Adaptability

A contribution from Dr. Rajdev (general surgery resident), Dr. Sullivan (anesthesiologist), Dr. Srinivasan (general surgeon):
​A few days ago, Greg, one of our wonderful scrub RNs very innocently leaned up against a wall in the pre-op area. Except it wasn’t just an ordinary wall…it was our OR schedule for the day. One minute it was there and the next minute it was gone, the shadows of its memory merely a smear on Greg’s back. The med students, who had meticulously drawn up the schedule the evening before, were momentarily crestfallen. But in what has become classic fashion, the students were on their feet in an instant, redrawing the board in their four-color dry erase markers (because of course this group of med students had four-color dry erase markers). That’s what this team of students does: they adapt.

​It’s not just the students. Our scrub nurses have figured out how to build OR trays for anything from a simple circumcision to a vesicovaginal fistula repair. Our PACU nurses, who are really ICU nurses at home, have brought their keen eye for patient care to a post-op area with limited monitors—they are our monitors. Our anesthesia team has managed to deliver world-class care while teaching both our team of med students as well as the HBP team of CRNA students. Our attendings, well not enough can be said about how much they have taught us about flexibility. “No weitlaner retractors? No problem.” “No oxygen from the wall? That is actually fine—we’ll hand bag the patient for this four-hour operation.” Most of all, our patients are extremely adaptable. They recover in wards without running water, in close quarters with other patients who have also had major procedures (such as open prostatectomies with continuous bladder irrigations), with nurses who are obviously extremely adept at managing a very large patient census, but can’t be expected to focus on our patients as closely as we can. And, of course, they are always willing to patiently work through our language barrier.

Week two has drawn to a close, and with that comes time for our trip veterans, Dr. Sullivan and Dr. Srinivasan, to leave us with a few parting words:

Notes from the Ether – Part III, by Dr. Sullivan
At the end of every trip I tend to reflect on the week and the bigger picture of working in a resource poor environment. It can be challenging, and even heartbreaking, to encounter another human who is either suffering or dying and try to weigh the benefit of performing surgery with the risk of literally (and I mean that) bankrupting a family and using precious OR time that could help two to three other patients. We, as US citizens, take for granted that health care is available for even the poorest through EMTALA laws. Healthcare workers rarely consider the cost of tests we order or procedures we perform. As physicians, we see a problem and we start fixing it. It’s expected of us by the public as well as ourselves.
 
We are forced to consider more here. We CANNOT just rush in if we see an emergency or get pulled aside by and begged for help. At L’Hopital Bienfaisance there is a process set up whereby they expect every patient to participate financially. Unfortunately, they run on an extremely tight budget (they paid their staff for the first time this year in April), and their experience is patients will say they can’t pay anything when asked. They want all patients to be seen by a Haitian physician for clearance and an administrator to decide how much they will be charged, even if it’s a nominal fee. So when we, as first-world intruders, rush in “doing something” it can be harmful. There is definitely a maturity that goes with doing this trip year after year: you stop seeing their policies via the Emory lens. You start appreciating the wisdom of having expectations of your patients. You still grieve when an easy fix in Atlanta becomes a guaranteed death sentence, but you stop pointing fingers when you remember just the workup for the surgery would deplete the radiology department of their entire stock of Isovue.
 
This is probably the greatest lesson I have learned in my decade coming down to Haiti. There is a need to learn judgment without judging. It is a valuable skill to bring back to the States, for there are times when we CAN operate, but maybe we shouldn’t. 

Reflections on a Week Gone By, by Dr. Srinivasan
I’m constantly surprised at how rapidly one week goes by, whether I’m in the States or in Haiti. My mother once told me when I was 19 that time flies more rapidly the older you get. I’ve marveled over time how spot on those words were back then (I shouldn’t have because my mother is among the wiser people I know). 
 
In this case, a full year’s worth of preparation and work goes into trying to make our time down in Haiti great not just for the patients and Hopital Bienfaisance, but for our Emory group. There is a part of me that is always sad to see the youthful exuberance of the students get replaced with the furrowed brows of concern over their patients.  It’s as if we’ve robbed them of that happy naiveté of youth.  Rounding at night with them, however, I’m struck by how every patient mentions that they’d have never made it through the night had they not had our students watching their vitals, checking their IVs, making sure they were not in pain, and providing them emotional comfort.  We get to give the students an in the trenches exposure that pulls out of them their greatest depths of humanism.  In fact, to watch this every year repeatedly redeems me from becoming entrenched in the cynicism that plagues so many of us when having to confront the day-to-day reality of our jobs.
 
So tomorrow morning our week 2 group heads back to Port-Au-Prince, leaving behind our fourth year medical students who will remain the entire month.  After an excursion to the beach, which we do as an annual wind down for our week, we will rendezvous with the week 3 group lead by Emory faculty Carla Haack (general surgery), Paul Parker (pediatric surgery), Mark Caridi-Scheible (anesthesiology), and Barb Pettitt (pediatric surgery) so we can pass the torch to the next group. 
 
I call myself an optimistic pessimist. Those of you like me will understand precisely what I mean and understand when I say I’m already looking forward to what we will accomplish in the future. We thank our annual partners at Hopital Bienfaisance, without whom all these efforts would be dead in the water.