the internet works again!

Our second week contains a mix of veterans and newbies; some are here for their 5th or 6th time while some are new even to medicine itself. The freshly minted M2 students have taken this charge with high spirits. The M4s have reciprocated this enthusiasm for learning with an enthusiasm for teaching by pairing with M2s, assisting with pre-op consenting, IV placement, scrubbing/gowning in to surgery, and post-op care.

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Beth, an M2, assisting for the first time

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Goodnight all!

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26
Jun

Week 1 down!…ready for round deux

We finished our first OR week last year with a total of 21 cases at Hospital St. Therese in Hinche and 9 cases at Hospital Bienfaisance in Pignon. We saw 87 patients in clinic, including 9 follow-up patients from previous years. We also performed more challenging cases this year including a hemithyroidectomy, nephrectomy, and (reportedly) the largest prostatectomy in Haiti! We also had a patient with significant blood loss that unfortunately was only able to receive 1 unit of blood from the blood bank (due to per patient restrictions) and required an epinephrine infusion (titrated by counting the drops per minute) throughout the night. The students received a crash course in ICU care and fortunately, all of these patients are recovering well.

We celebrated the end of a great week with an annual tradition of a team talent show at the local bar, Holly Wood Night Club (formerly named Crystal). We have an array of talent among our crew. Dr. Roser read one of his favorite poems “Casey at the Bat,” Dr. Parker serenaded us with his banjo, Maddie (M4) drew a homage to our attendings, several people gave their best Dr. Carney impersonations and Annie (M3) wrote a poem featuring some favorite memories from the trip:

 

“I remember finally getting an IV in a patient,

I remember being embraced by the staff here,

I remember ‘if I stay here any longer I may go to Haitian jail,’

I remember playing street soccer with little kids,

I remember the deep deep grace our patients have shown us.”

 

As we move forward into the next week, we look forward to welcoming a new team to Hinche–some strong returning members and many new faces, including the M1s! Dr. Srinivasan and Dr. Broecker will lead the operative team and Dr. Caridi-Scheible will lead the anesthesia team.

Some highlights from this past week:

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Working alongside our Haitian counterparts

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Reposing after a long day

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Amir had a great time with his patients

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But not so great a time with his bug net!

 

Thank you Team 1 for an amazing week!

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Team 2 let’s go!

23
Jun

Day 4 No Drugs

Another day complete! The team is getting into a good flow with clinic, the OR, and the wards, even though we are still without the medications that we brought down with us…

Today, we made it through 4 operations: a nephrectomy on a patient with a large renal tumor, a small bowel anastomosis on a child with a prolapsed ileostomy, a prostatectomy, and an inguinal hernia.

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In clinic today we saw 19 new patients, several of them being pediatric cases. One patient that particularly stands out is an infant with phimosis who has been unable to urinate. We are planning to take him to the OR tomorrow, aiming to greatly improve this kiddo’s quality of life.

This evening was filled with a bit of nice R&R, including an introductory ashtanga yoga session led by Dr. Haack! Who knew yoga could feel so, so good.

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We ended the day with a group lecture about prostatectomy post-op care and the usual team meeting prepping for tomorrow. What do you get when you combine a pediatric surgeon and a urologist? Well, we’re not sure, but here ya go:

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Annie, signing off

22
Jun

A New Day in Clinic

Hey everyone,

Clinic was busy as usual today, but things are finally coming along. As our first week progresses, we are finally putting our heads together and  developing a more efficient system in clinic. Forms ready in this room, prescription pads placed here, surgical candidates and appointments set up with the clinic leader of the day. It’s crazy how far we’ve come in a few days: from complete pandemonium to a beautiful sense of order. And here we are now reaching our 60th patient! In the OR we completed a hemithyroidectomy, an orchiectomy, a urethral dilation, two prostatectomies, and an inguinal hernia repair + circumcision.

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On a side note, I witnessed a fascinating trend in clinic today: the power of the testicle. From infancy to the end of life, today I saw firsthand how much of a part in a man’s life. As I explained to a 70 year old man with metastatic prostate cancer that he may need a bilateral orchiectomy, he gave me a befuddled look and started speaking in Creole with the translator, both of them laughing. “Cut off my balls?” he said. “I love sex. I don’t want to be less of a man. That’s what they do to the pigs they breed here in Haiti, not the men!” he chuckled.  Later in clinic, we were discussing with a mother that her child with cryptorchidism may need a unilateral orchiectomy. “Will it make him half a man? Oh no, I don’t want him not to be a man,” said the hesitant mother. As I witnessed these conversations, common in urology and often discussed with jokes and laughter, I realized the power that such a hidden, protected part of the male anatomy plays on male psyche and well-being, from birth to death. Such stories show me how complex male sexuality can be and how little we understand it. With the extreme prevalence of prostate cancer, we have a great opportunity, both in urology and medicine in general, to study and further understand the intricacies of male sexuality, whether in suburban Atlanta or rural Haiti.

Ok, no more philosophy about testicles. Here is a picture of my favorite patient, hungry and vigilantly guarding his bowl of rice and beans. Look at that face: “Amir, I like you. But you better back off my rice and beans, you dubby!”

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Ok, time for night call.

Au revoir,

Amir

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21
Jun

Smooth Sailing?!

Howdy friends, family, and followers (hi mom!),

Today was another busy day at Hopital St-Therese. It was a day for ironing out any kinks in the machine, and we are proud to say we’ve made huge strides since yesterday. After a long meeting last night, we went into the day with plans to improve flow through clinic, in the operating rooms, on the wards, and out of the supply rooms. We spent the night improving the flow through someone’s clotted catheter bag in order to get in the proper flow mindset. We are all about flow.

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Dr. Carney and Dr. Osiris, the Haitian urologist, probably talking about flow.

We were able to get our hands on some medications from the local stash to hold us over while our medications are still being held hostage in Port-au-Prince. This was a huge step in the right direction for booking patients for surgery and discharging non-surgical patients from clinic. We completed four cases today – orchiectomy, pediatric inguinal hernia repair, a pediatric urethral exam under anesthesia, and our first prostatectomy so night shifts will be in full swing with the ward quickly filling up. No one got electrocuted in the OR today! We are working on our Creole in order to keep the wards nurses updated – they have been incredibly welcoming and helpful, saving us from overflowing bedpans and q5min vital signs.

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No electrocutions! Exciting for our anesthesia attending, Dr. O’Reilly-Shah.

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Wen and Annie (BIRTHDAY GIRL) hanging out with Dr. Osiris and wards nurses.

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Another shot of the birthday girl, enjoying her birthday (also, Amir).

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M4s taking on clinic!

As always, a significant amount of energy went towards organizing our endless bags of supplies. With three supply rooms and only one key, it’s a constant pinball game to gather the supplies needed in order to discharge a patient, do a procedure, or prep for an operation. That being said, we are  really getting the hang of it.

Tomorrow will be a big day, as Dr. Sharma is heading off to explore another hospital in Pignon with Jesse(M3) and Luke. We will have to make some adjustments without our fearless leader, but we’re looking forward to welcoming Dr. Haack to Hinche!! Luckily, Dr. Haack is bringing a BP monitor so we don’t need to turn a med student into an OR BP-monitoring machine, and also don’t have to deal with shotty wrist-BP monitor that Jesse(M4) used.

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May be an inaccurate read, may be that he was just nervous, certainly might explain his headache.

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Safe travels to Pignon!

Note: all patients pictured in blog have consented to having their photo taken.

20
Jun

Day One in the OR Down…

Day One in the OR Down… without any narcotics. And that was only the first fire we had to put out.

Today was a day for practicing the art of flexibility and thinking on our feet. We started the day by learning that two suitcases full of antibiotics, anxiolytics, narcotics and other pain medications that we’d brought with us the day before would be staying in Port Au Prince while we procured some surprise paperwork. Lucky for us, we also brought a stellar anesthesia team who looked forward to facing the challenge of being without most medications. What they did not forsee was the “shocking” nature of the general anesthesia equipment… they were literally shocked every time they touched the thing.

Meanwhile, most of the medical students worked to set up on our first real day of clinic on the other end of the hospital compound. It was a bit rocky at first, but soon we were able to set up a triage system that suited us and the flow well. We managed to see 37 patients (3 of whom were follow-ups from last year) and schedule 15  procedures on our first day in clinic!

New this year, through the ingenuity of one Luke Philipp, we have developed a way to take images of cells we acquired through Fine Needle Aspiration. We were able to better assess a patient with a thyroid goiter for the potential for cancer.

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On the bright side, Amir brought enough bug spray for the entire team. And we only sweat through our scrubs a few times each.

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Emory Medishare