Visit to the citadelle and my last week in Haiti

Last weekend we went to visit the famous citadelle built by Roi Christophe, the king of the first independent black government of Haiti, to defend his country against the French and Napoleon in particular. This well preserved fortress is situated on top of a 900 meter high mountain which dominates the northern plain around Cap Haitien and was linked to a whole series of other forts along the coast line. The construction is an engineering master piece built around 1804-06. Apparently 20.000 people died during the construction and all the building materials had to be carried up the hill by human labour. The fortress was fitted with over 300 canons some of which are well preserved and beautifully decorated with french and english symbols. The view from the top was breathtaking and although we had to walk uphill for about 45 minutes in the intense tropical heat once on top it was nice and cool:the inside was naturally air conditioned and we really enjoyed the cool air!!!At the bottom of the hill was the ruined palace called "Sans Souci" where Roi Christophe lived with his wife and 2 children as well as his many servants. He eventually committed suicide but his burial place remains unknown to this day.

I have been very busy at the hospital over the last week teaching the residents and operating on the many acutes who present everyday. Cap Haitien is the capital of the compound tibia fractures. The reason is the many motorbikes circulating here in a chaotic traffic: the bikes are real tibia crackers!!! I have been able to achieve some changes in the management of the fractures and I am pleased with that. However I am concerned that the residents will go back to their old habits particularly if the orthopaedic surgeon in charge at the hospital is not endorsing what I have been teaching.

There are also many spinal injuries here mainly as a result of people falling from trees trying to collect certain fruits.Two days ago I was shown a patient who had fallen from a tree and was paraplegic. He was lying on the floor in the emergency department and when I enquired why he was not in a bed I was told that he had fallen out of bed. There was this poor chap lying in his own urine and nobody cared about him. I asked the residents whether they had a spinal board but they said there was none. However after a short period of time one of them turned up with exactly what was needed. This gave me the opportunity to teach the doctors how to lift a patient with a spinal injury safely and we all carried him to the surgical ward. The treatment for these patients is basically inexistant and they are left lying in bed with very little active management. The problem here is that the nurses only give injections and sit around in their impeccably white uniforms and matching white stockings doing very little. They don't want to get their uniform dirty and as a result it is the house surgeons who have to do all the dressings and even take charge of the pressure sore prevention. Yesterday I operated on this patient with a T9-T10 fracture dislocation using an old Hartshill rectangle I brought with me and fortunately they had some wires which I could use. The hospital was on generator power and as a result the airconditioner didn't work so it was hot like hell!! In addition there were about 10-12 doctors wanting to watch the operation which further contributed to the heat. I was dripping with perspiration after about an hour and had to have a change of clothes. Also in the tropics your hands sweat profusely when wearing surgical gloves and the sweat accumulates during the operation and when things start to overflow you have to put on a new pair. Anyway I got through the operation OK and the patient is doing well although I suspect that his paraplegia is permanent. I will try to get him into a spinal unit run by the Baptist church on the outskirts of Cap Haitien for his ongoing care. There is a great need for an orthopaedic surgeon with spinal expertise and I hope that in the future I will be able to teach some basic spinal surgery to one of the residents.

Tomorrow is my last day at the hospital and everybody wants me to come back next year which is very encouraging. I have also given the residents a small research project and I will set up a website so that I can do some distance teaching and provide them with teaching materials. I however think that yearly visits are required to teach them new surgical skills and help them to get access to better orthopaedic equipment and trauma implants. But one thing they desperately need is somebody who can fix their image intensifier for intraoperative Xray imaging so that they can treat the fractures by closed methods. This will also allow the surgeons to get post operative films which currently are difficult to obtain as the patients have to pay for them and they are not cheap in Haitien terms. Without post operative films they residents don't get any feedback on how they are performing and they will not be able to learn.

Finally I want to talk briefly about the Haitien food. I have been looked after very well by Robyn and Bernadette who has been cooking for us. Breakfast is quite substantial and normally has fresh food like papaya ( my favourite), pineapple, mango, grapefruit, and banana as well as cornflakes, yoghurt, toast, jam, peanut butter and eggs. And then there is the fantastic Haitien coffee! I will miss this when I have to return to my bowl of cornflakes and milk! Evening meals normally have meat or fish, bean sauce, fried plantain babanas, igname or sweet potatoes and salad. The meat here is mainly goat which is delicious and the other day I had "tete de cabri" which is goat's head and it was delicious. However I was not brave enough to eat the eyes! There is also very good 'free range chicken', pork and beef. I love their fresh juices and they have lemon, orange, grapefruit, orange etc. I certainly haven't lost any weight despite all the water which has gone through my sweat glands over the last 3 and a half weeks.

Well this is my last blog and on Friday I will head back to the Dominican Republic to fly to Auckland via Miama and LA. I can't imagine what it will feel like experiencing a temperature difference of over 30 degrees Celsius. I might have to buy an extra woollen jersey in Auckland!

I hope you enjoyed my blog and many thanks to those of you who left comments. I enjoyed reading them!

So it is au revoir from Haiti and I guess I will have to turn up at work next Monday.

The weekend: beach, church and Roi Christophe hotel

Saturdays are reserved for local excursions and everybody is looking forward to that day. There are very nice beaches around Cap Haitien but the problem is the access. The roads are bad and often the only way to get there is by boat.

The other problem is the pollution. As soon as there is human presence the sea is being used as a giant waste disposal system. Here in Cap Haitien the beaches are littered with millions of plastic bottles and domestic rubbish. When it rains the streets are transformed into raging rivers and all the rubbish is flushed out to sea. All the city sewers also drain into the sea. There are no water treatment plants as far as I can tell and the pollution here in the city is anenormous problem. as soon as one drives to the rural areas where the population concentration is less it looks relatively clean and there is less rubbish in the streets.

So we went toa small fishing village called Labadie, at an hours drive west of CapHaitien over a rather rutted road.The beach of Labadie is famous the large cruise ships as the water is very deep allowing them to get very close to shore. The beach has now been fencedoffand canonly be used by the tourists who get off the boat for the day to enjoy watersports. Haitiens are not allowed in and as a result we decided that this was true apartheid and that we would get a local boat to go to Labadie village situated in the next bay.

As soon as we arrived we saw most of the villagers gathered around a TV in the village square watching the Argentina Germany game. All the Bresil supporters were yhoping for Argentina to loose and they had a ball!!!. The end of the game was followed by great celebrations and even a mock funeral with a coffin carried through the streets.

We found a nice beach next to an old lodge restored by its owners and run as a bed and breakfast. Inside there were beautiful old pieces of Haitien furniture as well as a number of antiques. A great place to stay for the weekend and relax. The swimin the sea, in fact the Atlantic ocean rather than the Caribbean sea as I first thought, was pleasant but not very refreshing as the water was rather warm: it felt like being in a bath at home.

After our swim we had a small picnic followed by a walk through the picturesque village. We saw people cleaning fish caught the same day and came across a very odd looking specimen which turned out to be a puffer fish. Now this brought back some memories from 30 years ago when I was studying tropical medicine in France.: we learned about poisonous tropical fish and one of them was the puffer fish. We asked the locals but they said it was safe to eat.

A lot of the locals dive to catch fish using a spear gun but seem to get only small fish. They also catch crayfish, octopus, and what they call 'conch' here which is a large shell fish which has a beautiful shell which is sold to the tourists. Unfortunately there are no fisheries regulations here and the locals take everything irrespective of size.We bougth some crayfish and crabs to take home and some of it is in my lunchbox today.

Sunday starts very early with a church service at 6am. The Haitiens dress up in their best clothes for church. Ladies in beautifully colored dresses and hats which in NZ would be worn for weddings or goingtothe races. gentlemen wear suits, collar and tie despite the intenseheat. I wore a white shirt and tie last Sunday but dropped the tie this timefor personal comfort reasons!
The church service is attended by 2-3000 people which are crammed like sardines in a tin. The service is in Creole and French and takes 2-3 hours. I had to address the congregation in French last Sunday but this time I was off the hook. They have many choirs here and Haitiens love singing. The sermonisnormally very long and the minister sometimesgets very passionate about things and starts shouting and gesticulating letting out some strange high pitched sounds.It is all very entertaining although I don't follow Creole very well yet. I understand some words and occasionally I follow parts of the sermon. They have communion once a month which means the service takes an extra hour. You wouldn't believe it but they manage to serve bread and wine to over 2000people! Amazing really.

After church our routineis to go to the local Roi Christophe hotel which is like a green oasis in the centreof town.We have a nice breakfast there with local fruit like pineapple, mango, papaya followedby eggs and a big glass of freshly squeezed juice. The other attraction is that the hotel has wirelessinternet. Sowe allgetourlaptopsout and do our emails, check whats happening in NZ and I often use this time to write my blog. The hotel was built last century and has been restored nicely keeping the old features including a number of antiques. It is a peaceful haven in the middle of the dusty and dirty streets of the city. The largeoldtress in the garden provide the shade and coolness we enjoy and the day is spent there relaxing and using the pool!!!

After having dinner we return home refreshed for another week's work.

Finally I want to give you a brief account of the heat here in Haiti. Most days the temperature is around 33-35 degrees Celsius with a humidity of around 80% andat night it drops to30-31 degrees. This means that you sweat continously and your clothes stick to your skin permanently including whatever you wear at night. It feels like being in a sauna with your clothes on! There is no air conditioning at the hospital except in the 2 operating theatres. At home we use fans which are left on at night to cool things down. During the day I drinkabout 3-4 litresof fluids and as soon as I finish a bottle of water half of it has already come back out through my sweat glands.

Here in Haiti its drink or die!!

Miss Ro Mother Theresa of Cap Haitien

I want to dedicate this post to a very special person without whom our stay in Haiti would not have been possible: you guessed right it is Robyn. I have been here just over 10 days and have observed her in action and I also know that she operates invisibly in the background to make things happen miraculously. She has an endless circle of friends here in Cap Haitien but also across Haiti and having the right contacts here is so important. She speaks the local Creole language which immediately opens doors and hearts.

We were in Port au Prince last weekend having lunch when a person approached her remembering her from so many years ago. Then we had the routine which kicks in when Robyn meets old friends: big hug, kissess, excitment, jumping up and down, followed by a long chat. You walk around Cap Haitien with Robyn and she knows so many people that you have to stop every couple of 100 meters for a chat.It is wonderful to see how she relates to the Haitiens.

She is an amazing person who has spent her whole life serving others and in the process has helped so many people here in a spiritual and material sense. She is so generous of her time and the words no and impossible are not part of her vocabulary. Robyn is full of energy but some days she overstretcches herself and we have to tell her to slow down and rest.

Robyn's skills are exceptional and I will try to describe them although I know the list is endless. She is a manager, organiser, accountant, travel agent, catering manager, automatic cash machine, interpreter, cook, driver, personal assistant to the team, call centre, coach, counsellor, nurse, mother to Enoch and many others, guide, patient advocate etc.

She is an exceptional person who has achieved so much in this country and iI believe she deserves more recognition for what she has done and continues doing here. Haiti needs an great army of Robyn like soldiers to get this country back on its rails and achieve the social changes which will lift Haiti out of this mess. I guess it will take generations to achieve any visible changes and it is the seeds planted by Robyn which will grow into great big trees bearing the fruits of her labour.

I would like to take this opportunity to thank Robyn for all she has done for the team and to express my appreciation for her constant care about our material and spiritual needs.

Thank you for everything Robyn!

A day trip to hell

Last weekend we went to Port au Prince to get an idea of the scale of the devastation caused by the massive earthquake which struck the Haitien capital on 12 January 2010. In order to do this as a day trip we decided to fly using the Haitien domestic airline called Tortug'air. and after a short flight of 25 minutes we arrived in Port au Prince.
Already before landing we were able to see large blue tent cities spread across the city which were put up after the earthquake as temporary shelter but 6 months later they seem to have become a permanent accomodation for thousands of people who lost everything in the earthquake. A friend of Robyn's picked us up and drove us around the city for about half a day.
We were all shocked and couldn't believe what we saw: the extent of the devastation caused by the quake and the misery and suffering of the Haitien people was heart breaking. The most striking feature was that the city looked as if the earthquake had hit the previous day: there was no evidence of any reconstruction and during the time we spent there I only saw 2 bulldozers!!! Basically people have no means to reconstruct their houses and the government hasn't done anything apart from identifying the houses which have to be demolished. Property here is not insured and if your house is destroyed by an earthquake in the abscence of government help you have to finance the rebuilding yourself.
Most people in the affluent areas live in tents in front of their collapsed houses whereas the poor have been placed into tent cities where the living conditions are appalling: no running water, no electricity, crime and rape are rampant and I am sure that the risk of cholera and other infectious diseases is extreme. The tents are really cramped and the space between them is less than half a meter. However there seems to be some sanitation in the form of portaloos.
The pattern of destruction of the city is interesting. The destruction is worse in some areas compared to others and you can find a completely destroyed building next to one standing without any damage. I believe that the reason is the poor construction of modern houses as Haiti has no regulation of the building industry. Often the older houses built with a wooden frame were still standing whereas the use of concrete combined with poor building standards as well as the lack of earthquake resistant building technology was probably the main reason why so many buildings collapsed. Entire churches were standing there with toppled spires and some ripped open by the violence of the tremor. Some multi storey buildings simply crumbled and were reduced to a single level. The Presidential palace collapsed like a stack of cards and most of you probably have seen photos in the press.
The centre of the city was worse affected with complete streets wiped out. Driving through this area was for me the worst human suffering I have ever seen. It was like hell. The dust, the dirt, the smell, possibly of decomposing bodies left inside the buildings, the despair and misery was out of this world. It was like a nightmare and I felt nauseous. However despite the destruction life continues amongst the ruins. People have reestablished their businesses as best as possible trading on the side of the road or outside the damaged buildings. These people are tough and despite all the calamities they keep going: it is a struggle of survival!
As far as the reconstruction is concerned there was no sign of it. I saw people with pick, shovel and sledge hammer working here and there and a lot of rubble in the streets often completely blocking the traffic. In the presence of such destruction and in the context of the lack of resources in Haiti where do you start? The task is huge and it will probably take years to rebuild the city and I am not at all convinced that Port au Prince will ever recover.
At the end of the day we felt all overcome by the destruction and human suffering as we climbed back into the plane to fly back to Cap Haitien. It was a day in hell indeed!

The curse of western style orthopaedic surgery

I have now had 2 days working as part of the orthopaedic team at St Justinien Hospital.As opposed to general surgery we rely much more on technical equipment most of which is not available here. To do a hernia or a laparotomy only basic surgical instruments are required but for orthopaedics we rely heavily on implants, mainly for trauma here in Haiti, and intra operative Xrays. Plain radiographs are available in the hospital but patients have to pay: if they have no means one has to forgo the post operative or follow up Xrays. The same applies for blood tests, IV fluids, bandages etc.

In theatre there are some implants mainly plates and screws, K wires, some old nails and some external fixators. There are no pneumatic tourniquets and mostly I have to use Esmarch bandages until they run out and then I have to think of something else. The choice of implants is very limited and they do not come in all sizes. Often you are given a handful of all sorts of different plates, some Sherman plates 40 plus years old, which are meant to cover all options from a forearm to a femur. As they haven't got srcrews covering all the sizes they have to be cut to length using large bolt cutters. Drills are mainly hand driven although apparently there is one battery operated electric drill of the type you would buy at Mitre 10.

However the most frustating is the lack of intra operative imaging and scrub nurses!

There is an image intensifier parked in the theatre corridor but apparently it doesn't work and nobody knows how to fix it. So it sits there accumulating dust and nobody cares. This means that all internal fixations of fractures have to be done open in an environment where sterility is doubtful. The consequence, as you can imagine, is that the post operative infection rate is very high! Yesterday I saw an 8 year old boy who had a tibia fracture, probably open, a couple of months ago which was internally fixed and he now presents with a serious infection with skin defects, exposed metal, non union, and an ankle that is deformed and stiff. He is at risk of loosing his leg and I believe that if he had been treated in a closed fashion with an external fixator or simple plaster he might not be in this situation.

Now the abscence of scrub nurses. I do not know why this is the case but I will try to find out and see if this can be changed. However I guess nothing will change as the staff here have a very fatalistic approach to life and there is a complete lack of initiative amongst Haitiens who accept their fate as given. Normally there is one circulating nurse who's job it is to dish out instruments and disposables for 3 theatres and the first year resident acts as scrub nurse. To give you an idea of what an operating list is like here at Justinien Hospital I encourage you to read Ross Pettigrew's blog at http://www.rosspet.blogspot.com/. It is worth reading and I recommend it to you.

Now let me take you back to my first post in relation to the closed treatment of fractures as described by John Charnley. This is exactly what is required in the Haitien environment. I strongly believe that all fractures should be treated closed using either plaster of Paris, traction, pin and plaster or external fixation. Plaster is readily available but unfortunately there is no traction equipment, except for some skin traction, and they have a limited number of external fixators. Open fractures are very common here and they normally wash out the wound and then the patient is admitted to the ward splinted or plastered. A week or two later the fracture is then openly internally fixed even if the skin is not healed. Often the fracture is shortened when it comes to the definitive treatment which makes things worse. So you can imagine the possible disaster if it gets infected.
There is a lot of neglected trauma here either because people don't come to the hospital because they have no money or they go and see the witchdoctor first. Apparently they apply oils and herbs on the fracture and if that doesn't work they will eventually come to the hospital months later with severe deformities, infections and stiff joints. Some of the cases here are very challenging and would be so even in the NZ environment.
So for me there is a dilemma: should I teach the residents the western style fracture treatment using the shiny metal or the safer closed method as described by Charnley. I know the answer but I have noticed already that the residents want to learn how to operate on fractures and as soon as I carry out a closed manipulation of a fracture in theatre they seem to disappear and loose interest. My challenge is to get the message through that closed fracture treatment is safe and that open surgery should only be carried out if conservative management fails or is not possible like femoral fractures in adults.
The curse of the shiny metal is a reality here in Haiti . I must say that I have seen this in the past when I was working in Africa where western technology is introduced without taking into account the local environment.
As far as my dilemma is concerned I believe I need to do both: teach them the concept of non operative treatment of fractures and the principles of safe surgery.
My challenge next week is to get through 15 patients with serious limb fractures and my goal is to convince the Haitien doctors to treat at least half of them without the knife. Wish me luck.

I arrived in Cap Haitien yesterday after a 5 hour drive which was, in Haitien terms, uneventful although the border crossing was interesting. All was done through a middle man who takes away your passport and gets all the formalities done for a small fee. The Haitien immigration office was situated inside a container and everything was handwritten into a book, left hand side when you enter and right hand side when you leave. How they track people entering and leaving the country is anybody's guess.

Once in Cap Haitien I caught up with the other members of the team including Ross Pettigrew and everybody was happy to read the Otago Daily Times from last Saturday which I had slipped into my luggage. The we had a little farewell lunch for Dale one of the of physiotherapist who was finishing her stint here and in the evening we were invited for dinner at one of the local hotels. Most of us had goat stew and the meat was very tender and tasty.

I am staying with Ross in a private house which at the moment hasn't got any running water as the pump is broken. So we have to get the water from a well in front of the house and the shower is very simple:you stand in a baby bath, poor water over yourself using a container and the water is recycled and used to flush the toilet. That's it very simple and nothing can go wrong.

I had a reasonable night sleep under my mosquito net and luckily there was no power cut which meant that the fans were going all night yeah! This morning after we all had the great haitien breakfast in the form of spaghetti and then we were off to the hospital to meetthe membres of the orthopaedic department.

The only orthopod Dr Pierre Louis is a very nice man of my age (actually he was born in December 1952 just a week before myself) and we found him watching soccer in the operating theatre (the attached photo shows the TV and the arial is a used diathermy cord!!!). He showed me around the orthopaedic outpatient clinic where he introduced me to his registrars who currently are 2 first year trainees. After that we went on a ward round and saw only fractures: mainly tibias, including a nasty open pilon fracture, but also an elderly lady with a neck of femur fracture and some kids with upper and lower limb fractures.

The wards are very crowded without sense of hygiene: no hand washing facilities, no gloves, the windows have no glass ( shutters only) and open onto a central courtyard with flies on soaked dressings etc. There are a number of cases who require surgery and my challenge for tomorrow is to help the residents with an operating list as Dr Pierre Louis is away. I have no idea what implants they have but one thing I know is that the image intensifier parked in the corridor is not working. So all the internal fixations will have to be done open in an environment where the infection risk is very high. Well we shall see how things go but I will have to think out of the square, think Haitien and constantly remind myself that things are different here.

I spend a short period of time with Ross in the general surgery clinic and then attended some sort of medical round mainly for residents and nurses. Ross was asked to give a talk and he spoke about his research from 30 years ago with myself acting as simultaneous translater.

In the afternoon there is nothing happening at the hospital apart for the occasional emergency case and we normally go home at 2.00pm. This timetable would be a great opportunity for me to learn to play golf if only there was a golf course.

This gives you an idea of the local circumstances and our challenge is to find a way for us to contribute for the benefit of the local doctors and patients. We will certainly not be able to significantly change the system which basically lacks all the basic infrastructure and administrative organisation. If only we could send some of our managers here as they would be very useful in establishing basic organisational structures.

However every little step counts and when they are added up in the end I hope that we will be able to make some lasting contribution.

Well I have arrived in the Dominican Republic this morning after crossing the whole Pacific and then the North American Continent followed by a little escapade down south to the Carribean. The highlight of the long travel was being told just before landing in LA that the All Whites had drawn with Italy. The whole plane cheered when the pilot announced the result.
Travelling all that way will in the end have been quicker than going across the border to Haiti.
Let me explain. I arrived at 11.00am expecting to be picked up by Ruben a friend of Robyn's.Unfortunately he fell into the claws of the local constabulary and was taken to the police station because he had a missing rear vision mirror. He had to get it replaced, pay a fine of 50$ and return to the station so that they could check that it was fixed. By that stage most of the day had vanished.
As Ruben wasn't at the airport when I arrived I waited for a few hours and tried to contact Robyn. However my cellphone didn't work and anyway I didn't have her phone number. However I had the numbers of one of her friends so I bought a cheap local cellphone (18$) and tried to ring. Well when you get a new cellphone it is difficult at the start to navigate around until you get used to it and you can image what it would be like if it is all in Spanish! In the end after the advice, in fast Spanish, from quite a number of locals things didn't work out and I gave up.

I waited for about 3 hours and then decided to get a taxi and book into a hotel in town. Well to my surprise they had free WIFI and so I was able to contact Robyn by email. After a series of email exchanges I was told that Ruben had been delayed and that he would contact me at the hotel. By the time he reached the hotel it was to late to leave for Haiti. He told me the story and we had a good laugh.

Now the plan is to leave tomorrow morning at 7.00 am.

So by the time we reach Cap Haitien more than 24 hours will have passed which is more than the flying time from Dunedin.

Now it's time to put my feet up and have an early night.

Well my bags are packed and as always it was done with military or surgical precision one might say. Going to the tropics or a developing country always requires a bit more thinking to make sure that all the essentials are packed including mosquito net, malaria tablets, small first aid kit, Swiss army knife, sun protection etc. Looking at all the surgical stuff I have packed it feels like I am travelling with a mobile operating theatre in a suitcase. It might sound like something out of James Bond but it will hopefully make my work at the hospital in Haiti more effective.
Now its just a question of spending 24 hours in the plane and stepping onto the tarmac in Santiago, Dominican Republic, for the Haitien adventure to begin.

As you can see I have been reading John Charnley's book on 'The closed treatment of fractures' third edition 1968 in preparation of my posting at the Justinien Hospital in Cap Haitien. This is an excellent description of fracture treatment before the advent of the shiny metal implants and I recommend it to any orthopaedic trainee or anybody working in developing countries. This book was given to me by the late Bruce McMillan and it was purchased in Edinburgh at a price of 50 shillings.

Haiti here I come! I am in the process of getting myself organised before leaving for Haiti this coming Sunday 20 June. This means sorting out my work to make sure everything is taken care off over the next month and the biggest challenge is to clear my desk! Despite all the information I have received from Robyn and via Ross' and Steve's blogs I feel that I am going into the unknown.Over the weekend I finally managed to sit down and write a list of what I think I should take. I have been to the warehouse and have bought torches, a headlight and a supply of batteries for the power cuts, have taken my first dose of chloroquine ( although a bit late) and have been gathering old surgical instruments and used orthopaedic equipment donated by Dunedin Hospital. As the need in Haiti is so great it all feels to me like a drop in the ocean. However anything will come in handy I think and even if it benefits only one patient it will have been worthwhile.
I have also been reading the local Haitien newspapers on line to find out what is happening with the post earthquake reconstruction and also to get a sense of the political situation. I even managed to listen to some Haitien music for a short period of time until the family thought that I had used up their patience.
Well this is my first post on my first ever blog and I will try to keep it updated with interesting information and photos over the next 5 weeks. If you enjoy it please send me some feedback.