Brock Cummings, MD Trip Report

Dr Brock Cummings, LLUSM graduate and alumnus of the LL orthopaedic residency, returned home last night after spending over a week earlier this month volunteering at the Hopital Adventiste d'Haiti and kindly sent the following report.  Dr Cummings is currently in private practice in Northern California. 

My team arrived in Port-au-Prince late Friday night, the 12th.  The trip was made rather difficult due to the severe weather over much of the US which ended up costing us our anesthiologist.  He was unable to make it to Florida and didn't arrive in Haiti until the 18th.  We did have some anesthesia services from other teams but not always available.  The best word to describe the situation at Hopital Adventiste is "dynamic".  Everything is constantly changing.

 As has been stated by others, orthopedic surgery was not my only job.  There were frequently too few scrub teams and transport personel to go around.  We frequently transported, prepped, scrubbed, operated, and transported back to the post-op area ourselves.  At times, we were called upon to evaluate nonorthopedic problems.  Radiology is very primitive.  Getting an axillary lateral view of the shoulder or a cross-table or frogleg lateral of the hip is not going to happen unless you position the patient yourself.  As of my time (Feb 12th - 20th) there were no intraoperative imaging options but it sounds as if a C-arm will be delivered shortly.  However, space to maneuver and store the C-arm is going to be a challenge in the small and crowded ORs.  

 Surgical supplies are in fairly good supply but organization is desperately needed.  Things are steadily getting better in this regard.  During my time there, shelving was arriving and there were volunteers working on trying to unpack and organize the stacks of boxes, many of which had literally hundreds of random surgical supplies and products.  The teams before me had made great strides towards assembling basic sets of surgical instruments which was very helpful.  There were small and large fragment sets, external fixation sets, and a SIGN nail set packed and sterile (?).  The small and large fragment sets had basic stuff but none had a full compliment of plate options and none had a full set of screws.  Single packed sterile screws were found in some of the previously mentioned boxes of random supplies.  I spoke with Dr. Scott Nelson who was back in the States at the time and he has plans for getting a supply of screws and a method of organization for refills.  There are Haitian workers who do much of the sterilization of the instruments but they don't always keep the sets together.  We found it worked best to hand carry the sets back to them and assist in keeping the sets together.  This is particularly true of the SIGN nail set and it is up to the surgeon to restock the set with the nail size which was used.  A new autoclave arrived while I was there but was not yet installed by the time I left.  They removed 2 non-functioning autoclaves which required the use of a skillsaw, leaving sawdust covering the entire central supply/sterilization room, including hundreds of individually peel-packed instruments.  Once the new autoclave is functional, it would be beneficial to sterilize all of the peel-packed instruments which were sterilized who-knows-how-long ago, prior to shipment from who-knows-where.  One consistent shortage was working suction, and if suction was available,  sterile tubing usually wasn't.

 The kinds of cases predominantly needed at this stage are not very glamorous.  Lots of wound care needs including debridements, skin grafts, and revision fracture care. However, an untreated fracture or dislocation still shows up occasionally.   If not already familiar with the use of the SIGN nail, it would be worthwhile downloading the techniques from www.sign-post.org.  You need a username and password which are "sign" and "03signtech" respectively.  This may not be as important once the C-arm arrives but it is helpful to be able to put in a femoral, tibial, or humeral nail with distal interlocks without the aid of imaging. There are a huge number of external fixators walking around outside and pin site infections are starting to show up.  Except for the most severe infections, antibiotic treatment is limited to oral meds due to limited capacity in the hospital.  Post-op instructions, in terms of when to change dressings, pull pins, etc, were written on the dressing or cast since there are no patient charts.  Patients are pretty good about keeping their limited records and x-rays and bringing them with them when they return for follow-up.  

 In terms of manpower, it is helpful to have more than 1 orthopedist at the hospital at a time.  When I arrived, there were 3 of us and that number seemed ideal.  More than 1 room could be going on easier cases and it helps to have an experienced assist on the larger cases.  Additionally, as the magical 6 week post-op mark is approaching for many of the patients, having someone available to evaluate x-rays, remove casts, and change dressing is essential.  I was the only ortho the last 3 days I was there and felt I wasn't doing a very good job adequately covering all of the work.  Fortunately I had a very capable medical student, Daniel Patton who functioned like a resident, and also had the help of a general surgeon with ortho experiene from Martinique, Dr. Kanor, who made it managable.  As time passes, having an ortho "clinic" becomes more and more important and 2 rooms, not too far from x-ray have been reserved and stocked with casting and dressing supplies. 

The comforts of the hospital are rapidly improving.  There is now quite consistent electricity and running water (no hot water).  Safe drinking water is easily accessable.  Vegan food is provided and it sounds as if it will be for the immediate future.  Several people got sick while I was there and everyone seemed to think it had nothing to do with the food or water.  Most were feeling well in 24 hours but a couple ended up going home early because they weren't improving.  There were multiple confirmed cases of malaria in Haitian patients so take your prophylaxis.  

The Haitian people are wonderful.  They are truely appreciative, quick to smile, and incredibly stoic.  I had a lady with a Weber C ankle fracture with a widely displaced syndesmosis, and a femoral shaft fracture, stabilized in an angulated position with an ex-fix.  We revised the femur to a SIGN nail and took down the scarring in the syndesmosis and fixed her ankle (except for the medial maleollus which had an overlying wound).  She asked for no pain meds post-operatively until I went by to see her late that night and encouraged her to take some meds.  She left  the hospital the next day with a few percocet.  I saw her 2 days later and she stated she didn't need any more meds.  Not your average Californian!  The kids are truely spectacular.  If it weren't for the Baptists getting everyone on edge, I might have smuggled 1 or more home with me. 

Unless a permanent local orthopedic workforce is established, there will be a long-term need for volunteer orthopedists to continue to help these destitute but wonderful people.  It is important that we not lose interest after the media coverage disappears. 

Brock Cummings