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.
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.
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