More Magic from Team Goethke

April 21

Today was another very good surgery day.  Once again, Randy performed his usual magic and we finished with the first five cases by about 12:30.  We only had one afternoon case but it was a dandy.  A patient was transferred 2 days ago with an open fracture of her mid distal tibia and fibula.  She also had a complete laceration of the Anteror tibial tendon.  She had originally been debrided and an exfix

Terry, Carrie, and Randy doing a fracture reduction and casting

placed at a hospital a couple of hours away by a visiting foot and ankle surgeon from the US.  The surgeon was leaving the next day for the US and asked me to take over.   I extended the laceration toward the ankle and found the distal stump of the tendon and repaired it.  Then I reduced the fibula and fixed it.  I reduced the tibia and temporarily fixed it with K wires.  Then I put on a TSF and locked it down and took out the K wires.  I added a foot plate with metatarsal pins to hold the foot in dorsiflexion to take stress off the tendon repair.  The whole procedure took a while but came out nicely.  I really enjoy using the TSF.

April 22

Jeannie's birthday as well as Good Friday.  Only one patient showed up for surgery today.  He is a 14 year old who sustained an open fractured tibia in the earthquake.  He has had drainage nearly ever since.  The entire mid tibia had a big anterior bow and was very sclerotic.  I debrided the sclerotic area but didn't find a clear sequestrum.  I placed antibiotic cement in the canal.  I hope it gets rid of the

Carrie working in the Peds clinic

infection.  Jeannie and I went for a long walk in Carrefour with Randy and Carrie.  It has been really great having them here.  They leave tomorrow.  I had arranged for a birthday cake for Jeannie and we planned to celebrate with as many of our translators as possible.  They led us the back way to the Auberge and we got in a dip in the pool.  We all enjoyed a nice meal and then celebrated without the cake.  It was a lot of fun celebrating with Emmanuel, Roosevelt, Jacque, Franz and JJ.  JJ brought his mom who is visiting him from Boston.  They all escorted us safely back to the hospital well after dark.  While at the Auberge, I got a call from one of the mission projects about and hour and a half away.   A security guard had slammed a gate on his finger and amputated the tip of  a finger.  I told them to bring him over and they were waiting when we got back to the hospital.  We took him to the OR and I shortened the distal phalanx a bit so I could close the tip.

April 23

I took advantage of Randy being here and did an early morning case before they had to leave.  It was Randy's 26th anesthetic this week.  He has been surprised at the volume of cases and this has been a pretty quiet week.  I hardly scheduled any elective cases since I was all by myself and still recovering from whatever it was that I had.  I hope they can come back before our year here is over.  If not, there will undoubtedly be more opportunities in the future.

It is the Sabbath today, my favorite day of the week.  After finishing the case we made rounds.  After bidding Randy and Carrie 'goodbye', we went to church at the University up the street.  The rest of the day was very restful, just as God intended.  What a delight to be able to rest and read and send a few emails to family and friends.  I feel energized for the coming week.

A pediatric patient modeling the new gown sewn and donated by volunteers in Appleton, WI.

Team Goethke & Chocolate Cake!

April 10

The trip back was uneventful.  I had some night sweats again last night but definitely not as bad as in the past week.  I can't eat much before feeling a bit queazy.  I hope I'm not making a mistake by going back too soon.  The warm weather feels good.

April 11 - 15

This was pretty much a week of wheel spinning for most of us.  This is the first week since the beginning of the year that I don't have an orthopedist to help me.  Not only that, but I have no anesthesiologist either.  I did my best with my limited energy to make it through the clinic on Monday but didn't quite make it.  I left the last few patients for ZJ to see.  I laid down in our room and he came and told me about the patients and I gave him instructions.  With no anesthesia provider, I had to cancel all of the patients that Steve Lovejoy had scheduled for Tuesday.  There were 6 cases.  I did one wound vac change using conscious sedation and it went well.  I spent the rest of the day just journaling and emailing and resting and getting my energy back for the big clinic on Wednesday. 

The clinic was bigger than the one on Monday.  I felt pretty good until I kind of hit a wall at about 3 pm.  I once again let ZJ see the last few patients and had him tell me about them as I lay resting.  The last thing I want is to have  a relapse of some sort.  My appetite is better and I feel like I am slowly getting my energy back. 

I was able to do a case today.  A visiting general surgeon had an anesthesia provider who was available after they finished their cases.  The case was a multiple trauma I accepted from Milot near Cap Haitien.  It is about 8 hours away by car.  He was injured in a MVA more than 2 months ago.  He has a fractured femoral neck and midshaft femur fracture on the right and an open tibial fracture on the left.  He had external fixators on both his emu and his tibia.  I had planned to remove the ex fix on the femur in anticipation of fixing it with a SIGN nail in about 10 days.  I also wanted to add more pins for stability for the tibial fracture.  It turned out, the tibial ex fix was totally loose and needed to be converted to a hybrid.  I also put on a wound vac since the wound was open with exposed bone.  It took quite a bit longer than anticipated and I felt exhausted.  It didn't help that we lost our air conditioning during the case.  I was dripping with sweat when I finished.

The Friday clinic was not very large and went well.  I was able to finish it without having to lay down.  I am definitely getting stronger and feeling better day by day.

April 16

What a treat to have a full day of rest.  I made rounds on the patients and then just spent the day resting until mid afternoon.  I felt the need to get outside so went for a walk up the street past the University.  I spotted four guys playing dominos so I watched them for a while.  They had multicolored plastic clothes pins that they would trade back and forth depending on who was the winner of the hand just played.  They would clip the clothes pins to their chin and cheeks and ear lobes.  It looked like they had huge multicolored beards.  They seemed to be having a great time.  I didn't have my camera unfortunately.  They probably wouldn't have wanted me to take their pictures anyway.  The mental image I have will last a long time, especially when I reread this part of my journal.  I continued my walk up the hill partly to see how my energy level was.  I definitely want to resume exercising again.  I miss the endorphin high.  I tried using my limited Creole with the people I met as I walked.  They all responded in one way or another.  Usually it was with a big smile.  On the way back down, I passed the domino players who were still hard at it.  They greeted me with waves and big smiles as I passed by.  When I got back, it was time for a nice long rest.


April 17

Today turned out very interesting.  The Bryce family had invited us to their home for a meal.  Stephanie had severe Blounts disease and we did bilateral TSFs with osteotomies of the tibia and fibulas two and a half months ago.  We found out today that she had had two prior surgeries by a Haitian orthopedic surgeon and had paid him a total of $16000 US.  The deformities recurred.


Emmanuel, Roosevelt and Jacque went with us to visit the Bryces.  We found a place selling fresh cut flowers so we stopped and got a nice arrangement for the family.  We had a good time getting to know each other.  Mrs Bryce made us this awesome meal.  She made 3 different kinds of pasta and a huge green salad and cooked vegetables and a huge bowl of rice as well as fried plantains.  We were totally stuffed.  It was really tasty.

When we got back to the hospital, Randy Goethke and his wife Carrie had arrived.  He is an anesthesiologist from Appleton, Wisconsin.  His wife Carrie is a family practitioner with Thedacare.  We know them very well.  Randy gives anesthesia for me regularly at Appleton Medial Center. 

Terry, Randy, Carrie, and Jeannie

He is one of the best anesthesiologists I have ever worked with.  In addition, Carrie's mom built a house on the lot immediately next to our home in Appleton.  It's good to see faces from home.  We went right to work and did a case that I had pending.


Jeannie surprised me with a great chocolate cake for my birthday. She baked it in the Prosthetika oven.  Nathan and Amy joined us and we had a good time stuffing ourselves.  Jeannie also surprised me with  a great gift.  It is a pair of cute little external speakers for our computer.  They work really well.  Now we can watch an occasional video without having to use earbuds.  I tried them out with some music and Jeannie and I demonstrated a few of our rumba moves and a bit of tango that we have been practicing.  What a kick!  It was a fun celebration even if it was for an old man's 65th birthday.

April 18

The clinic was quite large today.  I saw several more very interesting new cases.  I am happy that the $6 clinic fee hasn't seemed to slow down the good new cases.  There have been many new cases of knock knees and bowlegs.  I am sending them all to the peds clinic for a rickets workup.  A patient came in with a post op infection that required I and D.  We had a wound vac change as well as 3 other small cases.  It turned out to be a long day.  My energy level still isn't normal so I took a few breaks during the day to lay down and rest.

I got some really good news today.  It turns out that the list of charges for major and minor surgical procedures only applies to OBGYN.  I'm not sure why the list was posted on the orthopedic clinic door.  All orthopedic cases are still done for no charge unless the patient has some arrangement with the organization that brings them here.

Carrie examining a pediatric patient in the clinic

Carrie spent her day working in the pediatric clinic.  Randy helped me see patients in the clinic all morning.  It really helped since I have no one else to help this week.  He could have easily justified waiting for me to finish and then giving anesthesia for the cases.   Most anesthesiologists would have likely done that and with good reason.  Many have not done any clinic work for many years and it is well out of their comfort zone.  Randy is clearly willing pitch in and help in most any way to share the work load.  I can't express how much I appreciate what  he did.

April 19

There were 7 cases on the list today and then we added on an ankle fracture that came in last night.  We tried to get the ankle case going before 8 am and almost succeeded.  It took me considerably longer than usual.  I couldn't seem to get into "high gear."   It was almost like I was wading in molasses.  Julie was scrubbed since JJ hadn't arrived yet and that was part of the slowdown since she speaks virtually no English.  I had to get virtual all of the instruments by myself.  None of the rest of the cases were very big and they all went well. We finished before 5 pm.  Randy is such a great anesthesiologist.  Nothing fazes him and he gets cases going so quickly.   I gave the guys their Packers tee shirts and they all look good.  It will be fun to scrimmage a bit with them when we get our football.  I took Jeannie and Randy and Carrie in the pickup over to the Auberge to take a dip in the pool and get some pizza.   Randy and Carrie were surprised that such a nice little spot was so close by.  We had a really good time.  The "peekleez" was very good on the pizza.

April 20

I saw 40 patients in the clinic today.  It was a zoo as usual for a Wednesday with the clubfoot clinic at the same time.  I finished before 4 pm and then had three cases which we finished by about 6 o'clock.  I still don't have my usual level of energy but it is slowly improving.  I am so glad the night sweats are over and I have no more nausea.  My appetite is very good.  Stephanie's dad brought us a box of very nice mangos.  That family is really appreciative of the surgery that was done on her legs.

Stateside Sabbatical

Mar 27

I made it to Miami but don’t feel very well.  I have been coming down with something for the last week or two.  It’s mainly headache and nausea.  I called Summer and she gave me the details of the patient with the tibia fracture.  She said that the doctors in Sarasota commented that he had gotten excellent care.  They recommended that he be transferred to a medical facility closer to his family in Michigan.  She gave me the phone number of the person making the arrangements and I called him.  He answered and said they were in a van on the freeway in Georgia with destination Southern Illinois University Medical Center.  They had the name of a Dr Gabriel who they wanted to take over his case.  Apparently some family member had been treated by Dr Gabriel in the past.  I made several calls to SIUMC and finally was able to talk to Dr Sands, the 3rd year ortho resident on call for trauma.  I explained that he was going to be getting a patient who had been injured in Haiti and then the strange “twilight zone” transfer by air transport to Florida and then by van from Florida to them.  He agreed to accept the patient.  I called the group in the van back to give them Dr Sand’s name.  The patient was doing well but apparently his wound vac canister was nearly full.  I advised them to stop at the nearest trauma center and “beg, borrow, or otherwise acquire” a replacement canister.  The alternative would be to drill a hole near the bottom of the canister and let some of the liquid drain out  (a very disgusting thing to do) then seal the drill hole and hope the vac would work.  I spent about two hours making all of those phone calls.

28 Mar

I made it in to Appleton but really didn’t feel good.   Whatever this is, it isn’t fun.  I feel a bit nauseated almost all the time and have a headache.  My skin is hypersensititive and I sweat a lot.   I immediately went to bed and slept for about 4 hours.  I tried to call Jeannie multiple times unsuccessfully.  I called Summer also but she hadn’t heard from her either.  I hope she was able to get a flight finally.

29 Mar

I soaked the sheets last night with sweating.  I finally found out that Jeannie is on her way and will be getting in today at about noon.  I’ve been taking Ibuprofen and Tylenol so I can work.  I went back home right after work and promptly went to bed for several hours and once again soaked the sheets.  I have several total joints scheduled this week.  I am also on call for the ER this coming weekend.   I hope I can do the work.  It is really nice to see Eric and Ken and everybody at work again.  Todd is on vacation this week.  It is really good to be back together with Jeannie again.

30 – 31 Mar   1-4 April

This whole week has been pretty much a blur with work and not feeling well.  All of the joint replacements went well.  The weekend wasn’t very busy.  I had a couple of hip fractures and an elbow fracture.  I was able to get a lot of rest.  Life is pretty “Blah” when you don’t feel good.  I decided to finally get some tests done since I seem to be slowly getting worse instead of better.  My guess was malaria but the smears were all negative, at least at first.  I took the full treatment of chloroquine anyway.  Then I thought maybe hepatitis since my liver enzymes were all very high.  I tested positive for hep b but that is due to the immunization.  I don’t have any active disease.

Apr 5 - 9

Finally one of the smears showed malaria.  Dr Brooks put me on malarone which made me even more nauseated.  The night sweats have nearly gone away but I still feel chronically nauseated and have no extra energy.  Dr Brooks wants to retest for malaria with daily smears.  My liver enzymes are coming down which is reassuring.  It has been beautiful weather this whole week.  I wish I could have enjoyed it.  A young reporter found out about our work in Haiti and interviewed me for about an hour.  He condensed it into about 2 minutes for the 10 o’clock news on Thursday.  They emphasized the coffee table book fund raising effort.  Lynne emailed me from HAH and said that she just found out that the hospital has decided to bill every patient for a bed and also for their surgery.  I am surprised since the last discussion with Nathan was pretty clear.  The financial screening process was going to be developed before billing would be implemented for orthopedics.  I knew it was coming since “fee for service” is the SDA hospital model all over the world.  I wish it had been delayed a bit more so that we could have funds in the Indigent Patient Endowment.  It will be interesting to see what the effect will be on the clinics and on elective surgery.  I hope we are not effectively shutting the door on those who cannot pay.  I plan to do my best under the circumstances.  I hope that orthopedists and anesthesia providers who are planning to come and help will not change their plans and go elsewhere.

Dr Brooks said it was ok for me to travel since my malaria smears were now negative.  Tomorrow I return to HAH.  Jeannie is in Southern California for her 40th nursing reunion and won’t be returning for a few more days.

Fireworks Fallout

Mar 23

Nathan let us know that the excitement last night's fireworks show had caused a lot of concern on the part of the administration and that Mrs Clotaire would be coming to talk to all of us.  Nathan’s words were critical but not overly so.  I interjected that I believe Steve has been an extremely positive influence here and has come here more often and spent more time here than virtually every other anesthesiologist.  He has a big heart for the Haitians and regularly visits the orphanages and supports

Kids at the orphanage flying kites

them.  It was certainly an unforseen consequence but there was never an intent to frighten anyone let alone terrify any patients.  I had already made a dunce cap for Steve to wear during worship.

A couple of days ago, Nathan asked me for a list of the 30 most common procedures we do here.  This morning there was talk as if the hospital was going to start implementing charges for those procedures.    Before that can be done social work capabilities have to be developed to try to discriminate indigents from those with resources.   It will also be important to notify EVERY orthopedist and anesthesia provider that the hospital is planning to do this before starting so that the volunteers know and can decide if they are going to continue to work here or not.  The issue is an important one.  There are many Haitians who are taking advantage of HAH not charging for orthopedics.  This is upsetting the normal situation for the local orthopedic surgeons who would normally be seeing these patients and charging them.  The hospital does have costs and the patients who have resources should help cover those costs.  I do want the hospital to return to being profitable and not have to rely on the current subsidies.  I am even willing to help with that by providing orthopedic services for patients that can pay as long as it is a low profile program.  I don’t want the local orthopedists to perceive me as a threat and disinvite me to their country.

We had a very large clinic today which was gratifying.  There were quite a few new patients also who seemed to fit the indigent profile.  Maybe the 150 goude charge won’t be a significant barrier after all.  I saw another 3 year old with major knock knees probably from rickets and a 5 y/o girl who was injured in the earthquake.  She has a malunited femur fracture that will need to be corrected.  Ron Anderson spent the middle of the day in the OR taking care of a couple of infections.  Then he came back and helped me finish clinic. He is a very hard working orthopedist.  I really am enjoying working with him.  I got called a bit ago for a transfer of a patient with an open tibia fracture.  It might be an interesting night.

Jeannie and Summer made great burritos and bean soup for all of the volunteers.  She also made brownies and baked them in the Prosthetics oven.  What a tasty meal.  She is such an excellent cook.  I am unbelievably lucky to have such a talented, hardworking, attractive woman in my life.

The patient with the tibia fracture is an American from Pennsylvania helping to build houses for the Haitians.  He was riding a 4 wheeler and turned onto a road and was hit by a car.  He had a Gustillo IIIB open fracture (a bit short of having your leg

Phil's ATV after being crushed by the truck.

completely detached.)  Ron and I took him directly to the OR and debrided the wound and washed it thoroughly.  We reduced the tibia and fixed it with a SIGN nail.  There was marked swelling with muscle bulging out of the wound.  The muscle looked viable but with these high energy injuries, it is not always possible to tell what might eventually become nonviable.  We put a wound vac on and a bulky compression dressing.  IIIB injuries by definition have extensive soft tissue loss with exposed bone that needs special attention.  Frequently, plastic surgeons are asked to evaluate and treat these cases.  It is important to get viable soft tissue to cover the exposed bone to reduce the chance of the bone becoming infected.  We do not currently have any plastic surgeons available for that kind of work.  The team that will be coming on Saturday has an upper extremity surgeon who is trained in that type of surgery and perhaps could do it.  Both Ron and I have encouraged The patient and his organization to Medevac him to the US.  We finished his surgery at midnight.  The beat goes on.

Mar 24

Both Ron and I put a lot of energy into that case last night and it tells today.  Steve put in a lot of work also and he could use a bit of extra rest.   I canceled a couple of cases that were elective but went ahead with some others including a redo ankle fusion and a one year old with clubfeet for posterior releases. Steve leaves tomorrow which means we won’t have anesthesia until the Lovejoy team gets here on Saturday.  Steve is a great anesthesiologist to work with.  I have enjoyed the conversations we have had as well as the visits to the orphanages and the “terrorist” plotting with the fireworks show.  I look forward to working more with him here and in the DR.  I also look forward to windsurfing with him in both Cabarete and the California coast.

Mar 25

Today  is our last day here in Haiti for a couple of weeks.  This will be our second trip back to Wisconsin for me to work.  I got notified today that there was another huge snowstorm in Appleton in the last couple of days.  Thirteen more inches of the white stuff.  Maybe some of it will melt a bit before we get back on Sunday. We got up very early to first transfer the patient with the bad tibia fracture to the US (6:15 departure from the hospital) and second to do a case.  Our anesthesiologist, terrorist Steve, had to leave at 8am.  We needed to a dressing change and vac removal and wound closure on a patient before he left.  We won’t have any anesthesia until the Lovejoy team gets in tomorrow afternoon.  The case went fine and Steve made it off just fine.   Ron and I made rounds with Lynn, ZJ and the CBM PT techs and then headed off to clinic.  I saw several of the TSF patients back and they are all doing fine.  I scheduled more cases for Dr Lovejoy and Dr Stutz, the upper extremity surgeon.  We wrapped up clinic by midafternoon which gave us some time to do some exploring.  We hopped in the pickup and Ron and Jeannie and I took JJ and Roosevelt downtown where many artists have their paintings displayed.  I found one small painting of a guy with a big hat and smoking a pipe.  It was really well done.  I paid $8 for it.  We saw a lot of very well done paintings but held off on buying any more.  The traffic was pretty bad on the return but we were able to avoid any fender benders and made it back ok.  We were able to get some good pictures of a voodoo themed taptap. Little by little I am getting used to the city and how to get around.

Mar 26

This morning we were notified that our afternoon flight to Wisconsin through Miami had been canceled.  Apparently a major fire had broken out in the aviation fuel storage area at Miami International.  The Lovejoy’s flight from Miami to Port au Prince was also canceled.  Jeannie and I quickly got ready and hustled down to the airport to see if we could get on some other flight.  There was one standby available and we decided that I would take it since I need to be at work on Monday.  Jeannie had to spend the night in Port au Prince.  She has her own stories of waiting at the airport, then going to a hotel in Port au Prince, and getting to observe a Haitian wedding and all its regalia.

Yesterday, the patient with the open tibia fracture was transferred to Florida.  His organization decided that $35000 for a Medevac flight was too much so they arranged with a small commercial transport to fly him to Sarasota via the Bahamas, a seven hour flight.  They asked if our daughter, Summer, would  be able to go with them and take care of the wound vac and give him his antibiotics.  She and Tim had plans to leave yesterday anyway.  I did my best to talk them out of it.  At least it isn’t by boat.

Firsts & Fireworks

Mar 20
That wonderful rest we all got yesterday has given us all a renewed supply of energy.  Dr Ron Anderson is an orthopedist from The Los Angeles area.   He came to HAH in the weeks after the earthquake.  He is back for another  2 weeks of helping Haitians with their orthopedic needs.  The compound was on lock down for the election so we concentrated on getting caught up with our cases.  Ron and Ben did a hip hemiarthroplasty and I made sure they had everything they needed.  Jeannie is off her back but the bug she had sapped her energy level and I don’t want her to overdo it. 

She had a ‘vegeburger feed’ planned for 7 pm for all of the volunteers and I wanted her to take it very easy in the OR.  For those of you who have never experienced one of her vegeburgers,

Ben, Terry, & Scott

you need to come to Haiti.  If you want to wait until November, you can visit us in Wisconsin and enjoy them there with us.  I know dedicated carnivores who would kill for the recipe.  The hemiarthroplasty went nicely.  Tim and Summer provided recovery services since nursing staff couldn’t provide any extra nurses on a Sunday.  That was really big because it freed up Dr Mulder, our anesthesiologist, to get right into the next cases without a prolonged delay.   Ben and I then did the distal femur fracture.  It turned out to be what appeared to be a nonunion that was possibly infected and took nearly 5 hours.  Fortunately, we had a periarticular distal locking plate for a LEFT femur. (now we have none).  We debrided everything completely and fixed him with the plate and screws and placed antibiotic beads.  Ben and Ron did two more cases together.  Then it was off to the feast.  As usual, Jeannie’s creations were a total hit.  It was a fun event to have all of the volunteers together for a social occasion in the break room.

Ben & Scott work on a TSF

Mar 21
The election yesterday went off with no apparent disturbances.  I was anticipating the typically huge Monday clinic but it was not big at all.  There could be two explanations.  It is apparently common after a big day like election day for people to stay home.  The second possible reason has ominous overtones.  The hospital started charging ALL patients 150 gourdes (about $4) for the clinic visit.  I hope it is not the latter.  If the charge (about half of what most other fee for service clinics charge) becomes an effective barrier for the true indigents, then it will have to be removed or there will be no point in me continuing to work here.  I didn’t come here to take care of people who have jobs and who can pay for their care. 

We had four good cases and Ben continues to be in seventh heaven. We had a hip hemiarthroplasty, bimalleolar ankle fracture, knee arthroscopy and ORIF BB forearm.  All of the cases went well.

I wanted to have Tim and Summer and Ben get a taste of “peekleez.”  We went to the Auberge and Steve, Ron and JJ went as well.  When we got there, another translator had included himself.  We got several pizzas and some rice and beans and peekleez.  Ron didn’t want to try the peekleez but everyone else thought it was really good.  Steve was stacking it on his pizza like there was no tomorrow.  I showed some pictures of Mardi Gras and we all had a great time.

Mar 22

First ever arthroscopic ACL reconstruction done in Haiti

It was surgery day.  We started with the first ACL ever done arthroscopically in the country to our knowledge.  I guess it was fitting that the patient was an earthquake victim.   It took a bit longer than the usual one at home.  The patient had a large bucket handle tear of the lateral meniscus.  Once we got the meniscus out, the case went like a standard ACL.  The second case was a high level soccer player who was playing several months ago, felt a ‘pop’ in his knee and got a big effusion.  He had the classic findings of grade 3 Lachman and positive ‘pivot shift.’  His case went smoothly.  His menisci were normal.  It will be great if these two patients spread the word and we get some more good arthroscopy cases.

New ACL graft in place!

It has the potential to bring good revenue in to the hospital.  The hospital certainly could use the support.  They were good cases for the resident since very few are being done at Loma Linda right now.  I hope it will motivate the powers to encourage the residents to come down for longer rotations.  I could certainly use the help.
 
Steve caused some excitement tonight.  He bought some rocket/fireworks in the delimart and waited until dark to set a couple off from the roof of the hospital.  The first took off high in the sky and exploded with the big blue shooting stars just like in a big pyrotechnics display.  It caused a lot of ‘oohs’ and ‘aaahs’ from the spectators.  The second misfired and twirled on the roof and exploded with a powerful bang roughly over room 209.  It caused some fairly serious concern on the part of the patients in that wing and Nathan put a stop to the show.  I'm not sure of all of the repercussions at this point but most of us that were in range are still trying to get our hearing back.  I saw Emily come in a bit ago apparently at Nathan's request or perhaps a patient's.  I hope we don't have to bail Steve out of jail.  Maybe he’ll have to sit in a corner with a dunce cap on for a little while.  We don’t have any cases scheduled tomorrow so maybe he will escape early to an orphanage or somewhere where it will be difficult for the police to find a 6 foot 9 inch white guy.