The following post was authored by Terry Dietrich, an othopaedic surgeon currently practicing in Wisconsin. Terry, along with his wife Jeannie, and orthopaedic PA Karen Fields, spent two weeks last month volunteering at Hopital Adventiste. Part 1 of Dr Dietrich's report can be read here. Thanks to Karen Fields for providing the photos.
April 21
Work in the OR ended at midnight after getting bumped for a C section for nearly 2 hours.. I finished the day with the lady with the AK amputation. Her wounds look MUCH better. She probably is going to live. I’ll have the plastic surgeons see her tomorrow. Dr Guptay came over again from the U of Miami facility since there isn’t much orthopedics being done there. I helped him with a hip hemiarthroplasty. He is a total joint specialist. He got a bit stuck at one point and I solved the problem for him. I assisted Scott on another Taylor Spacial Frame. This is a 15 y/o with a 40 degree back knee. He has a partial growth arrest. It is really remarkable what this device is able to do.
April 22Two of our patients didn’t show up for their scheduled surgery so I finished before 7 pm. We had some good cases. Two were tibial fractures that we fixed with SIGN interlocking nails. A different orthopedist came from the U of M facility today. He will be coming back in a couple of months to work for a week here. He is from Iowa and will bring his wife(OB-GYN) and two teenaged children. Scott and I showed him how the SIGN nailing system works. We planned to fix the pt with the tibial plateau fx with a hybrid fixator but he still needed debridement so we just debrided him again and put the wound vac back on. We are incredibly busy, but that is what we came to do. The volume of cases is really enormous. Today was just 13 hours of nonstop orthopedics. The patients just keep flowing in to the clinic and transferred from all the other hospitals in the country. We constantly work with plastic surgeons, general surgeons, pediatricians, neurosurgeons, anesthesiologists, ER docs, wound care specialists, therapists, nurses and technicians of all types. Fortunately, many of the hospitals want to get their patients back as soon as possible after we do their surgery. A surgeons dream - operate, operate, operate and have somebody else take care of the patients afterwards. Scott Nelson leaves tomorrow so I will be in charge until I leave next week. I'll probable age a couple of years during the next 7 days. I feel so fortunate to have such a good supply of energy. A hand/upper extremity surgeon is supposed to come tomorrow for a week and an LLU ortho resident is supposed to come on Sunday. Scott says he will be a big help. There have been a lot of key people who left today or will leave tomorrow including Jan the wound nurse and Kaye a terrific physical therapist. They will be missed, but you never know who might show up in the next group of volunteers.
Same start time. Wrapped up the OR at 11 pm. Scott left at 6 this morning. The day was a bit chaotic but we managed to get a lot done. Sanjay came over again from Medishare and stayed until 8 pm and was a big help. He is a really good guy. He is planning to come back again in July/ August. His wife is from San Sebastian, Spain and spends those two months there with their kids and her family. He says San Sebastian is a really neat city. It is on the north of Spain next to France on the Mediterranean. It has great surfing and restaurants and is really beautiful. He and I did the patient with the femur fx and the tibial plateau. We didn’t do the SIGN nail on the femur because the ex-fix pins had some drainage so we decided to replace the ex –fix with better pins and improve the alignment. We did fix the tibial plateau with a hybrid fixator and it went well. I am going to try to do the same with the patient with the infected tib plateau if the infection is cleared. The 80 y/o with the ex-fix on her femur also had pin issues and we decided to just revise her ex-fix instead of doing a SIGN nail. Sanjay was disappointed. He really wanted to do one before leaving in case Scott isn’t here when he comes back. I was able to do the girl with the very unstable recurrent dislocation of the patella. It went well. I finished with the 15 y/o with the infected tibia. He had a large piece of dead bone(sequestrum) surrounded by massive new bone. I removed the dead bone and shortened him about 2 inches and put in an ex-fix.
Fred Liss orthopedist upper extremity specialist from Pennsylvania got here today. His wife, Dianne(teacher), is with him. He did the GSW to the forearm and it went well. He seems to be a great guy. He has a connection with a health care organization that is meeting with the president of Haiti to make a long term project with one of the closed hospitals. They plan to open it as a public hospital and over 10-20 years gradually turn it over to the Haitians.
April 24Scott left yesterday so I'm trying to do my best SN impersonation. I have a hand surgeon from Philly who is great. A team of Italian plastic surgeons is here for 5 days. They have taken over many of the wound patients. They have done several flaps and grafts and do many of the wound vac changes. They are way cool and fun to work with. They have 3 anesthetists and nurses and scrub techs. Their organizer, Paula, speaks good English. They are very organized. Another orthopedist just arrived from Milwaukee. He will both be here for a week. A 5th year ortho resident from LLU is supposed to come in tomorrow or Monday. We've been operating all day today. I hope to finish in time to get a break this evening.
Our cases went well today. A 24 y/o came in to the ER first thing this morning. The tire of a passing bus exploded and something hit his leg about 3 or 4 inches below the knee and knocked him down. It left a wound about the size of a nickel that bled profusely and he couldn’t stand up. Xrays showed a fractured tibia with multiple fx lines starting just below the knee and extending more than halfway to the ankle. I took him to the OR right away and debrided the skin wound and opened it up a bit to clean the bone and irrigate the wound well. I was able to close the wound and get him in a nice padded cast. We’ll keep him on IV antibiotics for a few days just because the environment is not clean.
Another 20+y/o man came in to the clinic this morning with a closed displaced mid tibia fracture and I admitted him for surgery tomorrow. I’ll put a SIGN nail in him. The patient with the infected proximal tibia fracture is not doing as well as I had hoped. He had a high fever and pain. We changed his dressings in the OR today. He had some evidence of infection still but it doesn’t seem as deep. Fred and I washed him out again and packed the wounds wide open and then splinted the leg. We won’t wait 48 hours but will take him back to the OR tomorrow for another dressing change/washout. I’m still hopeful we will be able to save his leg. The Italian anesthesia staff helped us all day. Two of our patients for vac changes ate so we put them off until tomorrow. We’ll have more time then anyway.
We ventured out in Scott’s vehicle and “explored” a little on the way to join Fred and Dianne at their hotel for something to eat. The Italian team was all there too. The food selection was a bit limited since they were out of green salads, vegetable soup and Red snapper. A soft warmish tropical rain fell during the last half of dinner and lent a soothing effect.
Fourteen hours of work on my day of rest (Saturday) is not what I have chosen if there was a choice. Through the years I have discovered the delightfulness and personal necessity in my life of a weekly day of rest. The Biblical Sabbath that God gave to Adam and Eve in the Garden of Eden at the end of creation week is one of the best gifts that man has ever been given. The 24 hours of the Sabbath starting with sundown Friday and ending with the setting of the sun on Saturday are a joyous time that I anticipate every week. As each week goes on and I expend more and more energy and get progressively more tired, that 24 hours of rest look better and better. There is such peace, knowing that I will have that time to disengage from the continual involvement in physical activities that can be totally draining. There is no need to attend to the list of ‘to do’s” around the house. Quiet meditative music is commonly my choice for the beginning of this special day. Enjoying fellowship and worshipping with church members who also appreciate the rest and physical and emotional refreshment of the Sabbath is almost always a delight. An afternoon walk with friends enjoying the outdoors commonly caps the weekly experience. Unfortunately, none of those things happened on this particular Sabbath. Earthquakes with their devastating effects do not respect my particular world view. The Haitian people whose lives have been violated are now struggling with so much loss. When the loss takes the form of severe physical injury, the need is pressing for action to relieve pain, suffering and save lives and limbs. That God ordained 24 hour break just isn’t an option under these circumstances. There will be another to come soon – six days from now in fact. I look forward to it with even more anticipation than usual.
April 25I thought Sunday would be lighter and it was – only 12 hours. Rounds starting at 6 finished a bit faster than usual since several patients have been discharged and the new patient admissions haven’t been as heavy to the orthopedic service. I gave a short worship talk to the volunteer staff then had the morning report and introductions of new arrivals. Lee Tyne, orthopod from Milwaukee, is here for four days. He has been to Guatemala on many orthopedic mission trips. He does total joints and fractures and arthroscopy at a government hospital there. The prostheses are donated by Zimmer and Stryker and other companies to their church. They apparently get them without difficulty even since the Justice Department issues. I hope that contact might help us with our project in the DR.** Hasan, the LLU ortho resident made it today. He worked with Scott for a month in the DR several years ago. He will be a big help and make the transition possible when we leave this Friday. He will be by himself for 3 or 4 days. A new wound care specialist is here and is a huge help. She taught me several new things today about the wound vacs. Our patient with the postop infection of the humerus is cleaning up, but the plate and screws are still exposed in the bottom of the wound. We had other wounds for dressing changes including the patient with the infected tibia/ compartment syndrome. His wound looks MUCH better and for the first time I am optimistic that his leg can be saved. We’ll take him back to the OR again tomorrow to try our best to stay on top of it. Maybe by Tuesday or Wednesday we can place the hybrid ex-fix and get a wound vac back on. We did the SIGN nail on the fractured tibia. It was not easy to reduce the facture but we succeeded and now the fracture is fixed. Our 6 pm finish was our earliest so far. It gave us a chance to go over to the nearby hotel where Fred and Dianne are staying and swim in the pool. The Italian team were there and we had a great time swimming and playing with the beach ball in the pool. We talked with Fred and Dianne for a long time over soup and French fries. They are really fine people.
April 26Today started much earlier than anticipated with a frantic call from a volunteer nurse who had been called to the ER to see a 6 y/o girl who was having a grand mal seizure. The doctor responsible for the ER hadn’t responded when called. I tried unsuccessfully to call Brooke, the coordinator. I went down to the ER and the usual sized crowd of about a dozen Haitians were crowded around the stretcher. The child was breathing and not seizing which seemed a good thing. The nurse had given her some Valium. Her temp was 103 which accounted for the seizure. Rectal Tylenol was next. Within about 15 or 20 minutes she started to wake up. She didn’t seem any worse for the event but of course Creole to me sounds as if it is always being spoken in a postictal state. 5:15 came around pretty quickly. Our 6 o’clock rounds took nearly 1 ½ hours. Everybody seems to be progressing satisfactorily. I get a kick out of winking at the kids and giving fist bumps, thumbs up, and high fives to the guys. They were all pretty reserved at first but they are really warming up. The big, bad Monday orthopedic clinic went nicely with the four of us churning through the patients. We were able to spend thoughtful time assessing everyone. Two infected joints walked(limped) in. One was a knee and the other an ankle. Neither had any injury. We got them both admitted immediately and into the OR for open drainage. One patient vividly portrays the importance of a team approach and staging of management to give people the best chance of getting their lives back in order. He is a 40 y/o man who had both femurs fractured in the Jan 12 earthquake. He had surgery here at Hopitale Adventiste D’Haiti and Scott fixed both of his femurs surgically with SIGN nails. That was done several weeks after the injuries when the hospital was opened again and had electricity, water and sewerage. He is now nearly 3 months postop. He walked into the clinic today with two crutches. Xrays showed both fractures are healing satisfactorily. I found that he still has marked muscle weakness in the left thigh. Before the quake he had his own business buying wholesale and selling to retailers. The quantities were modest and he handled all of the boxes himself being the only employee of his business. I’m hopeful that Andy, our physical therapist, will be able to help him strengthen his quads so that he will be able to discontinue his crutches. It is tough to carry those boxes when your hands are full of crutches.
The patient with the many fractures and the postop infection in the lower leg is doing much better. His blood count dropped very low so we transfused him. The wound is really clean. I’m planning the hybrid ex-fix tomorrow. The possibility of amputation is certainly much less now.
I was able to close Mirlanda’s thigh wound over a drain. I hope the drain doesn’t freak her out as much as the wound vac did. She has filled sections of nearly all of our nights with long stretches of loud screaming. I imagine the thousands of people who live in the blocks around the hospital think we practice sacrificial voodoo most nights.
After finishing surgery and making quick rounds this afternoon, I went outside the hospital to check out the grounds. In back I found 5 men loading old junked and worthless hospital beds into a truck. The junk has been accumulating over the years and not only is an eyesore but I’m sure has led to poor JACO scores. The truck was about half full. I helped them hoist about a half dozen more large contraptions over the side and into the back. Then I took apart a couple of larger ones that they would have had to leave otherwise. They were fun to work with.
6am rounds went faster today. Jeannie has been working incredibly hard to get patients that are medically stable ready for discharge. Her multiple tasks defy description in a journal of this nature. Nurse, lab tech, counselor, wound specialist, PT assistant, phlebotomist, pharmacy tech, supply specialist, surgical schedule organizer, patient transporter, discharge planner, social worker, photographer, fly abatement specialist, and chief confidant to the acting director of orthopedic services. Those titles cover about 50% of what she does. Our inpatient list is about half as long as when her buzz saw first hit this institution. We still have many problems that require careful planning. Fortunately there has been a bit of a lull in new patient admissions. I have been called about several possible transfers but the patients haven’t shown up.
Dr Liss gave a short talk this morning before morning report. Several other volunteers also spoke a bit. Clinic today was harder than yesterday. It seemed that the decision making took longer than usual on many cases. The volunteer translators and other local volunteers were not all their usual enthusiastic selves especially in the afternoon. For some reason the kitchen staff only prepared enough meals for about ¾ of the patients. There was none for the volunteers , local or overseas. A ten year old girl came in with a history of a foot injury 8 years previously. She had been casted for a period of time. In the last 7 years she has been living “on the mountain.” She presented with a foot plantar flexed 90 degrees. She walks without a limp but has some pain after longer distances or increased activity. She will be a fun case for Scott to work with. Two more infections came in that we took to the OR. There were several upper extremity cases that were elective. I am so glad to have DRs Liss and Tyne here with their upper extremity expertise. The toughest case was a dislocated elbow that had recurred after an attempt had been made to openly reduce her and repair lat ligaments several weeks after the quake. She had been dislocated several weeks. Dr Tyne chiefed Dr Hasan and they openly reduced the joint and fixed it with a pin. She will have a very stiff elbow but it should be functional. Certainly it should be better than a chronically painful dislocation. Anesthesia may be a real issue for us in the next few days. The Italian plastics team has been really helpful in providing anesthesia but today is their last day. The Haitian anesthetists don’t get here until sometime later in the morning. Today they wanted to leave before 5 pm even though we still had a couple of cases. We were really spoiled last week with the anesthesia team from Pennsylvania. Scott and I were able to do cases until midnight or later every day. I can only hope that God will provide some help in that area.
I was very disappointed with our patient Joseph with the many fractures. The leg wound looks clean and would have been ready for hybrid ex-fix. Unfortunately, his hgb is very low(6.4) and we discovered a deep necrotic sacral pressure sore today. The plastic surgeon evaluated him and feels that a diverting colostomy is essential to get the pressure sore to heal. There is no general surgeon here so that might not be possible until the next one comes. We may need to do a high AK amputation in order to be able to adequately position him to keep pressure off the sacrum. The effort to save his leg has been great and now to lose it when it was nearly clear of infection is a bigger decision than I wanted to make. A patient with a femur fracture was transferred from the University of Miami facility. He was injured in a motorcycle accident this morning. He had classic Haitian “field traction.” A padded walking boot on the foot of the leg with the broken femur with a bag of stones hanging from it. Fred and I got a good laugh from that. We’ll try to get a SIGN nail in him tomorrow.
The many Haitian kids that are all around are a total delight. They come up in small clots with big smiles and grab your hand and giggle and then run off. They love to use my camera and take pictures of each other and us. The vast majority of Haitians seem to be taking everything in stride. Perhaps the centuries of living in abject poverty punctuated by periodic catastrophes have numbed them to what might be. This new disaster is just another episode in the ongoing procession.
Jeannie really wanted to get in the pool at the hotel where the Liss’s are staying so we hoofed it the 8 or 10 blocks. It did feel really great to get in. We had a good time again with the Italians until the hotel staff came out and told us the pool was closed at 6pm. It was 7:30. She wasn’t carrying anything that looked like a weapon so we made the decision to tone down the activities and stay where we were. I figured that someone with a gun would clearly have enough authority to convince me that the pool really did close at 6.
Several others from the hospital were also at the hotel to eat dinner(remember our one daily ‘provided’ meal that didn’t come today?). We all(14) crammed into the hospital ambulance for the ride back to our cots and air mattresses. The driver even gave the siren a short blast during the ride.
April 28Our patient rounds went well. Everyone is progressing quite well, even Joseph. Last night I analyzed the reasonable options for him and the pros and cons. I finally decided that adding an external fixator to his partially fixed femur fx would likely give enough stability that then he could be positioned and bridged off his sacral pressure sore. We would also be able more effectively to deal with the large open wound from his knee to his ankle and possibly fix the proximal tibial fracture with a hybrid external fixator.
Worship and morning report were quiet. Several midwives and a med student from LLU are new since yesterday morning. Several volunteers have expressed appreciation for the worships. I have been using Richard Swenson’s book, “A Minute of Margin.” This mornings thought was on the ‘Secret of Contentment.” Contentment is the freedom that comes when prosperity or poverty do not matter.
Our clinic was extraordinarily chaotic today. The clinic x-ray tech didn’t show up today. Something about not getting paid for 4 months and then not getting the promised lunch yesterday. That meant going to plan B. It is less satisfactory for the patients, making them wait several more days in some cases. We had 10 or more clubfeet patients – most bilateral. I taught Hasan and Fred the Ponseti technique. Karen did most of the casting. They all went well but they take time. Many new and follow up patients came in. We scheduled a bunch of cases. I had nonstop interruptions – mostly calls regarding transfers. One call was from “Love a Child” which transfers patients to us for surgery. The lady wanted to pass on equipment that had been donated to them after the quake. She sent me a list that looks like it includes 200- 300 thousand dollars of orthopedic implants. Everything is still new in the boxes. That call was certainly worth taking. A group from the University of Miami facility came with two patients that were being transferred to us. An orthopedist, Dr Naren Gurbani, was in the group. He does lots of ankle fusions and we have one scheduled for tomorrow. He was excited to come over and do it with Hasan. He is from LA. A total of 7 patients were transferred in today ending the minidrought with a flood. If we had anesthesia we could get a lot of cases done. Dr Gurbani says that he should be able to bring one with him from Medishare. We have about a dozen cases on the board.
The plastic surgeon with the LEAP program is a great guy. We have worked together on a number of our cases, including Joseph. Their anesthetist is from New Orleans. He might be able to help us some tomorrow too. We were able to work in all of our surgical cases while wading through the sea of pathology in the clinic. One patient was brought from about 6 hours away by a neighbor. She has the most unbelievable case of bilateral Blount’s Disease I have ever seen. The neighbor speaks perfect English. He is married to a woman from Kansas. They live and work mainly in Kansas but come down periodically to their home here. When I told him that we could do an operation to straighten her legs he got tears in his eyes. The Taylor Spatial Frame will be perfect for her. I want to do her surgery with Scott.
We got the femoral ex-fix on Joseph tonight. His sacral wound looks much better after the debridement yesterday and the huge lower leg wound is totally clean. Tomorrow we are going to try to get a hybrid ex-fix on the tibia fracture. It should help greatly to position him so that the sacral wound can be treated properly. Hasan and I took the patient with the femur fracture down to the OR to use the C-arm to help clear his C-spine. We finished everything a little after 7 pm. We are all pretty bushed tonight.
April 29, 2010Another incredibly busy day. Clinic was busier than usual. Lee had to leave for the airport at 10 but he helped us a lot until he left. The local anesthesia didn’t get here until nearly noon. Fortunately, the LEAP anesthesia helped us get started. Dr Gurbani came from Medishare and brought an anesthetist. He did the ankle fusion with Hasan. He may come back tomorrow and help. Fred saw many patients in clinic and did several wound cases. We told him and Dianna goodbye since they leave early in the morning. It has been terrific working with him. We plan to stay in touch.
The implants were sent over from “Love a Child”. It turns out they are all used sets that were donated by US hospitals. None of them are complete and some of the boxes hardly have any screws. There is still quite a bit of stuff that is useful. I wish I had time to go through it all and organize and consolidate it.
Two video journalists from the US came this afternoon to see the needs of the hospital. They are involved in ongoing fundraising for medical hospital supplies. The interview I gave will air in Denver sometime.
We had to put off the hybrid tibial ex-fix on Joseph until tomorrow. As it was, I didn’t finish the last case tonight until nearly 10 pm. Then cleaning and organizing the trays and instruments took about an hour. The Haitian workers that clean up in the ORs don’t know which instruments go in which boxes so the surgeon needs to do that task. They are usually bloody and need cleaning and washing first. We take so much for granted. There would be a major delay if a set of instruments like the SIGN nail tray were opened up to do a case and some key instruments weren’t in it. It might mean opening up most of the sterilized trays to find what was missing. Then other cases would be delayed waiting for things to be resterilized. Eventually we should have well trained people here full time but it is a wrk in progress. The case was a great one. I did a femoral SIGN nail and then fixed the femoral neck fracture with cannulated screws around the nail. It was a technical challenge because the femoral neck fracture had displaced. The reduction and fixation are nearly anatomic.
Tomorrow we leave.
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