An update from former Hanger Klinik lead prosthetist Anna Avakian

Leaving Haiti last October was kind of like saying goodbye to a dear friend when you’re moving far away.

You don’t know when you’ll see them next but there are constant reminders or flashes of experiences that bring you back, reminding you of their impact on your life, and how much you miss them.

For example, my friend Esther is forever linked to grocery store tomatoes. She’ll never let me forget a hilarious evening that started with me “squeezing tomatoes” to choose the ripe ones. This involved a mad rush back to the store since I had left the rental video near the pile of tomatoes because I just “had” to buy a couple more on the way out. In my defense they were perfectly ripe and an amazing price!

Reminders of Haiti are everywhere, too.

Summer has returned to the Atlanta area – hot and humid. So far, I’ve resisted turning on my AC at home and have an oscillating fan keeping the night air pulled in through the window to cool me off and lull me to sleep. It feels just like Haiti, and many nights my thoughts drift back there; the experiences and people that have changed my life.

A photo of some of those people, our amazing group of technicians and staff in Deschapelles, hangs on my wall at work. Their smiles forever ingrained in my memory. Above that hangs a colorful painting by a local Deschapelles artist reminding me of the vibrancy of life in a little town worlds away.

A book of Creole Proverbs sits on my shelf at home where, a couple of weeks ago, I even heard a rooster crowing in the middle of the night. I wonder if the time-confused rooster in Deschapelles is still around?

And, I will never be able to look at a hot dog the same way again. For the rest of my life, they will remind me of Haiti and the hot dogs and spaghetti meal that’s a common breakfast there.

I’m hopeful I’ll get to go back. A chance to spend time with a dear old friend. Time has changed us both. Situations are different. But, the love and connection I feel for Haiti and its people is unwavering.

Change

Anna Avakian, CPO, a former lead prosthetist at the Hanger Clinic, has returned to serve another term as lead clinician. Following is her first blog post since her return to Deschapelles.

Change.

Sometimes it seems to be the only constant in life.

In the past year I've experienced a lot of change: a new position within Hanger, a move to a new city/state, a new home, and recently a new boss.

But now I am back in Haiti. Back to the heat, the 3 minute walk to work, and working with the same great Haitian guys that have been our technicians since the doors opened here in February of last year. Many things are familiar here and it's like returning home in some ways; although, it's more like returning to a childhood home as an adult. The same, but changed.

One wonderful change to see is the growth in both the knowledge and skill of the four Haitian technicians. They now take the lead and we come alongside to instruct or guide as needed. They are confident in casting and modifying basic below-knee amputee patients, can fabricate all types of prostheses, and cast above-knee amputee patients well, too. It is a pleasure to see this change here. So many people have joined together and volunteered their time to make this reality that I have the pleasure of seeing. It's a nice change :)

A recap of weeks 4 & 5

I dropped off the last group of volunteers at the airport and waited for the new group to arrive. They weren’t too hard to pick out as they walked down the long walkway toward the parking lot. Jeff, Mark and Rolf all had that typical “deer in the headlights” look as they were being whisked along in a sea of people. We headed back to Deschapelles and, after a quick tour of the hospital grounds, got them settled into Kay Hanger. Since this is the rainy season, transportation becomes problematic for the patients traveling to HAS / Hanger Klinik. There is quite a bit of apprehensiveness for people to leave their homes for fear of not being able to return. Since our buses were not bringing patients in at the frequency of earlier rotations, we decided to make these next two weeks much about education. Joel, Cira, Alex, and Tcho have learned so much already and are more than capable of casting, fitting, aligning and delivering prostheses practically unassisted. The focus during this period of lighter patient loads will be to educate them further on some of the reasons why they make the adjustments they do and to associate a little anatomy and physiology with the cast modification techniques.

Joint teaching time with physical therapy students:
The physical therapy students were covering the psycho-social aspect of being an amputee in Haiti and we were able to join their classes. We had a great discussion group with both classes and our patients in the Klinik. There was a lot of sharing during this session and the technicians, therapists and patients gained knowledge from this opportunity. They were also able to learn about prevention of Cholera as this is the Cholera “season”.

Casting:
I also taught them a new way to cast above-knee amputees. We outlined a casting and modifying course while using Mark, one of our volunteers, as the patient model. The four technicians gathered around, taking notes and asking pertinent questions throughout the whole demonstration. We modified the cast together and they fabricated the standard AK prosthesis, which we would use later during the alignment portion of the course.
After day three of this rotation, we started to pick up again as the buses poured in from Port-au-Prince, Leogane, and Gonâve. While all four of us stayed very busy casting, fitting and delivering bilateral and unilateral above-knee and below-knee prostheses, we still had some time in the afternoons to integrate more education into our mission here.

Anatomy and Physiology:
We took some time to discuss some anatomy and physiology as it pertains to the above-knee amputee. We went over some very basic boney landmarks of the pelvis so they can see how they relate to the fit and alignment of the AK socket. We emphasized problematic areas such as the ramus and distal/lateral femur. This helped reinforce why certain cast modifications were made and why certain boney landmarks (such as the trochanter) are critical to proper AK alignment. Again, they all took several notes and were not afraid to ask questions. The questions they asked indicated that the information was making a lot of sense to them.

Alignment:
Later in week two of this rotation we went over AK alignment and some typical gait deviations they have seen over this past year. We put together a chart that shows the classic schematic man exhibiting the most common deviations such as, lateral trunk bending, circumducted gait, abducted gait, knee instability, and medial/lateral whips. The chart lists some basic causes and possible solutions. We used Mark and the prosthesis they made for him to put the lesson plan into practice. Starting with a perfectly aligned prosthesis we changed one variable at a time. They were to identify the deviation, the cause, and then practically apply the solution. This section of the course provided the most discussion and feedback. They all got a chance to problem solve and associate the reasons why they have been intuitively making these adjustments over the past year. While this group of technicians are extremely mechanical, it was good to show them why a gait deviation is not always associated with alignment but rather, the fit of the socket as well.

Last year, in the early weeks of this relief effort, the focus was to provide as many quality limbs as possible. However, with that said, I am grateful to be a part of the instructional efforts here. Providing 20 to 30 limbs over a two-week rotational span is nothing when compared to teaching four very highly motivated and talented Haitians to provide for their own people. This cliché is unfortunately overused but no words describe our efforts better than, “Give a man a fish and he eats for a day. Teach a man to fish and he will eat for a lifetime.”

A recap of weeks 2 & 3

After a great first week I was excited to really dig my heels in and get a lot of work done. The first task was to drop off the current volunteers and pick up my first group at the airport – Tom Sandy from Ohio and Carton Blasburg from Kolm, Germany. It was a good transition and we began our two-and-a-half hour journey back to Deschapelles. It is exciting to see new people come in to Haiti. I get to play tour guide for a while and show them the ropes. These guys really fit in well and have done a great job in the Klinik and made some new friends in the process.

Some other exciting news was the education and testing that Brandon and I started in my first week culminated in all of the technicians (Tcho, Cira, Alix, and Joel) passing an exam to become recognized for their hard work. They were presented with certificates for Technicians I. I was so honored to be a part of this experience. As I presented them with their certificates I could see how proud they all were. This is very important here as certificates are not given out on a regular basis. It is not just a symbol of recognition; it truly means a great deal more. These guys certainly deserve this honor. Thank you all who have been a part of the Haiti Klinik. The technicians have learned a lot from you.

In the upcoming weeks I will continue to increase their knowledge base in fabrication skills and introduce some more formal classes. We will begin teaching general terms, anatomy, and improving casting skills to allow them to improve their clinical skills. They will learn to become practitioners and be able to practice patient care.

Returning "home"

Last year Hanger prosthetist Chris Blades from Portland, Maine volunteered at the Hanger Clinic in Haiti for two weeks, and is currently serving a two-month term a as lead prosthetist at the Clinic.

I have been very excited to return to Haiti and Deschapelles. I had been looking forward to seeing my friends here again, and wondering how well they would remember me from my first two week rotation one year ago.

It was a great feeling arriving at Kay Hanger after the long journey from Port-Au-Prince. As Brandon had stated on his arrival it felt like coming home. As I saw each of the staff I was always met with big hugs. “Bon Jou!!” “Sak Pase!!” (The customary greetings). I was thrilled they all remembered me and were just as excited to see me. It felt more like a family reunion.

It was a quick week of learning the lead practitioner role and responsibilities. Brandon has done a great job and already having been here I already knew the general flow of the Klinik.

On Monday, the van from Port-Au-Prince arrived and out came one of my patients from a year ago. Kennda is a young teenaged woman who had great difficulty wearing her below-knee prosthesis. She had a very sharp tibia and despite many attempts to relive her pain in the prosthesis she could not get comfortable. We discussed with the surgeons at HAS the possibility of a revision of her residual limb. This was done the very next day (two days before I returned back home). We saw each other one last time to say goodbye on our last night here. I had prayed for her hoping the surgery would make the difference. To my surprise, Kennda stepped out of the van, walking so well you would never know she had a prosthesis at all. When she saw me she ran up to me and gave me a big hug and thanked me again for what we had done for her. It was a great start to my return to Haiti.

The week continued and I saw a few more patients that had returned for adjustments that all remembered me. I love this place; I love these people. It is amazing what an impact we all have here. It is a wonderful thing or as the Haitians would say “ Bon Bagay!”

Hangertat for Humanity

Friday was the day we put into action a plan that I had been working on for about a week now. I call it “Hangertat for Humanity”. I spoke earlier about how Joel’s mom’s house was partially covered by her roof, since the time I saw it I have been working out the details on how take care of this issue for her and Joel. Our trip home from the beach afforded us easy access to the materials in St. Marc. We stopped at the local “Home Depot”, or at least the Haitian version of it, and picked up three 12’x6”x1” boards, 16 pieces of roofing tin, and an assortment of the needed nails. While we were in St. Marc, we also took advantage of having access to the local Deli Mart, a grocery store chain with actual air conditioning. I picked up some milk and cheese, items that aren’t readily available at the Deschapelles market.

As we were getting ready to head back home, Tim realized that we miscalculated and we only purchased half of the needed boards for our project. Thankfully he realized it while we were only five minutes away, as opposed to 45 minutes away. So we returned to “Home Depot” and picked up the additional boards we needed, then we were on our way. Another miscalculation on our drive home nearly forced us to return again. One of the boards came loose while driving through the valley and flew off the back of the truck. Luckily, no one was following too closely behind us, but when the board hit the road, a two foot section broke away. Joel quickly brought our truck to a stop and Franz, the owner of the truck, jumped out and ran after the board. Just before he got there, an on-coming vehicle ran it over instead of maneuvering around it. It broke the remaining 10’ board into two 5’ pieces. This created a new problem for us, seeing how the spans between the support beams on the house were 6’. But, instead of turning around and going back for a replacement, we decided to keep going and figure out a way to make it work when we got there.

We had plenty of time to figure it out because our trip was severely slowed by presence of multiple Ra-Ra bands. Ra-Ras take place for several weeks leading up to Easter. They are a makeshift band that marches down the middle of the road while a large crowd of young Haitians follow as they dance and celebrate. There is man with a whip at the front who will help guide traffic past the band by using his whip to keep people in line. This isn’t the first time we have run into Ra-Ra bands, but since it is the day before Easter, they were particularly prevalent. Historically, the Ra-Ra bands were used to help reduce inbreeding within the various slave groups. The bands were organized as social events and the man with the whip would prevent slaves from trying to run away. On one hand it was sad to think that the youth would continue a tradition that reflected the days of slavery here. But, on the other hand, they did look like they were having a lot of fun! Some of the crowds got so big that they clogged the street and created a human roadblock. Joel would turn us off the main road and we would find another way around. 8 bands later and we were home.

Saturday afternoon, on the 23rd, was spent doing the work on Lorencier’s (Joel’s mother’s) home. She was very excited and was expecting us. Joel and Franz drove all the materials up to her house so we didn’t have to carry them up the mountain. She lives probably 20 minutes away from the hospital, but is probably a third of the way up the foot of the mountain. It is not a very steep climb, but it certainly would not have been any fun having to carry all the supplies. Unfortunately, we still had to carry all the tools, including a 6’ ladder. But, we made the trek and didn’t waste anytime before we started working. Tim must have been sent from God because he had a lot of experience installing tin roofs and nearly put the entire thing up himself. It didn’t seem like long before we were out of sunlight, but we weren’t quite finished. We still had to install the peak of the roof, but that had to wait until another day.

Niekka Love returns & an update on baby Brahms

Monday brought a welcome surprise for me. Niekka Love returned for a follow up and adjustment. If you remember, this was the little girl that broke my heart when I didn’t get to say goodbye. Her mother reports that she has been doing very well and that Niekka said she wanted to stay for a few days. But, she is in school in Port-au-Prince and will be returning as quickly as she arrived. Since our time was limited, we didn’t waste a second. As soon as she was happy with the adjustment I made, out came the soccer ball. Michele joined us at the clinic, and got to kick the ball around with Niekka while I saw other patients. I’m glad she will get to see many of the patients I talk to her about. It is now a memory we can share, instead of a story I can tell.

Another patient she has heard a lot about, returned on Monday as well. Baby Brahms made an appearance for his first tune-up. It was difficult to properly align an infant. His tentativeness, lack of balance, and weak leg muscles masked a few issues that would normally be spotted at first glance.

Last week, when Brahms would stand or walk, it was mostly in a half crouched over position. Today, he was standing up straight, a clear sign that he was becoming more comfortable with his new prosthesis. It also clearly demonstrated that the initial height setting of the prosthesis was too short. When mom tried to let go of his hand, he would have difficulty balancing and wouldn’t take a step without her. After we corrected the length issue, Brahms took off after the soccer ball like a horse from the starting gate. It was probably as close to running as you could get without officially running. We also made an adjustment to the suspension sleeve that holds the leg on securely. We made it tighter, because his Mom said he could kick it off when he would throw a temper tantrum. I think the adjustment help significantly, because Brahms’ self confidence seemed to elevate rather quickly. In fact, I would later catch the little boy that would barely let go of Mom’s hand, walk across the clinic, go outside, and walk the entire length of the front walkway without any help at all. Not only that, but he would do it while carrying a beach ball! A small beach ball, but a beach ball none the less.

So, two of my favorite patients made the day for me. And you better believe that I got my goodbye hug from Niekka this time. Brahms, however, would be staying with us for a few days.

I got a big surprise on Tuesday that kept me busy for the next few days. On March 18th, a cargo ship left Miami carrying some supplies that would help sustain the clinic into the future. It was thought that the shipment would not be received for several months, after I would have already returned home. But, Tuesday would bring box after box of supplies. We took the opportunity to rearrange a few things in the shop to help accommodate the additional stock and it seemed like my first week all over again… counting inventory! It seemed like every time we would finish sorting and counting our stock, a new wave of boxes would arrive. This would happen for the next two days, and a few boxes would linger in during the following week. This particular week would end quietly though. Thursday and Friday was HAS holidays in recognition of Easter. I found the timing perfect though, it allowed my wife and me to take a few days off and enjoy an overnight trip to the beach on those two days.