Day 10 - All In A Day's Work

Some of you may be interested in what we do all day long.  We usually get up around 6:30am, shower, grab a bite to eat and head down to the OR to check out the schedule.  After confirming the list for the day we head out to morning report held on the front steps of the hospital.  There the IC (before his departure) and now Dr Bob organize a brief worship then the department heads give report.

Then depending on how many operating rooms we have assigned to us (ranges from 1-3 depending on how busy other services are) some of us head to the OR, others  start making floor rounds, and others go to clinic.

Pictured below is a patient we rounded on who had bilateral Taylor Spatial Frames  applied for knee flexion flexion contractures secondary to arthrogryposis. 

Laura, Pete's wife, put in some long hours working with her team moving the organizing the new Pharmacy department.

If the transporters are not available to bring patients to the operating room, we have to take matters in our own hands...literally.

The case load in the OR ranges all the way from the simple such as dressing changes under anesthesia to the more sophisticated.  In the shot below, Corey excises a mass from the anterior aspect of the tibia while one of his colleagues keeps the flies away with the electric swatter.

Surprisingly, Pete and I performed the first SIGN nailing of a tibia this late on this trip.  Pete performed the case in exemplary fashion.

We have dealt with a lot of tumors this trip.  The patient below sadly had a large osteosarcoma around the knee necessitating an above the knee amuptation.

Whenever we can, we head up to the breakroom for a quick lunch or dinner.  The last few days it seems as though we've been late for both meals.  In the picture below, Pete was late for a prepared meal and is enjoying a snack from a prepackaged Humanitarian Daily Ration.  Stay tuned for a formal review of the contents of the packet from Pete to follow.

Unlike the young patient below who slept through his xray in the middle of the day, bedtime for us is somewhere around 11pm.  The nights are short and the days are rewarding, but long.

Clinic Is The Same 'Round The World

As orthopods, we view clinic as a necessary evil that we tolerate so we can operate.  The residents are masters of clinic avoidance at home and here in Haiti as well.  I can't blame them as they've learned many of the best avoidance techniques from me.  Every morning the patients are lined up and ready to be seen primarily by myself, Scott, or Dave.

Most of the patients have a date of injury 12.01.10 written on their chart.  Pathology ranges all the way from untreated fractures and dislocations, nonunions, malunions, and on to chronic infections.  We also get occasional consultations for congenital abnormalities and chronic  problems. Case in point is the young woman who presented with a marked various knee  deformity following a neglected tibial plateau fracture 15 years ago. 

Becky has been a tremendous help directing flow of traffic around the clinic area, changing dressings, removing sutures, applying casts, filling prescriptions, and attempting to console patients who have waited to see us for hours.  It has been a thankless job for her.

We're usually dead in the water without xray and we've been fortunate to have a beautiful portable digital xray unit in the clinic which makes it nice for reviewing images.  The last few days we have been sharing our xray tech and machine with the patients from the Emergency Room (image below) which has clogged up our clinic flow somewhat.

However, at the end of the day, in spite of all of the hassles, I believe that we are making a difference, even in clinic.

Jason Tan, Anesthesiologist

I've mentioned before how thankful we are to have excellent anesthesia on this trip.  On Monday, we were joined by Jason Tan, anesthesiologist from the VA Hospital in Loma Linda.  Jason jumped right in and has been a tremendous help as we have been able to consistently run three rooms simultaneously.

I know that Kevin has appreciated having Jason as it has been nice to have an extra pair of hands when managing some of the more challenging cases.

 I would be remiss if I didn't pay homage to our two Haitian anthesiologists, Elkine Jean Pierre on the left and Yvrose Chrysostome on the right.  The former trained in Switzerland and the latter in France and both have been excellent to work with and their services greatly appreciated.

Day 9 - Tragedy and Triumph

Called out of bed this morning to evaluate a 40ish male who presented with a 48h history of insidious onset leg pain.  No history of trauma, infection, fever, or prior DVT.  Since the calf was so tense we elected to take the patient to the operating room on an emergent basis for fasciotomies.  When we opened up his leg, all we found was incredibly foul smelling necrotic muscle, consistent with a diagnosis of necrotizing fasciitis.  Unfortunately, the patient's vital signs began to deteriorate as well necessitating an aggressive approach in an attempt to control the infection.  In spite of performing an above the knee amputation, the patient ultimately succumbed to this incredibly malignant disease process.

As we were struggling to get the aforementioned patient off the table,  I could hear the sounds of a newborn cry in the hallway after an emergent C-section.  I'm consistently amazed at the continuous parade of tragedy and triumph that one is subjected to in the 3rd world environment.

Hopital Adventiste d'Haiti is fortunate to have a rotating team of plastic surgeons visit on a weekly basis.  They are sponsored by the LEAP Foundation and come every Tuesday, usually accompanied by their own anesthesiologist and nurses.  Today we were fortunate to have Dr Ale Mitchell visit with her crew from Dallas, Texas. 

In the photo below, Dr David Wood provides an excellent example of the gentle art of orthopaedics.

In the photo below, Corey Fuller performs his first knee aspiration under the tutellage of Dave Wood and Zach Hadley.  They both reported that Corey has the potential to go all the way.

Yesterday, senior med student Alex Coutsoumpos also joined the surgical team.  In the image below he excises a cyst under the watchful eye of General Surgeon Tom Kramer.

Overall it was a good day.  In spite of all of the challenges this facility will face in the months to come, I remain optimistic.

Norgrove Penny Visits HAH

Norgrove Penny, Senior Advisor for Physical Impairment for the Christian Blind Mission, visited the campus of Hopital Adventisite d'Haiti today.  I'm proud to say that Norgrove hails from my home town, Victoria, British Columbia.   Pictured below are Liala on the left, CBM physical therapist extraordinaire, and Dr Penny in the center.

Dr Penny is internationally recognized for his work and knowledge to help physically disabled children in Africa and Asia. He used a series of techniques for club feet that were among the most advanced in the world and trained doctors in basic medical care and surgeons in advanced skills. He works as CBM's international director for othopaedic work and came to HAH to assess the potential for a collaborative effort with CURE and CBM.

Pa Mange, Pa Bwe

The title phrase above is the admonition given to preoperative patients not to eat or drink past midnight on the night before surgery.  Unfortunately, the edict is often ignored. 

We've had several cancellations including the young lad pictured above and below due to violations of the NPO rule.  

We've had at least two general anesthetic patients aspirate the contents of allegedly  NPO but apparently full stomachs.  Consequently, the anesthesiologists on our team try to employ spinal anesthesia as often as they can.  Kevin's become exceptionally adept at placing these blocks.

"The Quake" Tonight

The PBS series FRONTLINE airs The Quake tonight at 9:00 pm in most locations (check your local listings). This episode investigates the efforts of those responsible for handling the catastrophic January 12 earthquake in Haiti. Correspondent Martin Smith bears witness to the unprecedented scale of the disaster and takes viewers on a searing and intimate journey into Port-au-Princes’ spontaneous settlements, hospitals, and broken neighborhoods in this hour-long documentary.

The Quake questions Haiti’s prospects for real change during this pivotal period, drawing on interviews from a number of experts, including PIH co-founder Paul Farmer; Louise Ivers, PIH’s Clinical Director for Haiti; and PIH physician David Walton.

“This is an opportunity to rethink how aid works and how we, the most powerful country I this part of the world, can work with our oldest neighbor,” said Dr. Farmer. “So I think all that possibility is build into this tragedy.”

CURE Clubfoot Program

Clubfoot is the single most common congenital physical disability - 1 out of every 750 children born in every country in the world regardless of race or geographic region suffers from clubfoot. Over 220,000 children, in the developing world are born each year with clubfoot.

Troy Aikman, Christi Yamaguchi and Mia Hamm are excellent examples of individuals born with clubfoot who went on to become successful in life. A child born with a clubfoot in a developing country however, has very little chance of being a productive, contributing adult.

Clubfoot is a congenital deformity that severely twists the foot downward and inward, making walking difficult or impossible. The good news is that clubfoot is curable and the treatment is inexpensive. It can be permanently corrected without surgery using the Ponseti Method of serial casting if these children can be reached before the age of two.  In the image below, Scott is applying a Ponseti cast on a patient in the Hopital Adventiste d'Haiti Orthopaedic Clinic.

Another happy customer.

If serial casting is ineffective, operative intervention is indicated.  Here Scott is making postoperative rounds on a clubfoot release we performed last week.

The vision of CURE Clubfoot is to eradicate clubfoot in the developing world by working in partnership with number of other international NGO’s, the donor community, and in-country partners to establish countrywide clubfoot treatment programs in the 100 largest developing countries over the next ten years.

Day 8 - The Supreme Master Ching Hai

Many people have inquired as to what we've been eating since we got here.  Other than a couple  of brief forays into the city, we have taken all of our meals on the premises.  We have been fortunate enough to eat delicious vegan meals prepared by followers of the Supreme Master Ching Hai.

 

Supreme Master Ching Hai is the self-titled founder and spiritual teacher of the Quan Yin Method of Meditation with an estimated 20,000 followers world wide.  Ching Hai is a poet, painter, musician, self-published writer and entrepreneur who heads Suma Ching Hai International, a group with business interests in restaurants, fashion and jewelery design. She is known for her philanthropic and humanitarian work and over 30 of her followers have been here since a few days after the big quake providing meals for employees, volunteers, and patients.

They are currently making 3000 meals/day on the campus of Hopital Adventiste d'Haiti.  The menu usually consist of some type of noodle and gluten, aka vegemeat.

The Supreme Master team have also been working with the Haitians to provide a more traditional fare such as rice, beans, and some type of relish.  Every evening we're faced with a major culinary delimma...traditional Haitian vs Supreme Master.

Fortunately, we have plenty of fresh water to drink and cook with.  The water is first passed through a large filtration machine housed on a trailer all donated by the World Health Organization.

Then the water is bottled, sealed, and delivered around the hospital.  I was told that 75 of the bottles pictured below are consumed by the campus per day.

There have been few instances of GI upset among the staff, in part because of the strict sanitary standards.  Every time one of the volunteers enters the living quarter, there is a sentry standing guard who administers a small dollop of disenfectant to cleanse your hands.

Day 7 - The Incident Commander Has Left The Building

After arriving January 19, the Interim Hospital Adminstrator, Andrew Haglund, left Hopital Adventiste d'Haiti early this morning and is returning home.  Andrew drove with the Nelson family to Santa Domingo and will be catching a flight back to Southern California later this week.  The Nelsons will be packing up all of their belongings in the Dominican Republic and ultimately re-establishing their home in Southern California as well.  Dr Nelson will be returning back to HAH early next  Monday for a few more weeks before he assumes his new role as a Pediatric Orthopaedic Surgeon at Loma Linda University.

Pictured above from L to R are Scott Nelson (Medical Director), Christa Chandy (Chief Medical Officer), Ashleigh Cohen (Social Services), Andrew Haglund (Relief Administrator), and Brooke Beck (Nursing Director).  Collectively, this group and others, have faced an unprecedented set of challenges and have skillfully guided this institution figuratively and literally across shaky ground.

Our newly arrived, transient group of Metro Volunteers have been amazed at the efficiency  and accomplishments of the on-site core team that have been working side by side over the past couple of months.  Pictured below from L to R are Dan Patchin (Central Supply), Bob Chase  (Central  Supply) and Jerry Northrup (Facilities Manager).  Jerry's wife, Lanelle also works as a nurse on the wards and has been helping to take excellent care of our patients.

From a staffing standpoint, this place is in a constant state of transition with ever changing  personnel.  It was nice to recognize a new but familiar face when future LLU Ortho Resident Corey Fuller walked through the door to the operating room.  We promptly celebrated his arrival by loaning him to General Surgeon Tom to help with a hernia repair. 

At the end of the day we all packed into the CURE vehicle and drove over to the Hotel Auberge du Quebec for a change of pace including pizza, Haitian style.

In spite of the loss of Andrew and other members of his team, life will move on as exemplified by this little one born prematurely earlier this weekend.  Hopefully, both this little fella and Hopital Adventiste d'Haiti will continue to thrive and grow over the years to come.

Day 6 - Six Days Shalt Thou Labor

Nice to have a relative rest day today.  That is for all of us except for Kevin who was essentially up all last night.  The little fellow with the gunshot wound took a turn for the worse and was transferred back down to the operating room for more intense monitoring.

Early this morning, Kevin, along with General Surgeon Tom and a couple of nurses attempted to transport the boy across town to the General Hospital where it was rumored there might be more sophisticated ICU facilities.  However, when they got there they realized that the "higher" level of care might indeed be a "lower" level of care than what they were ultimately providing.  Running low on supplemental oxygen, the team carried on to the Miami Field Hospital by the airport where they were able to pass the patient on to a truly higher level of intensive care.

The orthopaedic team only had three cases scheduled for the day so we were able to make fairly complete rounds on most of the patients under our care.

As orthopods, we tend to prefer cutting on patients as opposed to writing about them so seeing patients in the clinic and making rounds are our least favorite activities but we always get out spirits lifted when we get a chance to meet up with some of our favorite patients such as Chantelle pictured below with Zach.

Scott has been able to procure a couple of vacuum assisted closure (VAC) devices which have been a tremendous boon for wound management on the orthopaedic service. 

After rounds, we attended the morning church service and enjoyed some beautiful singing.  I'm sure that the non-Adventist visitors in the congregation could have done without the Ellen White homily that followed.

After the church service, the volunteers met in the break room and listened to another farewell tribute presented by the translators from the emergency room and the orthopaedic department.

After the morning services, we got back to work.  There is only one gurney in hospital which necessitates the occasional use of a stretcher to transport our patients to the operating room.

The case of the day was an unfortunate woman who had a huge sarcoma on her right thigh necessitating a hip disarticulation.  Prior to surgery, her family was required to go to the General Hospital downtown to obtain 3 units of blood in the case of excessive blood loss.  Sadly for this patient, she had her left lower extremity removed a few months ago for a similar sarcoma.