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.