Things that Inspire Us…

 May and June have been rough on Haiti. COVID-19 cases have been spiking and gang violence has increased to unprecedented levels, highlighting and spawning a host of problems. There’s plenty in the news about that, and Jeff Cho wrote a great blog post about how the good Lord extended our oxygen supplies past what they should have lasted for. In the O&P clinic at HAH, May and June have been our first 2 months of operation and it has been an absolute joy to see patients being fit with new legs and devices. So far there have been about 10 prosthetic cases (evenly split between below knee (BK) and above knee (AK) cases) and about the same number of orthotic cases. A few highlights for us (all names changed):

-Anders (BK) He came from far, far away from our clinic with a group of other patients. Everyone else in his group was hospitalized and waiting for operations, so Anders wandered around the hospital. Tim saw him hanging around and invited him into the O&P shop to watch his leg get made. He kept Tim company all day, got his leg, and then ran around the wards until it was time to go home. 

-Lance (AK)-Hadn’t walked since he lost his leg 8 years ago. Tim built him a leg that will tolerate incredible amounts of gait deviation without buckling. He left the clinic in his wheelchair because the first steps were exhausting. A few weeks later he slowly, but steadily walked in for his follow up appointment. 

-Curt (BK)-Young guy who lost his leg in a moto accident-he drove moto taxi for a living. Hadn’t been able to drive moto since the accident, got a leg, and proudly told us at his follow up visit that he picked up passengers on his way to the hospital. And that he’s been dancing-we figure that means the prosthetic is comfortable.

-Pierre. Bilateral AK. Initially his mom asked Tim to make covers for his residual limbs-she carries him long distances on her back, but for the short distances he was walking on his residual limbs and that was painful. Being here long term allowed Tim to gradually raise him up from stubbies until he was ready to graduate to knees. His first priority after getting legs was to hug his mom.

Amid the crazy we are thankful for a good God and the opportunity to work alongside Him.

Leg Day!

 This last week Tim casted, fit, and sent a patient home with a new prosthetic leg. For the patient, it was his first prosthesis. For us, it was the first prosthetic or orthotic fabricated and delivered by Haiti Adventist Hospital’s O&P clinic. It’s also the first leg Tim has made in over a year (he was furloughed early March last year due to COVID). It’s all pretty cool! 

I got to be in the room with Tim and the patient during the fitting and as I watched I thought of all the things that have gone into the making of the moment. Tim’s hands cast the limb, shaped the mold, selected the componentry, and tightened the bolts, but to enable that many other hands have been involved. Our first patient walking out on a new leg is truly an act of God-but one that we hope to make routine. I have written about how Tim and I came to work at HAH, but I would like to share more about how this O&P clinic puts together leg days.

The mission of Haiti Adventist Hospital is to continue the healing ministry of Jesus Christ by providing quality care to all classes of people. Specifically, the problem the O&P department is addressing is an under availability of O&P care to patients in Haiti, particularly poor patients. The goal has been to open an O&P clinic at HAH to provide quality care at a price that is appropriate for the needs and means of our patients. The logistics of doing so are complex. Simply making prosthetic legs anywhere requires large amounts of bulky equipment and a laundry list of supplies. The mechanics of fabrication requires grinders, an oven, heat guns, a sandbox, suction stands, an industrial sewing machine, plus a large assortment of hand tools, as well as consumables like plastic, plaster, glue, rivets, and componentry (prosthetic knees, pylons, and feet, plus all the little things to get those to stay together). Setting appropriate prices is another gambit. Health insurance in Haiti doesn’t cover prosthetic devices so everything here is essentially cash pay. If we give prosthetic legs away for free, we will decimate the industry in Haiti (there are a few-precious few-O&P clinics that already operate in Haiti and we’d very much like to see them continue). But if we set prices based on the cost to actually deliver the service, we may provide for the rich, but rarely for the poor. What do we do? How do we get the stuff here and figure out how to provide it?

First of all, we pray. These are multifaceted issues that are beyond us. We pray for wisdom, partners, guidance. We’ve been nudged and directed and others have too.

To meet the challenges of equipment and supplies, our philosophy has been to purchase what we can locally, as long as the price is not significantly more than in the US, both because it is better for the economy and the climate, and because it is (sometimes) easier than shipping things down. What we cannot purchase in Haiti, we procure and import from the US. Much of the specialized equipment and supplies could not be purchased in Haiti and so it was acquired by donation or with donated funds in the US, and loaded onto a container that HAH was already planning to ship down. A few items (for example: glue, an industrial sewing machine) were available locally and so were purchased in Haiti. Initially, we explored the idea of manufacturing our own components locally, but the equipment to do so was costly and complex, and the product inferior. Instead, we have accepted donations from Tim’s O&P network and created a partnership with a company in the US (Penta Prosthetics) which cleans, tabulates, and shares out used prosthetic componentry to international clinics. Through these partnership we have been able to get componentry our patients will benefit from at the cost of getting it down here. There are certainly supply and shipping costs, but through these collaborations, they are much reduced.

The sum of all these efforts is that O&P clinic operating expenses are low enough that we can set prices-not on our costs or on for-profit targets-but based on Haiti’s funky market and patient need and means. We determine what the patient pays in a few stages. To determine base pricing, we evaluated the local products and prices, our costs, and developed a price list. From there we rely on HAH’s financial counseling office. The financial counseling department assesses patient need and means and can adjust the price paid, pulling from outside sources as needed to get the patient care and keep the hospital solvent. Our systems are not perfect and we have made mistakes (there will be more), but we celebrate that our first patient walked out last week with a leg that fits him. Assuming he continues to show up for follow up visits, and nothing too crazy happens, he will continue to get follow up care at our clinic in the coming months. It’s all pretty cool. We rejoice, thank you for lending a hand, and invite you to join with us in praising a big God who has been knitting legs together for a lot longer than we have.

Leg #1

Container Arrival!

 It felt surreal watching the big, loud truck pull in the gate, but on Friday, April 9, the long awaited container finally arrived at HAH! We have all been hoping and praying for it for so long, and have been disappointed many times, that we did not want to be too excited until it really was real, until we saw the contents with our own eyes! But it was real! A thick, heavy, metal miracle. This last week has been a flurry of activities as we have worked to unpack, catalog, and distribute. Tim has been working in his O&P office as much as he can to get all the new things in place. So far everything works, which is another answer to prayer. He plans to start seeing patients next week-more to follow!

Healing in Chaos

 As March 2021 begins I find myself thinking back to March 2020. Around this time COVID was starting to burst upon us and the pace was incredible. I had worked in a busy MICU for over 4 years by that time and there was a part of me that was excited. Some (pre-pandemic) days at work we would get a few crashing patients at once and the noise level and intensity would hit a certain pitch. The unit would become like a little pressure cooker and I loved it. We had the expertise, tools, and team to handle it. The pandemic started out like that-these were critically ill patients-and we had the expertise, tools, and team to handle it. It was going to be exhilarating-and over by June.

What actually happened was months of semi mitigated chaos, in which we did not have all that we needed to handle it. It pushed us all beyond what we knew was possible. When I left the MICU at the end of July I was worn thin. And then we moved to Haiti. Haiti is not know for stability. Fortunately, we came to HAH. HAH has seen lots of chaos, but for us, in large degree, it has been a place of calm. The pandemic doesn’t rage here like I was used to it raging. Our ex-pat team is incredibly welcoming, kind, and peaceful. We are surrounded by all sorts of chaos, but on our campus we have grass and trees, clean water and calls to prayer. In the opening lines of Genesis there is this beautiful phrase-“and the Spirit of God hovered over the water”. The water was chaotic, and the Spirit hovered there, and then brought order. HAH is not perfect, but the Spirit hovers here, and we actively strive to make it a place of order and healing. 

February 2021 in Haiti has not been particularly peaceful. I do not understand all (most) of the reasons (none of them COVID-mostly about elected term/not elected term, coup/ante-coup? 1? 2? 3 presidents?), but intermittently throughout the month Haiti was effectively locked down in a sort of series of active shooter drills. Some days, transportation vehicles did not run, and the port and schools were closed. Other days, things cautiously opened up. Our employees that live close to campus were able to make it to work consistently, but farther away they contended with blocked roads and might arrive late. Some days they were not able to make it out of their homes at all. Correspondingly, our outpatient visits and inpatient census are down. The container arrived in port (YAY!!) but then the port promptly closed (deep sadness).

Despite all the chaos, HAH continues to hum, albeit a little rougher. In the sputtering lulls, we have kept busy with various projects-remodeling in our front desk area, installed new lights and fans, hung signs, repainted areas that have peeled. I was encouraged one day when I walked into the deserted pediatric ward and found the housekeeping team doing a deep clean. Our day laborers are eager for work and Tim has been doing his best to manage effectively. Over the last two weeks the chaos outside has subsided a little (at least for now) the port has reopened (at least for now) and Tim has begun letting go of construction projects and turn his attention toward getting the O&P clinic set up, working to maintain and propitiate this place as a place of order and healing.

Projects.

I think it is generally true that hospitals breed projects at astonishing rates. Mission hospitals, like HAH, are no exception. Here, besides normal wear and tear, we work with heat, humidity, dirty air/water/fuel, and wide fluctuations in power; serving up conditions seemingly bent upon destroying or disabling machinery of any type. Pipes break, filters clog, the part is out of stock and so forth. It has become even more clear to me that for medical work to be efficient and effective, whole systems are required. 

If you know Tim, you know that Tim loves projects. Let me rephrase-Tim needs projects. I did not quite comprehend the depth of this need when I married him, but this truth was revealed to me one day, early in our marriage, when I came home to find a partially build cornhole set on our coffee table. In any home I think this would have been arresting, but we lived in under 1000 square feet. And he’d been sanding. We didn’t have a garage at the time (and it was cold outside, what, oh lovely wife, was he supposed to do?), so we got him a membership to a maker space so that he could have a place to go and work on “stuff”. After that there was less sanding in the living room, more cornhole sets, and a steady stream of cutting boards, boxes, and other things. He dreamt of building us a house out of shipping containers-one Sabbath we spent a happy afternoon laying out the hypothetical floor plan. What do you think, oh wife, about us buying a house to fix up? Wouldn’t that be fun?

In Haiti, we’ve been oh-so-excited to set up an Orthotics and Prosthetics (O&P) clinic. It is going to be so good and I will write lots more about it-but in order to be able to build prosthetic legs and braces, Tim needs some large, bulky equipment and supplies (think industrial oven and bags of plaster). The best way to get those to Haiti is via a container, and Haiti Adventist Hospital (HAH) has been planning to ship one down. In August 2020, the purchased O&P equipment and supplies were loaded onto said container, and Tim and I loaded onto a plane. We hoped to see the container by Christmas. In reality (2020), it’s nearly February and the container is still not in country, let alone through customs. So after Tim set up all that he could for the O&P clinic, he dove into project work. 

The projects themselves have been quite varied. Tim learned (thank you youtube) how to rekey locks and has rekeyed the hospital. Seems like a small thing, but it has decreased all sorts of frustration and increased efficiency. He’s fixed a fair number of small engines (pressure washer, lawnmowers, chain saw) for the maintenance crew, cut down a few big trees, supervised the planting of others, and has facilitated a lot of trench digging and block laying. He’s happily working on remodeling two 20 ft containers into nice living spaces. Imagine the excitement! Dr. Scott Nelson loves (needs?) projects too and there are hours spent discussing the details. Mostly confined to campus, we’ve built a wellness trail. We’re building a swimming pool. To be sure, Tim is looking forward to starting an O&P clinic, but with that pending, he has immersed himself in fixing and building, figuratively and sometimes literally greasing the wheels that help the hospital run.

Admittedly, I have a soft spot for projects myself, but mine usually don’t involved brick and mortar. I have been working with the team at HAH on process improvement in a variety of ways. The eventual goal is to build up the hospital so that it could support the opening of an intensive care unit. This will be difficult-a 2019 survey noted “124 reported ICU beds” (Losonczy et al., 2019, p. 5) in Haiti and cites the familiar barriers of lack of supplies, training, and so forth. For HAH, overcoming those challenges will require many of our systems to become more efficient-in fact, that is one of drivers for undertaking such an endeavor. In broad strokes, we are examining and implementing new ways to facilitate more timely patient care and waste less (supplies, equipment, and money). We’ve done a couple of things over the last bit:

-Charge Sheet Implementation. We did a QI project around how medications and supplies arrive to the bedside, and then how patients are billed. We made and submitted a nice poster about that, which I’ve attached here for your viewing pleasure. The poster is neat and tidy (thank you Dr. Jeff Cho), but the reality involved cleaning out some terribly dirty storerooms to make space for supplies to be stored closer to patients, and explaining the ideas and steps with our clumsy creole and lots of hand motions. 

-Supplies inventory. We did a physical inventory of supplies at HAH. We sorted through, among other things, cubic feet of ETTs, several years supply of speculums, and PPE left over from Ebola scares. This first step is groundwork for changes to our supply acquisition process.

-Biomedical inventory. Similar to supplies, we needed to know what we have (and what works) in order to inform our purchasing and requests down the road.

We also have a nice education room set up and in use-which brings me great joy. All in all, it has been busy, rewarding, and we look forward to more projects over the next months! 

Losonczy, L. I., Barnes, S. L., Liu, S., Williams, S. R., McCurdy, M. T., Lemos, V., Chandler, J., Colas, L. N., Augustin, M. E., and Papali, A. (2019). Critical care capacity in Haiti: A nationwide cross-sectional survey. PLOS ONE, 14(6), e0218141. https://doi.org/10.1371/journal.pone.0218141