Hans Martin Sturm

Hans Martin Sturm is a Swiss architect who along with his colleagues designed 8 dispensaries in the area surrounding the hospital. The idea is to make it much easier for patients to get care, especially for routine matters. Patients shouldn’t have to walk for 5 or more miles on mountain trails and then take a tap-tap (truck with wooden benches in the back) to the hospital. Hans supervised the design and negotiated with both the hospital and the contractors. He was usually quiet spoken, but showed a lot of passion about his task. This involved tough discussions with administrators who were at the same time cutting their budget in other areas. I may be wrong, but I don’t think that architects normally have to negotiate with contractors too. Much of the funds for building these structures comes from the Swiss government. Martin has worked in many developing countries in Africa, Asia, South America.

Many people come to Haiti using their skills to help the people. This is the good news that you don’t hear about much.

Hans relaxing.

Sketch of dispensary.

Back of hospital.

Photo at bar.

Hans’ sketch.

“Doctor: Look!”

About 11 pm a few days before Christmas.

Along with the nurse anesthetist, I had just wheeled back a patient from the operating room to the ICU. There is no intensive care unit (with careful monitoring and close nurse supervision). There is simply a room that we call the ICU because we put the sickest patients there.

The room was dark and crowded. All beds were filled with patients. Family members slept on the concrete floor between and under the beds. This is the usual situation here and in most third world countries. The family takes care of the patient: food, bedding, bathing are their responsibility. The nurses check vital signs, give IV fluids and medications, and change dressings.

In the bed next to my patient’s was a young woman had given birth to twins by Caesarean the day before. The weather was cool, and most of the people on the floor were covered with sheets. Mother was asleep and Grandmother was under the bed with the newborns. The twins looked tiny.

Grandma held out one baby to me. It seemed limp. I touched its arm: Cold. I didn’t see any movement or breathing.

Grandma said something I couldn’t understand. Her eyes said, “Doctor: Look!”

“Oh, God,” I thought, “This baby may be dead.”

Two seconds later, the baby cried loudly.

I said, “Wi, bebe bèl,” (Yes, beautiful baby) to Grandma, and finished the post-operative orders on my patient.

Linda’s visit to Haiti

My wife, Linda, returned home to Florida today. She was here only 6 days. She spent time visiting schools in the neighborhood. Tuition is about US $100 to $200 per year for elementary school. There is no public education, and many people, most people in this rural area, are illiterate.

She told me that the schools she visited have very little supplies. Mostly, they have only a teacher and a blackboard. The pupils, clean and dressed in neat uniforms, repeat after the teacher and copy into their notebooks. Children are polite and behavior problems unusual. Parents value education.

As usual, Linda made friends with everyone. She was a good sport and seemed to really enjoy the long hikes, up and down mountain trails, fording rivers, traveling by tap-tap. She didn’t complain when we missed lunch because of over-optimistic scheduling by our trek leader. She was just happy that we had plenty of clean, fresh spring water to drink at the spring above Verrettes falls. Many people were walking up to their homes from the market. Linda seemed to establish a friendly relationship with them, in spite of the language barrier.

We ran into many pigs, goats, donkeys, horses, and poultry on our hikes. It was quite warm for most of the hike to Verrettes. Afterward, some of the younger trekkers  (and also myself) were exhausted.  Linda though, after a cold shower, was her customary lively, friendly self at dinner.

She showed me her usual affection, which I’ll miss. As you know, I hadn’t seen her since Dec. 19. She even said she was proud of me. (Well, what would you expect?)

I have 3 more weeks here.

Encountering a pig.

On a hike.

At children’s Carnival celebration.

Autopsy

My friend, Marc Fernandez, a 27-year-old internal medicine resident from the UK, arranged for an autopsy last week. Marc is working here for 6 months. His patient, a 33-year-old man with AIDS and hepatitis, had a very large liver. Ultrasonography had shown multiple liver lesions. An ante-mortem diagnosis of metastatic liver disease was made. Unknown primary malignancy.

He had called me in consultation several days earlier. I had recommended no surgery. The patient then suddenly died.

Marc saw me outside of the OR. “They’re starting,” he said. “Come on in.”

The Morgue table (slab) looked identical to those I had seen in the US. A dim light high overhead illuminated the room. In the US there was always a bright spotlight. The air conditioner was working and loud, but the room was warm. There were three young men in the room who I didn’t recognize. They were standing by the door, silent.

The diener (pathologist’s assistant who removes the organs from the body) was amazingly skilled. I recognized him as a man who usually works in the Sterilization room. Using a power saw and a large scalpel, he expertly opened the thoracic and abdominal cavities and removed the lungs, heart, liver, and other abdominal organs in one piece. Quick. Marc and I stood back.

The belly was distended with blood and the liver consumed with necrotic tumor. In fact, most of the liver was tumor. One of the tumors had ruptured, causing the hemorrhage. This was the direct cause of death. Other organs were normal. We suspect that the primary was in the liver (hepatoma), which is known to be associated with hepatitis. We sent a few slivers of liver for microscopic examination. (Some Florida pathologists do microscopic examinations for the hospital gratis. Results take 6 weeks.)

I had my camera in my fanny pack. “Should I take a picture?” I asked Marc.

“You could,” he said tentatively.

My eyes settled on the three men at the door. “Who are those guys?” I asked.

“Friends and family,” he answered.

I put my camera away.

Fête

Sunday, February 5, 2006

There was a fête (party) last night for Drs. Danielle Fleurant and Frantz Ovide (husband and wife), two Haitian physicians who are leaving this week to live in the States. Both have worked (as surgeon and anesthesiologist) here at Hôpital Albert Schweitzer for four years. Both are in their mid 30’s and live with their 9-year-old daughter on campus. This summer Danielle had a bad experience. She told me about it when I was here in August. Two robbers broke into her parents’ home bedroom in Port-au-Prince when Danielle was there. They held a gun to her and stole whatever they could. There was no serious physical injury, but she was frightened and angry. “This is a bad country,” she said. Also she said her daughter could not get a good education in this rural area.

Dr. Ovide doesn’t have a job yet. He wants to practice surgery in the States, but tells me that he would have to take another surgical residency to do this. And that’s what he really wants to do!

There were about a hundred people at the party. It was held around the pool at 8 pm on Saturday. A disk jockey was playing Haitian music over a very good set of speakers. He would turn it down when people would give speeches of tribute to the couple. At least 20 people stood up and gave testimonials. about how wonderful these people are. I’ve worked with Danielle, and I agree that she is a very conscientious and knowledgeable physician. There were a lot tears. Good friends were leaving, probably permanently. Everyone knew why.

Chicken and pork along with fried plantains were cooking on two large charcoal grills. The smell was wonderful, especially since all I had for supper was the routine soup jòn (yellow soup) with potatoes and doughy dumplings. I decided I would stay for all the speeches–and try the barbeque.

Just as the speeches were winding up, a hospital guard hurried up to me. “Gunshot to the neck,” he said. I left the fête with two other doctors. I was wearing my best sport shirt (rather than my usual scrubs). The patient, a 26-year-old man, about 6’2”, 210#, was on a stretcher in the front lobby. The patient was oriented, but spoke very quietly. He was lying in feces. A lot. The smell kept the gawkers back a few steps. There was an obvious left neck swelling pushing his trachea to the right. He seemed generally weak. With urging he wiggled his fingers and toes a little. We moved him to a gurney. We asked for a neck collar, but it wasn’t available. Four people moved him. Six or eight would have been better. One physician held his head as we moved him. When we turned him to examine his back, his sister tried to clean him by scrubbing with a rag and splashing him with basins of water. A gesture for social acceptability.

An x ray showed two cervical vertebral fractures. A bullet was visible in the same area.

Because of the compression of the trachea, we elected to explore the neck. The carotid and jugular were normal. We found a hematoma of the muscles of the neck, we felt the fractures of the vertebrae, and the bullet was extracted. We drained the hematoma.

The next day he was quadriplegic. He could move his left arm a little bit. A tragedy. He developed pneumonia, and two days later, he died. In the US a protective collar is worn by nearly all trauma patients. I think this patient had severe spinal cord injury when he arrived, but it is possible to make a spinal injury worse by moving a patient without very careful precautions. I hope that is not what happened here. Bleeding into the spinal canal and epidural space could easily have caused the problem. The vertebral bodies were intact, and most likely the fracture was stable.

Two days later a nurse found some collars in a large storeroom called the Depôt.

Rotary “mission”

Sun. afternoon, Jan. 29

Dear Family and Friends,

Last night John Judson and his entourage arrived: 6 people from his hometown near Harristown, PA. Dr. Judson was chief of surgery and Medical Director for four years in the late 90’s. He’s about 70 now. He had practiced as a cardiac surgeon previously. He came with (2) his wife, (3) retired orthopedic surgeon, Bill Murray, (4) his wife, a community organizer, (5) a very successful businessman from PA (pension management), Bob Hall and (6) another fellow, David, who works for the State of PA trying to get companies to relocate there. Bob owns several Porches and has met Jerry at some Porche Owners’ get togethers.

Judson is slim, fast walking and talking, very decisive.  He deals well with crises. His crew are all associated with Rotary. They call it a “mission.” They’ve already built a dental clinic in the Dominican Republic with donations from Rotary. The non-physicians in the group work in the medical records department, thinning records. This must be the most boring job in the world. They want to help, and they do.

Working here, a person could get the impression that there are lots of people in this world who are trying to figure out ways of helping very poor people.

Dr. Katy Close went to Moulin-sur-mer today. People here refer to this as “the beach,” but it’s a very pleasant resort. $60 a night includes very good food including lobster, conch, and a great buffet. Also 2 drinks. Katy gave me her fiancé’s phone numbers. I’m to call him if she doesn’t come back.

Katy doing a do.

————————

Do you like any of these paintings? Linda hasn’t always agreed with my taste.

Election

Fri. eve., Feb. 3

The Presidential election is scheduled for this coming Tuesday, Feb. 7. Everyone here seems to think that it will come off on time. They say it’s too late to cancel it. All the Haitians have their Carte d’identité, which is necessary for voting. These are quite fancy and were paid for by some international organization. The election results have to be completed and announced on the day of the election. The winner must get a majority or a runoff will be held with the 1^st and 2^nd place winners. Held when? I wonder if it’s around the time that Linda is supposed to travel.

There are 32 candidates. I asked a guy who hangs around here to try find a complete set of posters. He gave me only a dozen. Each candidate has a motto. For example,

Déjean Bélizaire: “Solèy la ap klere pou tout moun.” (The sun shines for everyone.)

Charles Baker: “Lod-disiplin-travay” (Order, discipline, work.) He also has a bus with “Charlito” painted on the side and the saying, “There’s a place for everyone!”

Stanley Joseph, an administrator here, gave us a lecture on security this morning. He said that American Airlines had canceled flights Mon. through Wed. – and maybe longer. The hospital had canceled all trips to or from P-a-P Sunday through Thursday. All our guards will be on duty here. That’s just great. Some carry machetes. (They’re not allowed to carry firearms.) There will be a policeman on campus. He will have a gun. Joseph said, “Don’t worry, we have plenty of diesel fuel (for the generator) and propane (for cooking). Then he said, “Try to conserve fuel. And be sure you have enough food.” He mentioned that after Aristide left the country, no fuel was available for 2 weeks. Actually I don’t have enough food now. No bread for a week. No crackers. In the cupboard I found some flour, yeast, Crisco. I’m thinking, I could get this propane oven going. Of course, that wouldn’t be in the spirit of conservation.

Dr. Chauvet Exé, a Haitian, the only full-time surgeon currently working with me here, will be going to P-a-P tomorrow morning and won’t be back until Thursday afternoon. He says he wants vote on Tuesday. OK. You see, he can’t come back sooner because of the lack of transportation, and they don’t do absentee ballots.

There’s a visiting orthopedist here, Bill Murray, who has agreed to help me. I’m going to try to get off some extra time when Linda arrives Feb. 16.

Sat., Feb. 4

Yesterday afternoon, the chief of Pediatrics walked into my clinic and dropped a chart on my desk. “Typhoid perforation,” he said.

I quickly wrote a prescription for Tylenol for the clinic patient whose cast had just been removed and told him “Pa randevou.” (No return visit.)

The father of typhoid patient set his son on the examining table. The boy, 13, looked about the size of a 9-year-old. Markedly dehydrated, listless, groaning quietly, dirty, with an umbilical hernia sticking out of a massively-distended exquisitely-tender abdomen.

“How long has he been sick?” I asked Papa.

“Three weeks, he said.”

There was a referral note attached to his “dossier” (chart), largely illegible and completely unintelligible, written by one of the Cuban physicians who work at the Charles Colimòn hospital in Petite Rivière where the patient had gone earlier. Colimòn deals only with the most minor of complaints, and they send everything serious to us.

He received fluids and antibiotics overnight, and this morning, laparotomy. As the belly was opened, a strong putrid smell was apparent. The pus was suctioned out. The nurses were quick to empty the suction reservoirs and removed saturated sponges from the room because the odor was so disagreeable. The patient had generalized peritonitis with a large abdominal abscess. There was 2-mm perforation in his small intestine, which was leaking bowel contents. It would have taken at least several days for a single tiny hole to make the patient so ill. Had he received treatment early in his disease, this complication requiring operation might have been avoided. He should recover fully. John Judson, a former chief of staff here and cardiac surgeon, assisted me.

After this I drained an ankle of a young man with an abscess within his left ankle joint. He said that he had been playing soccer a week ago and a few days later developed pain in the ankle. He claimed that no one kicked him and he didn’t fall. I could see no break in the skin and an x ray was normal. Why would someone like this develop a septic joint?

Dr. Judson hired Linus, one of the guys who hangs around, to catch lizards. He caught 32. They were released in each room of our house as insect-eaters.

Note: after 3 weeks, only 1 lizard remained.

Several weeks later, we realized that we were actually growing mosquitos in large blue barrels which had been placed in the bathrooms to store water for the inevitable shortage.

Closeup of a mosquito larva strained out of a blue barrel.

We (Alumni house residents) could have covered the barrels or put a little oil on the surface. We took a more direct approach.

Ambulance

Fri. Eve., Jan. 27

Dear Friends and Family,

Three of our housemates are leaving early tomorrow morning, a doctor and his family. He’s an internist from a small town in NC. His wife is a nurse and they brought their 13-year-old daughter along. They’ve been here for a month. The Dr. grew attached to one of his patients, a pleasant 15-year-old girl, with possible Hodgkin’s disease. In Haiti, she has no chance of treatment, and her death in a few months to years is likely. He gave money to her mother to go to Port-au-Prince to get passports, and arranged for a special US visa. In a few weeks he expects the mother and patient to come live in his home and get free treatment at his hospital.

He has no definite diagnosis (a biopsy of a lymph node in her neck showed “possible Hodgkin’s”) and no staging of the disease.  He had discussed his idea with his wife and daughter, but he made the final decision alone.

I’m skeptical. Is this really a good deed?  The patient’s family is very poor, they don’t speak English, and the last thing you want if you’re dying is to feel alone. Or to watch your daughter die while you feel alone. Or the letdown of being sent home sicker.

[Followup: March 25, 2006: The family did travel to the States and settled in with the doctor's family. He wrote me:

A biopsy confirmed Hodgkins and CT showed
involvement of the liver and possibly spleen. Bone marrow bx was positive
also, thus stage IV disease. She had her first round of chemo without
problem 2 weeks ago and is due for her second tomorrow. She has her ups
and downs but seems overall to be doing well.

I've thought a lot about this. I seems that things are working out. He may have been right to just follow his heart. She still has a chance for cure.]

——————-

We only have two surgeons here now. The chief, a Swiss, Christian Blanc, left suddenly last week. This increases the workload on the two of us. He was in the OR, and I was alone in a busy clinic today, seeing new and follow-up fractures, gangrenous toes, giant hydroceles, and young men wanting circumcision for cosmetic reasons. At the busiest time, the main triage nurse came in, and said that an “accident, cas d’urgence” had arrived.

I finished writing a prescription for Tylenol (the hospital doesn’t have any narcotics) and I walked over the front of the hospital. I was surprised to see an actual ambulance parked in front. It was painted white and red and had a rotating red light on top. The patient, who was said to have been in a tap-tap accident, was on a stretcher, which had been set on a cement bench inside. This took place in the main lobby, which is the same as the accident reception area. A crowd of about 30 had gathered to watch the patient and me. Gathered around me were the ambulance drivers in uniform and several people who seemed to know the victim. The rest were just people who happened to be in the lobby.

The patient looked about 20. Muscular and good-looking. He was warm, and some bloody froth had dribbled from the corner of his mouth. There was no breathing or pulse. His trunk and extremities were free of any marks of trauma, but behind his left ear was a very large hematoma, which suggests a basilar skull fracture. On turning him, his head flopped abnormally. I suspect that he had broken neck with a high spinal cord injury causing respiratory arrest and death. After this was obvious—in about 5 minutes—I indicated that there was nothing to be done. This was something that probably all the bystanders already knew. I went to the adjoining room and asked the triage nurse if there was any paperwork to be done.

“Non.”

“E kouman li rele? (And what was his name?”), I asked.

“Pa konnen. (I don’t know),” she answered.

A minute later, I stepped back into the lobby on my way back to the clinic. The dead boy and ambulance had gone.

How things “work”

Wednesday, January 18, 2006

Dear Family & friends,

Well, tomorrow I’ll be 1/3 done. 33% is a big chunk. I’m in the groove. I understand how this organization “works.” It has peculiarities.

Actually, I work less here than I did in Florida. We have a meeting most mornings at 7 am, then rounds for about 45 min., then checking the patients who were admitted overnight. Some are in the “adult or pediatric overnight wards,” and others assigned to “overnight outside.” For example, if you break your leg at 9 am, and you hobble or are carried down the mountain over the next six hours, and then wait an hour to get your chart (or “dossier,” as they call it), and then see me who examines you and then orders “radiographie,” well, in that case, you’d be admitted to an overnight ward with no definitive treatment. You would get some pain medication, but not narcotic. No ice to the fracture. I wouldn’t see the x ray because, although the film might be taken, they process it by hand, and there’s no way they’d have it ready. The next day, I’d find the film and the patient, hopefully, not always, put them together and get Albert the cast man to put on the cast. Then, you’d spend another night in the hospital so that your cast could be checked the next day. (They had a child who was casted in August; the cast was too tight, circulation was lost, and the child ended up losing his forearm.)

I can call in staff at night, but it’s not done very often. I had a patient with ruptured appendicitis. Admitted at 6 pm, operated the next day. He did well.

A lot of the doctors complain about the nurses and their attitudes. I don’t say anything, but really, they’re no worse than Largo Medical Center. I used to wait around longer there. They move slowly, but they’re paid peanuts, and their working conditions are not good.

If you don’t find the patient, or if the nurse doesn’t give you the dossier, then you might not see the patient until the next day. This happened to me twice. They don’t call if you skip someone. There’s no telephone between the hospital and the doctors’ homes. Used to be. Fell into disrepair. They send a messenger who knocks on the door. He does not speak English. He carries a note written in French or Creole asking you to come “for better care.” Knocks and knocks sometimes. I always answer, no matter whom it’s for.

I found out last week that the chief of surgery, Christian Blanc, is leaving, permanently. Supposedly has a peach of a job with the International Red Cross. Now, he’ll be able to spend more time with his voluptuous girlfriend in Connecticut. He’s been here for four years. I can’t blame him for wanting to make a change. I just wonder, when he asked me to come down for 3 months, did he know then that he would be gone before I left? I don’t know, and I’m not going to ask him.

I’m on duty this weekend, alone in the surgery department. The other surgeon, Dr. Chauvet Exé, goes to Port-au-Prince every other weekend, to see his wife and family. The medical department has four members. Three of them, including most of the people in my House are going to the beach resort this weekend, Moulin-sur-mer. It's a beautiful place. Delicious fish. I was there in August. Unfortunately, Linda isn't interested.

Pt take chest ball

A knock on the screen door Sunday morning, 3:30 am, Jan. 22.

Note handed to me by a Security guard:

“Allo Dr. Lerner
I need you for emergency

pt take chest ball.”

I put on my scrubs, forget my stethoscope, and trudge to the hospital. Try to avoid stepping on the goat shit. Patient is outside of “X Rayon” waiting for the technician to take films that had been ordered by the physician extender. No orderly. His family, rather calm, considering, are standing around the gurney. They wheel him in and help him onto the X ray table. They actually hold the X ray cassette, since the patient can barely sit up. No effort to protect the family with lead aprons.

The family tells me that the patient was simply lying down in his home when an unknown person shot him through his doorway. They say that they know of no possible reason.

Patient, a tall muscular man of 36 says “Vant fè mal” meaning belly hurts. Multiple puncture wounds from a shotgun on his neck both right and left, his left chest, left wrist and hand, and right scapular area. Chest and cervical films look normal and surprisingly, I can see no shot or bullets anywhere. Examination shows marked abdominal tenderness, distension, and guarding. Neck and hand show puncture wounds, but otherwise normal.

The family wheels him back to the reception area and I call for the OR staff. The nurse helping me is almost my age and slow moving. She is also the only nurse working in the overnight area. I ask her for a urinary catheter and nasogastric tube. She gets everything I need in a few minutes.

I place the catheter into the bladder and notice that there is semen on the patient’s penis. Is this relevant?

OR staff arrives and family wheels patient into the OR. OR nurses are polite to me, but seem a little gruff to the family. The nurses insist that they remove their sandals, so they walk into the room barefoot and move the patient onto the OR table.

Abdominal exploration showed two holes in the stomach, two in the colon, and eight in the small bowel. I sewed them up. I didn’t get back for shower time (6 to 7 am) but I had breakfast: fried eggs, not overcooked.

Today the patient developed a hemopneumothorax and required a chest tube. He looks very weak, but I think he’ll make it.

I received a friendly e mail from Michael Doren, a boyhood friend. He’s traveled a lot, but says that nothing I’ve told him or nothing in my photos have encouraged him to visit Haiti. Maybe I am presenting a bad image of Haiti. Things can be pretty grim in US hospitals too.

A quiet moment between cases