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Today, after the last few days of travelling for hours to reach the more isolated parts of Puerto Rico, we drove only twenty minutes from our hotel to pull up under a bridge in Rio Piedras. Our group went to the same location last week with Intercambios Puerto Rico, an organization that provides mental health, social work, and needle exchange services to the homeless population in the area. You can read Nishone’s Day 4 blog post for more background about the organization and the group’s first experience there, and this week we were back to do the same thing, but armed with more supplies: basic medical check-ups, handing out toiletries, and connecting people with social services. I jumped out of the car ready for an entirely different experience than what we had done earlier in the week making house calls and working in clinics. I was ready for patients who were less cared-for and with worse medical conditions than patients the previous days. I was nervous and unsure about how much I could actually help these people in what seemed like such a foreign place, but as soon as I started talking with the men and women who lived under the bridge or slowly came out of the surrounding dilapidated houses, I felt like I was back home 10 minutes from Grady working with Atlanta's homeless population. What I always found on the streets in Atlanta was that people do indeed need healthcare, but they mostly wanted somebody to care and recognize them as individual people with previous lives, families, and a story. My mind quickly shifted from worrying about how to treat patients under a bridge with limited supplies to hearing their stories (as best I could without actually speaking Spanish), listening to their everyday struggles, and helping with whatever they needed, whether that was actual medical care or making sure they got a pair of socks. One man I met was born in New York and came down to Puerto Rico with his parents when he was a kid. Since then, both of his parents died and he fell into poverty. He broke down in tears telling me how much he wanted to go back to New York to be with his extended family and see his new niece and nephew. Even though he had a myriad of medical problems that I tried to focus on, he couldn’t articulate them to us well. I was hardly able to do anything for him medically, but I was able to sit and listen to him talk about his family and support him while he was speaking with the social worker. In that moment, I had to realize that his family was his number one priority, not his health or food security or money. Medicine is such an integral part of my everyday life that it can be hard to realize that it is not necessarily a priority for a lot of people.
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Though today was our third day in Humacao overall, it was my first day in Humacao since I arrived this week and spent yesterday in Ponce. As we drove in to Humacao, I did not know what to expect. I had heard that the town where we would be spending our day, Punta Santiago, took a devastating blow from Hurricane Maria, as it is located directly on the coast. As we approached, I saw both lasting signs of Maria’s footprint, including abandoned storefronts, as well as signs of rebirth, resilience, and strength: a tree with words painted in Spanish saying “I’m still standing” and beautiful murals of Puerto Rican flags. Today we divided into three groups. One stayed at the newly renovated community center for a primary care clinic, while the two others, working alongside P.E.C.E.S and Coalición de Coaliciones employees, made house visits throughout the community. My group began our day by revisiting patients from the previous day who were in need of surgical consultation. As Bonnie mentioned in yesterday’s post, we returned to see our patient with lymphedema. Though we unfortunately did not have a surgical option to offer that would resolve his problems, we could provide additional wound care supplies. In speaking with him and his wife, we learned that the most difficult aspect of his care is getting compression devices to stay around his legs, given that all succumb to gravity as the day progresses. When Dr. Haack reached into her bag and pulled out full-leg compression stockings that clip to a waist belt to avoid slippage, both the patient and his wife were ecstatic. What was a simple medical device to us was in actuality a life changing gift to them. The patient felt that with this he would be better equipped to control his swelling, allowing him a limited degree of ambulation throughout the day, which he had been lacking previously. He then repeatedly insisted that we all receive his phone number so that we have a place to stay the next time we come to Puerto Rico. As we left his house, I was disheartened that there was no surgical miracle that could ameliorate his problem; however, his gratitude in response to our simple supply donation proved that maintaining the status quo and preventing a disease from progressing can also have great value in a patient’s life. Our second house visit included incision and drainage of a sebaceous cyst. The patient was in his 60’s and had suffered a debilitating stroke years ago. His 90 year-old mother was his primary caregiver, welcoming us with outstretched arms into their home. Thankfully, the procedure was straightforward and uneventful. As we were educating the mother on how to care for the patient’s wounds, we heard a knock on the door. An emergency medicine physician and nurse were also conducting house visits. The physician was born and raised in Punta Santiago. She weathered the storm here with her family and feels a strong connection to the community that raised and nurtured her. Now, as a young physician, she makes house visits for patients who are elderly, disabled, or without transportation. All of this is strictly volunteer; she does this on top of her daily eight hour shifts at the local hospital. Her commitment and generosity towards her community epitomized the people we have met thus far in Puerto Rico—continually going above and beyond to aid their fellow human beings as they strive to achieve health equity, not simply equality. A report from a community member gave a slight alteration in our afternoon plans. We were told there was a wheelchair bound gentleman who was without food and water so his home immediately became our next stop. He has had little contact with the healthcare system and was initially reluctant to let us into his home; however, over the course of 45 minutes that we spent with him, he gradually opened up. Tears welled in his eyes as he shared that he was shot five years ago because he was mistaken for his brother who had stolen from the assailant. Since then, his life had been mired by depression, barely getting by with food and water, immobility, and loneliness. He lived alone in a home that was severely hurricane damaged, with repairs moving like molasses whenever he had spare money to put towards them. He slept on a mattress without any sheets on concrete floors with no air conditioning. By far, the greatest impact of our visit was connecting him with social workers who could help him long term in regards to food security, adequate housing, and access to necessary medications. However, I did not feel that we had made a sizeable medical impact. We gave him food, water, and personal care items in addition to checking his vital signs. Nevertheless, I learned that mental healthcare can have a much greater impact. This patient showed me the importance of being present and listening to one’s life story; simply being heard was impactful to this gentleman. As he shared with us his many ups and downs, we were cutting and attaching two twin fitted sheets into one fitted sheet to cover his bare, full-size mattress.
As an aspiring surgeon, never did I think that the most fulfilling part of my day would be listening to a gentleman’s life story while anastomosing two fitted sheets within an un-airconditioned home in Puerto Rico, alongside fellow medical students and an attending surgeon. This shows the importance of applying one’s skill set, coupled with respecting and acknowledging others’ humanity in order to make an impact in others’ lives—no matter how unexpected or unconventional that impact may be. -- Emily DeMaio, MS3 Today, our group split up: some of us went to Ponce to work in the Suboxone clinic there, and the rest returned to Punta Santiago. I was in the Punta Santiago group, so I’ll write about that. Punta Santiago is a beautiful place with rows of houses only a few hundred yards from the beach, and it was one of the first areas to be hit by Hurricane Maria almost two years ago. Flooding from the ocean and the nearby river destroyed many homes, and recovery efforts are ongoing. We visited here last week to meet with a nonprofit called P.E.C.E.S. (El Programa de Educación Comunal de Entrega y Servicio). At its inception, P.E.C.E.S. began as a nonprofit organization focused on promoting economic growth. However, since Hurricane Maria, it has expanded its efforts to provide housing, in-home social work care for elderly community members, and fills in the gaps for whatever else is needed in the region. At our meeting with P.E.C.E.S. last week, we learned more about the community, the storm’s lasting effects, physical and emotional, continuing recovery efforts, and current needs. We also outlined the capabilities of our team and the supplies we had with us. Today, we returned to implement some of the outreach activities that came out of last week’s meeting. The Punta Santiago group split in half, with some staying in a local community center to run a primary care walk-in clinic. The other half went on home visits to see people who, for various reasons, were unable to come to the walk-in clinic. The group going on home visits consisted of fourth-year medical students, two social workers, and a Medicare specialist who worked as both an interpreter and a resource for families on how to take advantage of their healthcare plans. I want to highlight two patients from the morning home visits. The first was a pleasant gentleman from Brooklyn, New York who had chronic lower extremity swelling (lymphedema), a condition that can be life-limiting. When we arrived he was sitting in a big plush chair, cracking jokes and watching a huge TV screen. His left foot and lower leg were swollen, tight, and bright red. His right leg was covered. He told us about his leg swelling, how it had started 10 years ago on the right and then two years later on the left, how a wound care nurse came every other day to change the bandages, how even with her help he never had enough bandaging material, how no matter how much he scrubbed his leg wispy cotton remnants of bandaging would get stuck in the crevices. He told us to prepare ourselves to see his right leg. I was skeptical that I would need to prepare myself, after spending time on the burn unit and vascular surgery. But his leg was one of the most painful-looking, devastating limbs I have ever seen: his right leg was extremely large, swollen, and tight. Lymphedema, an abnormal accumulation of lymphatic fluid that helps fight infection, had distorted it to twice or three times its normal size. Some regions looked like cobblestones, and green mold was growing in between the cracks. There was an open ulcer along the back of his calf as big as my hand, oozing fluid. He had a prescription for naproxen, a medication similar to ibuprofen, which he tried to take only every few days when the pain was unbearable. He told us how during hurricane Maria his house had flooded with five feet of water, and I tried to imagine how he had managed his legs. Soon, he returned to chatting about his favorite sports teams, and told us anytime we wanted to come to Puerto Rico, we had a place to stay. The second notable patient was a 90-something year old, tiny lady who lived alone. She had asthma, had had a few falls, but couldn’t tell us much about them except that she had hurt her shoulder. What she really wanted to talk about was her son, who had died after Hurricane Maria. He had suffered some type of fall, had been unable to get adequate medical care due to the storm’s aftermath, and had died. She was currently living in her son’s house, which brought back her memories of him. She did have a local daughter, but her daughter had cancer. We tried to take her blood pressure, but she became tearful and did not want to stay still. We gave up on the blood pressure cuff, and instead focused on learning more about her son, and listened to her talk about her family and life. As we walked out of her house, we talked with the social workers and Medicare expert about options available for elderly people whose families were no longer able to provide medical attention and in-home care. We learned that there are assisted living facilities that government-issued insurance must help pay for, but most elderly people are reluctant to leave their communities and their land--having now traveled around this region of Puerto Rico, being welcomed by the various communities we have engaged with, we can understand this reluctance to leave. Also, unfortunately, much of the care in these facilities is inadequate for the myriad needs of patients with diverse medical problems. Our patient, left alone after multiple falls and mourning her dead son, had devised several ways to stay safe on her own: she wore a whistle around her neck, and demonstrated how she would use it if she needed help; she had close relationships with her neighbors, who stopped by regularly and sometimes helped her with groceries. It’s a challenge trying to summarize stories like these into a concise take-away. For those who are curious, the first patient will be evaluated by our surgeons tomorrow to explore treatment options. The second patient is working with P.E.C.E.S and other organizations to find opportunities for housing and home care.
I’ll close with a few reflections. First, it was an amazing learning experience to see the process of meeting with a nonprofit, assessing the needs of a local community, and attempting to meet some of those needs. Being able to attend the meeting last week and the outreach today helped me understand the work involved in making a meaningful outreach activity. Second, the outreach and work done by the local Puerto Rican community is impressive. Their patience, care, welcoming nature, and dedication to educating people and connecting them to resources is truly inspiring. Finally, being welcomed into other people’s stories and homes is a privilege. These experiences are reinforcing that sitting, listening, and connecting with other people is a therapeutic intervention that can always be done, even in the most difficult of circumstances. -- Bonnie Stedge, MS4  Today our team revisited the community of Yabucoa to make good on the promises of the first week. We started the day by meeting with community leaders from Parroquia Santos Angeles Custodios, who had already planned for our team to be divided into two groups and visit the more elderly, home-bound members of the community. One team was led by Dr. Haack and the other was led by Emory anesthesiologist Dr. Mark Caridi-Schieble, who has joined us for the second week of activities. The medical students on each team performed vital signs, physical exams, blood glucose checks, and wound care as necessary for each patient while the attending physician interviewed the patient and family regarding their current medical problems, treatments received, and ongoing medical needs. Overall, our team made 26 patient visits for the day and began to function like a well-oiled NASCAR pit crew team as the day went on. We were, in the literal sense, making house calls. My first observation was that the doctor-patient interaction takes on an entirely different dynamic when the encounter occurs within the patient’s own home. In the office, you can’t see a bed-bound patient’s daughter waking her up with a shower of kisses. You can’t see the hole drilled through a wall of the family’s home for the oxygen tubing. You can’t see the positioning schedule posted on the bedroom wall to prevent bed sores.  In these home visits, I gained a new appreciation the people who become caregivers at home--the sons and daughters, the cousins, the neighbors, the social workers. They care for patients long after the visit to the doctor's office is complete, and they do so from a place of deep respect and love; I noticed how the simplest of praises, such as a “good job” for preventing bed sores or following a strict diet, had a marked effect on these caregivers' morale. In discussing this with Dr. Haack on the car ride back from Yabucoa, she told me “Never underestimate the power of just showing up. Showing up lets these people know that their work is not forgotten.” Seeing these small details brought me to another realization – this type of home care, with multiple children and grandchildren living in the same household and caring for the elderly of the family – seems less common, or is at least less visible, on the mainland, where most of the patients we visited today might have been placed in nursing home or assisted living facility. In fact, there are entire books dedicated to the subject of the different ways in which diverse cultures treat and care for the elderly and bed-bound (see Atul Gawande’s Being Mortal for some excellent examples), so I will refrain from rehashing the subject in this blog post. Truly, the devotion and love of the patients’ family members, many of whom had either stopped working or cut back on working to care for their elders, is something that I will not soon forget. Here, in a rural area of Puerto Rico, I saw a segment of American culture that treats aging as a natural, inevitable process that we will all experience, hopefully with grace and dignity, surrounded by the people we love. Our team had a great day today. As a medical student, we crave the feeling of putting in an honest day’s work in the craft in which we are training. The obligations of book-learning sometimes obscure the joy that comes from having a positive impact on a patient’s day--the "soulcraft" of simply working without expectations of results. Today, was one of those days. Our team was smiling on the drive home, with the tired satisfaction that comes from a day spent serving the people of Yabucoa. “You know if you visit Puerto Rico once you’ll keep coming back,” Sacha said to me, “you just won’t be able to forget how beautiful it is.” The conviction in her statement was the same as her passion for helping others: unrelenting. Sacha is one of the social workers who works for Coalición de Coaliciones, spending her days trying to improve the lives of the homeless, addicted, and marginalized community in Puerto Rico. She’s right, too. I won’t be able to forget how beautiful this place is, but it might not be only for the reason Sacha cited. From the pictures on the blog anyone can see that the beauty of this island is obvious. The mountain ranges pour deep green rainforest into a perfectly clear sea painted in different shades of blue. The brightly colored houses populate every ridge and valley seemingly as a natural part of the landscape. But this is not the beauty I will always remember from our journey here. It’s the beauty of the people we have had the privilege of the serving here and the workers who will continue to serve long after we are gone. The beauty is in the family who opened their homes to us and, while apologizing that they did not have enough chairs because they were lost during Hurricane Maria, told us that four of the surrounding families lived in the attic of their neighbor because their houses had completed flooded after the storm. The elderly women shrugged her shoulders as she described the feeling of huddling in the bathroom as the roof was quite literally ripped of their house. “We have our lives,” she said pointing at the empty house they had not been able to repair since the storm; “the rest is just stuff.”
By now if you’ve been reading the blog you’ve probably noticed the amazing amount of local organizations that are doing powerful service in Puerto Rico. Coalición de Coaliciones, P.E.C.E.S., and Intercambios Puerto Rico are filled with amazing people and it is only by their grace that we’ve been able to do the little amount that we have. Standing in Punto Santiago (the area hit hardest by the storm) with Felix, the supervisor of the P.E.C.E.S, he discussed his connection to the community. He explained how the army couldn’t reach the area on land so he gathered as much food and water he could and rode on helicopters that would drop the supplies over the town. Our group has been extraordinarily lucky to make connections to people like Felix. He is an integral part of this community and he has given us a pathway to help his community. One of the men who spoke to us at the opioid rehabilitation clinic told us that he had finally entered the clinic because he simply felt “miserable.” He had stayed, however, because of the community he found within the center. He discussed the joy he felt helping other members navigate the journey to end their addiction. His positivity illustrates the beauty this community brings. The beauty stems from a connection these communities have with each other, forged in the despair of shared crisis in Maria and made unbreakable by the joint humanity they shared afterwards. One night as we ate dinner, we discussed what it takes to serve a community well--I can see clearly now that it is the connections you develop. Whether it is connections to the under-served or connections to those within the community that have dedicated themselves to serve that purpose, their buy-in to our program is essential. Thinking of Felix, Francisco, and all the patients we have been lucky enough to serve, I believe we’ve made a good start. -- John Larson, MS4 Our week began with new intentions. Out of disappointment towards not going to Haiti arose a new sense of responsibility towards Puerto Rico and its beautiful people. Over the past week, we have been gifted the opportunity to meet these people, hear their stories, build relationships, and provide what services we can. Seeing the devastation left by Hurricane Maria, we have often had to remind ourselves that we are still in the United States. Yet, through fallen trees, leaking rooftops, and crumbling walls, the resilience and kindness of the Puerto Rican people has never failed to shine through. In Humacao, we were welcomed into homes with open arms and offerings of cold water bottles. A gentleman who received medical care under a bridge of Rio Piedras gifted our team one of his only possessions – watches he had intended to sell. He was profusely apologetic he did not have the correct batteries but insisted that we purchase the batteries and keep the watch to remember him. We wish to become doctors in order to serve others, but the benevolence that pervades Puerto Rican culture has showed us what “to serve” truly means. We experienced such kind gestures even beyond our medical relief efforts. Walking to a nearby beach after a long day’s work, a homeless gentleman selflessly stopped traffic so our sizable team of 12 people could cross the street safely. Acts of kindness such as these remind us of our commonalities as human beings. Under the bridge in Rio Piedras, we were united by something as simple as turkey sandwiches (turns out, food is delicious no matter what race, religion, or ethnicity people identify with). Sharing a simple meal was all that was needed to build enough trust and rapport with the community to allow us to address their blood pressure and glucose levels.
In all honesty, this trip is not our annual surgical relief trip to Haiti. We do not have the current capability or capacity to address acute surgical issues in Puerto Rico as we did in Haiti. Our success here cannot be measured by the number of patients we see or operations we perform. And that’s okay. But even though this is not our usual Haiti trip, we have found some similarities: we have been humbled by similar smiles and gratitude we found in Haiti, we have been welcomed with kindness and warmth, we have been given the opportunity to learn how to care for people who are far less fortunate. The Puerto Rican people seem grateful for the simple reminder that they have not been forgotten, and we ourselves are equally grateful for the opportunity to show the people here that we care. We are working to ensure that our primary care efforts and medical supplies distributions will linked many Puerto Ricans who fall into the medical coverage gap with services that would not have otherwise been available. Furthermore, we hope that the partnerships we are building and research we are conducting will go towards building a surgical capacity network much like what exists in Haiti. As we head into the second half of our two-week trip, there are no feelings of disappointment. Only a sense of hope towards the future and a realization that there is only one rule on this island: you’ve got to be kind. Kareem Al-Mulki, MS4 On our fourth day, we loaded our cars with supplies, grabbed our stethoscopes and blood pressure cuffs and headed out to the streets of Río Piedras, San Juan. Even though it was only a 20 minute drive from Miramar where our hotel stands, the contrast was evident. We rode into an area plagued with beaten-up shops and abandoned houses covered with shrubs, in the middle of which was our base for the day; underneath large bridge. Uncertain of what to expect, we kept our minds open; ready to serve in any small way. It was under this bridge that we met with representatives from the non-government organization, Intercambios Puerto Rico (http://intercambiospr.org/) Since 2008, Intercambios has been providing clean needles to IV drug users in different cities in Puerto Rico. The organization has since started offering other necessary services to the community. While speaking with Jennifer, one of the representatives, we learned that the branch we met with focuses on providing mental health and social work services to the homeless population in Farjado and San Juan several times per week. The large bridge under which we gathered acted as a central spot where the individuals of the Río Piedras community could conveniently meet. Additionally, it was interesting to find that though services provided by Intercambios are limited, the organization expands their effect by collaborating with other nonprofits such as Coalición de Coaliciones. After speaking with the representatives, we populated the table they assigned to us with the supplies we had. One by one, individuals, some of whom had not been to a doctor in months, trickled in for blood pressure and glucose checks, wound care or simply to thank us for being present. We also had the joy of providing sandwiches and water before or after people made their way over to our table. As frustrating as it was to know that longitudinal care was not something we could offer, the gratitude expressed by each patient made it worthwhile. Furthermore, this experience has made us more aware of the assistance that this particular community needs. Now we will be better equipped to serve in the upcoming week.
While one part of our team served in the neighborhood, a few others attended the “Respuestas al Consumo de Opioides en Puerto Rico” conference. The conference highlighted various issues associated with the opioid crisis in Puerto Rico and the different strategies proposed to combat it. I particularly enjoyed a panel centered on the opioid crisis and the Justice system. The panelists discussed various legal measures that are being used to assist persons with a drugs addiction. This brought a new perspective to me as a medical student: here, an issue which I initially considered totally medically was being positively addressed legally. Everyday while in Puerto Rico, I am constantly reminded of the power of unity and positivity. Whether it is collaborating in the effort against poverty and homelessness or drug addiction, unity and positivity are crucial components for triumph. When we unite ideas are coalesced to create workable ones. When we remain positive, we gain the strength to overcome the insurmountable. http://intercambiospr.org/ -Nishone Thompson, MS3 Our third day in Puerto Rico brought us to a part of the island we had not yet ventured to, Humacao. This municipality sits on the Eastern most side of the island, just North of Yabucoa. After a long journey through the hills, we arrived in the barrio of Punta Santiago, a beach town that has found itself in disrepair since the destruction caused by Hurricane Maria. The picturesque ocean vista prefaced by a lawn of idyllic palm trees is marred only by the realization that with such natural beauty comes a predilection for tropical storms that cause destruction unlike anything a landlocked Atlanta-native such as myself can comprehend. Our goal for the day was to meet with members of the organization P.E.C.E.S. (Programa de Educación Comunal de Entrega y Servicio), a non-profit dedicated to supporting the development of southeastern Puerto Rico. The team sat down with two members of their team, Felix and Alexandra, who elucidated the unique role P.E.C.E.S. played in recovering from the storm. Due to the path of the hurricane, Humacao and Punta Santiago in particular, were some of the first and hardest hit areas of the island. It was here that citizens infamously spelled out, “S.O.S. Necesitamos agua/comida" (“S.O.S. We need water/food”) on the streets before federal aid workers would begin dropping supply packages to them and it was also here that P.E.C.E.S. received these packages and distributed the food to citizens in an organized manner. In speaking with Felix, a program manager for P.E.C.E.S., we asked, “What do you believe has been the biggest barrier to Punta Santiago’s recovery from the storm?” To which he instantly responded, “the flooding.” In an environment where tropical storms and flooding are guaranteed to arrive each year, Punta Santiago weathers an annual beating of its land, buildings and public morale. The resources available allow the town to barely recover the losses and physical damage incurred each year with little money left to even consider investing in preventative measures or substantial renovation. For added effect, Felix points to the wall behind him to show water stains several feet high that have persisted since Hurricane Maria in 2017.  Endowed with at least an initial understanding of the organization’s history and mission, we left Punta Santiago with plan a to return for two full days next week to aid in outreach to the community’s elderly and bedridden population. Additionally, our conversations identified potential for a future collaboration between their organization and other departments at our institution.
An early evening provided an opportunity for the team to get to know San Juan in new ways. As we roamed the dimly-lit cobblestone streets of Old San Juan at the end of the night, it was Felix’s words that my mind found itself perseverating. What struck me most was the earnest positivity he maintained in his efforts to better his community, despite his frustrations with the economic and physical state of Punta Santiago. His concerns stem from the equally immutable forces of nature and government, flood waters and bureaucracy—yet somehow his spirit pushes on. This energy and positivity have been shared by all the Puerto Ricans we have interacted with but it was not until today that I internalized how special and uniquely Puerto Rican these qualities were. The energy is contagious and we are excited and ready for what awaits us tomorrow. -Amit Pujari, MS4 The second day of rural travel took us to Ponce. Nestled on the southern coast of the island, Ponce is the second largest Puerto Rican city. Entrance into the city is marked by a monument spelling P-O-N-C-E, each 20-foot letter proudly guarding the way into town. We met Francisco Rodriguez, Director of Coalición de Coaliciones (see our last post for details), just inside the city and followed him through the town center towards our day’s destination. The streets of Ponce are lined with beautiful homes and storefronts, huddled together next to the narrow avenues. Many of the old facades are vibrantly colored, the Puerto Rican flag painted on the occasional door.  Source: https://en.m.wikipedia.org/wiki/Letras_de_Ponce We arrived shortly at an unassuming building on a busy street corner. Inside lay Francisco’s pride and joy – an opioid addiction clinic that serves marginalized members of Ponce’s community. We were promptly introduced to the clinic staff with many hugs, smiles, and handshakes. In tune with the rest of the surrounding city, the clinic was brightly decorated and the walls were adorned with messages spreading motivation and the importance of community. The clinic offers numerous services to its patients, including suboxone prescriptions, group therapy sessions, and social resources such as housing placement and employment options. Our task for the day was simple: listen and learn. Some of us were fortunate enough to sit down with two of the clinic’s patients to hear their stories. They discussed their struggles with opiate use, their paths to addiction and their motivations for seeking help. The conversations were remarkably similar to ones I’d had at Grady. Each of us on the team were humbled by the level of positivity expressed by these two Puerto Rican men—when asked how life was different before and after the storm, one of the men explained that people seemed to look out for each other more, even amongst the most marginalized members of the community. Other students began to look through some of the data and records that Francisco and his clinic have been meticulously collecting for years. Dr. Haack received an unexpected consult on one of the clinic’s patients who, amongst many other difficult life circumstances, had been living with wrist pain for six months due to a retained piece of glass. I had a chance today to reflect upon each of the patient encounters that I’ve had over the past two days. As a medical student, all these interactions had a refrain that I am all too familiar with: an overwhelming number of people enter a room to talk to a patient about a sensitive matter and I quickly become conscious of my inability to provide any clinical utility to the situation. When I’d applied to be part of the trip during my first year of school, I dreamt of the rewarding feelings I’d get after helping to perform surgeries in impoverished foreign communities. The feelings I had after these recent patient encounters were far from rewarding. I felt intrusive, even embarrassed by the fact that I had imagined I could help even a single struggling Puerto Rican.
But the more I think about it, the more I am starting to realize why I came here and what we can do to help. As a new third-year medical student, I have three well-refined skills: listening, waiting until the right moment to ask questions, and staying out of the way. While these talents are marginal in a busy academic hospital in the mainland United States, they seem to be the perfect fit for house visits in rural Puerto Rico in the wake of a natural disaster. More than surgical procedures or new prescriptions or advanced imaging, these Americans seem to want to know that their pain and loss has not been forgotten. They have stories to tell. With the strength they derive from their pride and sense of community, they have been able to weather the hurricane and its aftermath thus far. Perhaps the most meaningful way to contribute right now is to present ourselves as fellow members of the American community who want to listen, ask questions, and be unobtrusive. If it takes a room chock full of young adults in blue scrubs to make a family feel that they are heard and cared for, then the value of the trip thus far cannot be overstated. - Sam Broida, MS3 On our first day trip into rural Puerto Rico, we traveled to Yabucoa, one of the poorest towns in the region. Francisco Rodriguez is the director of Coalicion de Coaliciones, the organization that Dr. Haack has been working with since the storm, and he was our guide and educator for the day. As we drove out of San Juan, he told us about Yabucoa: a low-lying valley in the heart of the sugar cane-producing region of southeast Puerto Rico that suffered a massive economic decline in the mid-20th century as the result of an effort to transform the country from an agricultural to an industrial economy. Unfortunately, this drastic shift spurred a wave of migration into the cities, leaving Yabucoa with little means of supporting itself. In terms of access to healthcare, the nearest hospital is in neighboring Humacao, a 30-minute drive when the roads are clear and transportation is available. But when the storm hit, Francisco said, the water poured down from the mountains and rose in from the sea, trapping the people of Yabucoa for over two weeks. Flooding in the valley utterly isolated those in the surrounding mountains, cutting off communication and transportation with neighboring towns. Then, after the water receded, the people of Puerto Rico suffered from la desastre despues de la desastre – the “second disaster” of the sociopolitical crisis that engulfed the island in the aftermath of the storm. The confluence of these factors mean that, close to two years later, rural communities across Puerto Rico are still recovering. Our first stop was at the residence of Giña, an elderly woman that suffers from Alzheimer’s dementia. Giña was born in Puerto Rico and is an American citizen. However, due to the peculiarities surrounding Puerto Rico’s status as a territory of the United States, Americans born in Puerto Rico are not always eligible for Social Security benefits in the same way they might be in the 50 states. Therefore, currently, Giña can only obtain Medicare Part A and depends on income earned by her children to pay for medications and treatments not covered under this plan. Indeed, family bonds in this community form a safety net: Giña’s children said they were taking turns raising the funds to pay out-of-pocket for office visits to her neurologist and to pay for the seven different medications she was prescribed. As we spoke with her family and worked on finding her a neurologist that would take her insurance, questions arose: which of these medications is making an impact on the course of this woman’s disease? What are the specific benefits that are worth the cost incurred by obtaining them? How can we alleviate the obstacles to care for this woman? And for this group, with the comparison of Haiti always in the back of our minds, we wonder how we can improve the ways American citizens in rural areas gain access to medical care. We continued visiting homes in the area and experienced just how difficult it is to get from one place to another in hilly areas with narrow (through well-paved) roads; getting from one home visit to another took 30-45 minutes, and while we were fortunate enough to enjoy some beautiful countryside vistas, we could see and hear echoes of Hurricane Maria everywhere we went—torn awnings, downed trees, rooves under various stages of renovation—and we could imagine the isolation and desperation many of these people felt during and after the storm. As we continued our trip through Yabucoa, we learned that one of the patients Francisco had seen a year ago was currently hospitalized, and two had since passed away. We ended our day with a visit to two neighboring families. We first visited Buenaventura, an 82-year-old man with Parkinson disease who had excellent family support, but required the basics of elderly care: adult diapers, gloves, lotion and antibiotic cream for skin breakdown. Across the street, we visited Iris and Joaquin, a couple whose home had been completely destroyed by the storm. For over a year, they lived across the street with Buenaventura and his wife while they rebuilt their house.
Leaving Yabucoa, I felt like I was starting to see Hurricane Maria and its aftermath in a different light: as a great equalizer that tested the resilience of all. Today’s stories showed me that a person’s ability to recover from the storm was not measured by their family wealth or access to healthcare, but by the strength of their bonds with friends and family. We’ll return next week with supplies in hand to do our part for this community and to get to know its members better. --Brian Pettitt-Schieber, MS3  Welcome to the first blog post of the Emory Haiti Alliance’s trip to Puerto Rico! I know that it may be confusing to follow a blog post from Puerto Rico on the Emory Haiti Alliance page, so let me take a second to explain!
As you may know, the Emory Haiti Alliance has been committed to serving the people of Haiti for the past 10 years. Every year we bring a dedicated group of surgeons, anesthesiologists, scrub technicians, nurses, residents, and medical students to perform surgeries for the people of Haiti and give many of them the opportunity to gain a new lease on life. We spend countless weeks preparing for a four-week trip where we provide general surgery, urology, oral maxillofacial, and pediatric surgical care. At the end of our trip, we return back home and immediately prepare for the next year’s trip. As we prepared for the Haiti trip this year, we learned of the political unrest that began to unfold in the country. After many weeks of deliberation, we decided to forego the Haiti trip this year due to safety issues. We were all very excited to return to Haiti this year and were disappointed when we came to our final decision. We could have decided to just entirely cancel any global health effort this year, but this team of fourth-year medical students isn’t like any you’ve seen before. Peyton Hanson and Amit Pujari, two of our trip leaders, led the charge this year to find another avenue to help. Luckily, we didn’t have to look far. Dr. Carla Haack, a general surgeon and one of the surgeons participating with the efforts of the Emory Haiti Alliance, suggested that we look into assisting her in Puerto Rico. Dr. Haack was born in Atlanta, but is strongly tied to her Puerto Rican heritage. After Hurricane Maria, she was one of the first physicians to land in Puerto Rico to assist with the post-hurricane medical efforts. Since then, she has made countless trips to the most vulnerable regions of Puerto Rico, providing any assistance she can as the island recovers from such a powerful natural disaster. Along the way, she has developed strong ties with various non-profit organizations and other healthcare providers; additionally, she has also become intimately familiar with the people of Puerto Rico, and has made it her personal goal to give back to them. So where do we come in? This year, our goal is to assist Dr. Haack with her efforts in Puerto Rico. This will mainly include developing detailed surveys of the healthcare needs of different communities in Puerto Rico. We will work with different communities and discuss with the different citizens what sorts of medical care they need, such as wound care, blood glucose monitoring, and basic medication refills. After these surveys, we will go back to our base camp for the day and organize our supplies so we can make sure to meet the needs of the community. When we revisit these communities, we will come with supplies-in-hand and be prepared to efficiently provide care in the exact way that these members need it most. Another large component of our trip is research and global education. As members of the Emory Haiti Alliance, we pride ourselves on developing our own global health acumen, while avoiding the trap of global “volun-tourism”. One of the main ways we combat this is developing research questions that we strive to answer during our time away from home. This year, it becomes especially important to pursue these research questions for two reasons. First, for many of us this is our first time in Puerto Rico, and we are not familiar with the culture and views on healthcare; thus, research provides education for us as we enter into this community, to ensure that we provide care while not violating any cultural norms. Secondly, after the physician shortage following Hurricane Maria, there has been a scarcity of reports outlining the health care needs of the community, both from a medical and surgical perspective. Our goal is to close this gap of knowledge by communicating with the people of Puerto Rico, non-profit organizations, and members of the hospital system, and to implement surveys that will elucidate the barriers to care that currently exist. For the next two weeks, we will be updating this blog as frequently as possible. You’ll get to meet our medical student team (6 fourth-year medical students and 6 third-year medical students), see pictures, and hear some amazing stories as we travel through this beautiful island. I’m excited, and I hope you all are too. So sit back, relax, and enjoy the blog! Stay tuned for the next blog, where we introduce ourselves a bit more and outline our first day coming into Puerto Rico! - Ehab Nazzal, MS4 Thank you to all of those that followed us this past month on the blog! This will be our last post of the 2018 trip, so please follow along with us next year. And if what we have written about this summer resonated with you, please consider donating to our trip. We always have unexpected costs to reconcile when we come home, and we start planning for the next year's trip the day we come back! Absolutely any amount helps.  A contribution from MS4 Beth Carpenter: A summer thunderstorm is rolling in when Dr. Pettitt, MS4 Uday Betarbet, and I make our slow progress up the long, steep driveway from our house to that of Dr. Guy Theodore, the founder and father of Hospital Bienfaisance de Pignon. The road is heavily shaded by the Caribbean jacardanda trees and palms, and as we approach the house we begin to see Dr. Theodore’s beloved birds wandering around: chickens, turkeys, ducks with chicks, geese (who have taken a nip at more than one of us), and his gorgeous peacocks. When he’s nowhere to be found, we start the descent down thinking we misunderstood and we must be meeting him at the hospital—corrected when we see his early 2000’s land cruiser headed our way. “Our meeting is not until 1pm, no?” he cheekily asks. It is 1pm on the dot. We all climb in and head to his house, where he seats us on a beautiful cantaloupe-colored veranda overlooking the trees on his property. We are rather humorously joined by at least five different kinds of birds, who clearly follow Dr. Theodore. To meet Dr. Theodore is to meet the soul of Hospital Bienfaisance, a dream since eleven years old in the 1950s when he lost a close friend. There was no medical provider at all in Pignon to come take care of his friend who fell sick and soon after died, and Dr. Theodore promised himself that if he could become a doctor he would come back to Pignon to serve. He did well in primary and secondary school with high expectations from his family, who raised him to believe that intelligence is a gift from God and one must give to their country. He went to medical school and completed his internship in New Jersey and surgical residency in New York at Kings County Hospital, afterwards serving in the US Air Force for seven years starting in 1977. Every year during his vacation time, Dr. Theodore would come back to Pignon to help in the Catholic and Baptist clinics. During this time, he created a leadership group to whom he presented in 1978 his vision for a hospital. “When you get the acceptance from the community, that is the biggest thing,” he told us. Because while the majority of the money to build the hospital was sent by Dr. Theodore (for the most part earned by moonlighting as a surgical resident in Arkansas), the community banded together to assist. In 1978, only one truck a week made the journey through Pignon on the way from Hinche to Cap Haitien and thus a truck was unavailable to assist in construction.
 From left: Des (translator extraordinaire) MS4 Corinne, Dr. Painson (local general surgeon), MS4 Beth, Dr. Theodore, MS4 Lindsey, MS4 Danielle, MS4 Uday  Hillary Clinton visits Dr. Theodore at the hospital The community of Pignon organized a rotation among the different schools of the town to haul sand, water, and rock from the mountain themselves. “It is their hospital—they have the sweat in it, the contribution in it. The hospital of Pignon is not like the common missionary hospital where outsiders came. They did the whole thing, and then others joined,” Dr. Theodore explained. The hospital was completed in 1981, and Dr. Theodore sought out a partner in the United States. He founded the Christian Mission of Pignon in Arkansas, but a name change was soon in order. “It was a commitment that you made at eleven years old, and--they said—a promise made is a promise kept,” Dr. Theodore recalls. The organization Promise for Haiti continues to be the main partner of the hospital to this day. Dr. Theodore retired from the USAF as a full-bird colonel in 1983. He could not advance any further without giving up his Haitian nationality, which he refused to do. Instead, he returned home to Pignon. The structure was there, but now he needed to build a hospital. “If I’m being honest with you—I’m a surgeon, not a hospital administrator. That’s the reality! So I came and I made something kind of like a hospital,” he joked. He recruited nurses and techs from around Haiti. International groups such as ours from Emory soon started coming to assist in 1983, with the first group from Arkansas. But Dr. Theodore understood that sustainability was at stake with these strategies. “Just like in the States, when you’re in a small community like Pignon it is hard to retain! But I want a system which will sustain itself.” He created a scholarship for the poor, sending children of Pignon to primary and secondary school to become nurses and lab technicians and doctors. Without naming any names, he told us that many of the faces we see in the hospital every day were once children in his scholarship program. His life’s work is recognized internationally. Pignon was the site of the first rural rotary club in Haiti, and as the president of the rotary club of Pignon and later Governor of the districts of the Caribbean, Dr. Theodore traveled throughout the region. He was chosen in 1999 as “Man of the Week” by ABC news in the United States. He was honored by the American College of Surgeons in 2000 with the Humanitarian Award, and shortly after by USAID as an international leader. He will be celebrated at his upcoming 50-year medical school reunion this year in New York City. Throughout our meeting, Dr. Theodore fondly recalls the evolution of medicine over the span of his career, citing the birth of the nurse practitioner and physician assistant. He experienced the development of surgical operations commonly performed today, such as the carotid endarterectomy, and the dawn of surgical specialties such as head and neck surgery and pediatric surgery. “When people talk about novelty in medicine today, sometimes I laugh!” he chuckled. His sense of humor entertains us for the entirety of the meeting. When asked if there is a video tape of his 1999 interview by ABC, he quips that the footage is better found on YouTube. When a rooster begins getting a little too feisty, he yells as him to be nice and eventually expels the rooster from his presence for being too loud.
He explains that the hospital requires over $40,000 a month to run, and Promise for Haiti contributes only about $10,000 a month—so where must the rest of the money come from to keep the lights on if we don’t ask patients to contribute what they can for their medical care? Many of his words carry an undertone of the ethical principle of justice, which describes fair distribution amongst the many. In a world where it feels like we characterize the success of a surgical trip like ours by the sheer number of operative cases and the complexity of the care we deliver, can we truly state that we are helping the region when our case load may place the hospital generator and/or available hospital resources at risk? And as we've discussed before, our most valuable surgery to offer in Haiti may be the humble hernia repair, which can give a patient back his or her chance to provide for their family. Perhaps we can redefine our idea of a job well done not by the number of cases, but rather by the strength of the partnership we build with our host institution, which will hopefully translate into many more lives and livelihoods saved. On the very first day of our first week of operating this summer, Dr. Sharma stated rather colorfully that he didn’t care how many cases we did this year because that wasn’t how he wanted us to characterize the success of our mission here. “Many come, but few return,” he stated one morning as we walked to the hospital. We look forward to be among those that return.  "Core M4s"
 She is here for her first follow-up appointment to have her sutures cut and the JP drain pulled, which is often placed at the end of an operation to drain excess fluid from healing tissue. Pulling a drain after 10 days is no comfortable affair, as the body has begun to heal and form adhesions to the drain. These adhesions do not break painlessly. As I turn back to face the patient, she clutches my scrub top with her arthritic right hand and winces in anticipation of what is to come. Des, our faithful translator, speaks calming words to her in Creole as I tighten my grip on the drain. “Okay, now pull it and don’t stop,” Dr. Pettitt commands. In one fell swoop I pull the drain and place gauze over the wound it left behind. The patient yelps and gives a retaliatory yank to my scrub top. She pants her breaths and whispers “Merci, merci,” relief showing as the pain passes by. It is moments like this encounter with a patient and her daughter that have struck me most during my first time here in Haiti. The daughter was her mother’s primary caretaker and was present for every step of her care with us. She had brought her mother to us to help alleviate her suffering. The patient and her daughter placed faith in us - people who do not look like them, do not act like them, and do not speak the same language as them. They trusted us to cut her open. They trusted we would do our best. And they have trusted us to take care of her after surgery. We are foreigners to this country and this city and have been granted an incredible trust by the people of Pignon that we will do unto them as we would unto ourselves, our mothers, our fathers, our siblings, and our families. This thought caused me to ask a series of questions to myself over the next few days - how would I feel if a group of foreigners came to my hometown of Toccoa, Georgia, and were performing surgery on my own mother? How would I want them to treat her? How would I want them to act towards us? Would I wonder what their intentions were?
Dr. Paul Parker, an old warhorse pediatric surgeon who has frequented this trip, explained it best when he told me, “We don’t get excited for hernia repair back in the States, but here these people’s livelihood depends on their ability to perform manual labor, rendering the hernia repair of utmost importance.” Most importantly, I would want them to work humbly, treating my family and my hometown with respect and dignity. For this thought I must give due credit to Dr. Carla Haack, an Emory acute care surgeon with whom I got to operate this week. At the beginning of each case, she would end the call to order by saying, “and we are here to care for this person with as much love, dignity, and respect as we would our own family.” If someone were to perform surgery on myself or my family, I would undoubtedly hope that the surgeon would refocus the OR on this objective before the case begins. Admittedly, I had hoped to come to Pignon to find answers, such as how to care for patients in low-resource settings and how to be a better student of surgery. But I found that I have left with more questions than I have found answers. How can I serve these people best? What improvements can be made to the care we provide, as myself and my student colleagues begin to plan next year’s trip? And most importantly, how can we best do unto others as we would have done to ourselves? 
One year ago, he underwent an Indiana pouch, which is an extremely complex operation in this environment. His postoperative course was rocky to say the least. He developed an ileus and needed an NG tube for decompression—try managing a nasogastric tube without any wall suction available! Despite his difficult recovery, he got better and charmed the entire surgical team while he was at it. At his discharge we were all wrapped around his little finger. When the word came that he had seen a local physician who told him his operation had failed and that he needed dialysis, hearts broke on all sides of the Caribbean. Arrangements were made to see him in Clinic as soon as possible. He and his mother made the long, long journey from the island of LaGonave to Pignon to generously share the news, in person, that he was thriving! He’s doing well in school, and his biggest complaint is that mom won’t let him play soccer. His workup indicates intact kidney function. Perhaps we can make a difference, one case at a time. This brings me to considering the aspect beyond humans- the environment. We are spoiled by our hosts this year- 24 hour power, toilets that flush, bottled water. Bottled water, while an incredible convenience, creates an unimaginable amount of waste in greater than 90 degree heat. Haiti struggles to manage basic needs, recycling is not an option locally- plastic gets burned. Yep- burned. That’s it. Well, this year, I am personally carrying all the recyclables we consumed back to Atlanta with me- a small portion of the waste generated by humans in their day to day lives. A minuscule, perhaps insignificant, dent in the amount of waste we dump into our Mother Earth every day, but I refuse to add to the problem if it within my power to do otherwise. I come to be part of the solution, not the problem.
Some of today's photos from Week 3! |
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