Wednesday 26 October 2011

Today is outpatient clinic day. After a teaching ward round on the assessment of a multiply injured patient we selected the patients for tomorrows operating list: forearm fracture 3 weeks old, fracture tibia, fracture femur and osteomyelitis foot. I am still trying to get the message through to the registrars that fractures heal without surgery and a closed tibia fracture is best treated in a plaster and that an external fixator is a safe way of treating unstable and open tibial fractures.
The outpatient clinic was busy and there are endless discussions between the patients and staff as to the payment of clinic fees, plaster, bandages, drugs and implants for the surgery. For example a patient who requires surgery for a forearm fracture has to pay for the blood tests, ECG, drugs, IV fluids, Xrays and implants. The cost is substantial considering that a lot of Haitians can barely afford clothes and daily food.
Overall patients are treated without respect and often fobbed off and asked to come back the next day.
I saw a number of interesting patients including a 5 year old boy with swelling of his left arm and deformity of the shoulder. Xrays showed what looked like osteomyelitis involving the entire bone and extensive periosteal new bone formation. The child was systemically well and was simply prescribed some blood tests and antibiotics. Then we saw a middle aged man who suffered a bimalleolar fracture dislocation of the ankle treated by closed reduction and plaster immobilization with a perfect result: fracture healed in anatomical position and of course no infection because the fracture wasn’t opened. There were other patients with all sort of different fractures, infected femoral fractures following plating, osteoarthritis of the knee etc. It is also interesting to listen to the discussions amongst the staff. Most are very unhappy with the mean salaries the government is paying them and the registrar I was working with this morning wants to go straight into private practice when he has finished his training but even better would like to work in France.
The stories you hear are amazing: the hospital ambulance is for the private use of staff to pick up their kids from school, the danger of being a soccer player ( you get beaten up by your fans if you lose the game ), poisoning somebody at a distance ( in a spiritual sense ) etc.
At the end of the clinic I visited the cholera ward where currently there are approximately 15 patient being rehydrated intravenously and lying on a wooden bed with a hole in the middle and a bucket underneath for obvious reasons. Finally I visited the new Emergency Department donated by the Israeli government. It has 2 resuscitation bays with modern monitoring equipment and a ward with 6 beds. Today it was empty and I was told it is reserved for patients with life threatening conditions only. It looks very nice and clean at the moment but I wonder what will happen to it over the next few years.

By that stage it was 2.00 pm and time for lunch before walking back home.

In the evening Robyn and I were invited by Dr Pierre Louis to welcome us back to Haiti and he had organized for the whole orthopaedic department to have a meal at a local restaurant. The evening was very pleasant and after a number of speeches and a bottle of champagne we had a nice meal of fish and chicken. It was great talking to everybody and we thanked them for their welcome and generosity.



Thursday 27 October 2011

Today was operating theatre day. I was told that we would start early at 7.00 am but I didn’t think I had to hurry with my cornflakes. I got there at 7.30 and the patient was on the table ready for the spinal anaesthetic. After that there was quite a long wait to see whether the spinal worked with the anaesthetist repeatedly stabbing the patient from the umbilicus down to the toes to check the sensory level. Eventually the decision was made the proceed to a general anaesthetic. The first patient was a grade 1 open fracture of the tibia 4 days old. The decision was to proceed to an open nailing. The reaming was laborious due to the lack of power tools and had to be done by hand. The registrar was struggling and I had to show him the proper reaming technique joking that his lack of power was due to the fact that he hadn’t eaten cornflakes that morning. Then we had to choose an appropriate nail of the without any way of accurately measuring the length except for some brilliant guesswork! The nail went down ok and the fracture nicely reduced and stable. In the absence of locking nail the patient will require a plaster for 4 weeks.
Whilst waiting for the second case I was trying to get the pneumatic drills from NZ going. Hand reaming and drilling is no fun I can tell you. The only electric drill they had last year is out of action as the battery charger has died. So I am absolutely determined to get these power tools going. Dr Pierre Louis, the local orthopaedic surgeon, told me that they had compressed air available which was not quite the whole story unfortunately. However he told me that he had an air compressor at home which was given to him by a friend in the past but that he hasn’t had any use for it since. So I asked him to bring it to the hospital so that we could try to connect the drill and see whether we could get it working. The compressor looked new but there was a problem with the connectors between the compressor and the drill. So at the moment I am working on getting the connection sorted. I think I have to visit a few mechanical repair workshops and hard ware stores this weekend.
After having tried out my mechanical skills it was back in the operating theatre for the second case: a middle aged lady with a 6 month old neglected angulated fracture of both bones of the forearm with severe stiffness of her shoulder, elbow, wrist and fingers. She obviously hadn’t moved her arm very much over that time. We managed to correct the deformity by shortening the bones by 1 cm and apply to plates which straightened here arm nice. However the drilling of the bone to insert the screws was laborious again due to the absence of power tools. In the end we got there and the fixation was solid.

The last case was a young man with a recurrent abscess over the anterolateral aspect of the foot and the registrars told me that he had osteomyelitis which was drained on a number of occasions. There was no Xray and after incision a large abscess was evacuated. I was looking for a piece of dead bone (sequestrum) which is often the cause of the chronicity and recurrence of the infection and when I saw it in the bottom of the wound I pointed it out to the medical students and when I retrieved it with a forceps I got a surprise: this was not a piece of dead bone but a piece of ‘jandal’ or sole of some sort of local footwear. Even the Haitiens were surprised and laughed whole heartedly. One of the doctors thought that it might have been placed there by a ‘Hougan” or Voodoo Doctors. Any way this was the highlight of the day and after that the anaesthetists refused to continue with the list which finished a 3.30 pm despite the fact that a patient with a 5 day old anterior shoulder dislocation had to be sent home and asked to come back tomorrow.

‘C’est la vie’ that’s life as the Haitiens would say.


Friday 28 October 2011


The day started with a presentation by the ‘internes’ or house surgeons on the anatomy of the gluteal region and the hand. The hand presentation didn’t get off the ground because one of the presenters was absent. The presentation was followed by a grilling session from the audience and the young doctors looked very sheepish when asked questions. The Haitiens are well trained at root learning but when it comes to comprehension there is a problem. I was very impressed this morning by the anatomy knowledge of the resident Dr Cherubin who was able to describe the anatomy of the brachial plexus perfectly in front of the students.

After the presentation we went on the ward round to check the post operative patients and those for theatre next week. Everybody was fine which was very pleasing.

Then it was off to the outpatient clinic for the usual mix of patients with fractures and other orthopaedic complaints. As the clinic was quiet today I took the opportunity to do some clinical teaching for the medical students and had a long teaching session with the new orthopaedic registrars.

Well the news of the day is that I managed to get the pneumatic drills working using a compressor. A friend of Robyn’s called “Major” is my hero as he was able to sort out the connection problem very professionally and quickly. The compressor works and next week I will try it in the operating theatre. It will have to be positioned outside the theatre block and I have an extension hose with will hopefully reach the operating room. If it works it will make such a difference to my work and that of the surgeons I work with.

So watch this space.

Cap Haitien 2nd visit 23 October – 2 December 2011


Saturday 22 October 2011

Left Dunedin to Auckland, Los Angeles, New York, Santiago
( Dominican Republic)and then bus to Cap Haitien arrived on Sunday 4.30 pm local time.

Managed to get from the airport in Santiago to the bus station 2 minutes before the bus left for Cap Haitien. The taxi driver only spoke Spanish and didn’t know where the Caribe Tours bus depot was. Took me to the wrong place and then had to ask at least 5 times before we got to the right place. No problem getting a ticket at this late stage and after paying I asked for my passport back but was told that it would be taken care of by the bus ‘hostess” as they call the person who accompanies the driver on the bus. I was given a warm meal in a polystyrene container ( rice and chicken) and off we went. The border crossing was straight forward. You stay on the bus and the hostess takes all the passports and takes care of the paperwork if any. I didn’t have to get off the bus and the crossing was very quick as there was barely any traffic.
We stopped once more on the way to Cap Haitien for a luggage check. They look at the baggage but don’t open anything. Arrived in Cap Haitien at the bus station where a band played Haitien music on our arrival. As I was so efficient in getting from Dunedin to Cap Haitien in 48hrs Robyn wasn’t there to pick me up. So I got a taxi who had difficulties stowing my 2 heavy suitcases and as always he took 2 other customers who were confined to the backseat. He could only fit one suitcase in the boot and please the second one on the outside on top of the boot without tying it down. I wasn’t happy with it for obvious reasons and he then put it in the back seat asking the other two customers to ‘squeeze’ a bit!!! I got to rue 13 but the door to the house was locked. Fortunately there was an old patient of mine standing outside and so I asked him whether he had Robyn’s phone number. I had a phone number which Robyn gave me but unfortunately the number had been reallocated to somebody else since last time when Robyn was here.
Then a white Landcruiser stopped in the street and a young man got out asking whether we were looking for Robyn. We said yes and without any hesitation got his cellphone out of his pocket and rang Robyn. She then appeared on the balcony instantly and was very surprised to see me not expecting my arrival until the next day.
We had dinner in the form of toasted sandwiches and it was an early bed for me after we set up the traditional mosquito net, as I want to avoid catching malaria or dengue fever.

Monday 24 Octobre 2011

I had a fantastic sleep despite the heat and humidity and didn’t wake till 7.00 am to the usual street noise and thought I had slept in. After a hearty breakfast Robyn and I dragging a heavy suitcase with orthopaedic instruments and implants went to the money changer around the corner who now lives in a fortified office as he has been attacked and robbed a few times. There is a tiny slot in a wall and you can talk to the person behind a one way darkened glass and the only thing you see of him is his hand which crawls out of the slot to take your money and then to return with your Haitien gourdes which is the local currency. There is no paperwork or any record of transaction and really very hassle free!!!
We then took a taxi to the hospital and first had to meet the medical superintendent Dr Coq whom I had met on my previous visit and he was very welcoming and he said that it was OK for me to work at the hospital without any further forms to be filled out. We were then joined by Dr Pierre Louis who is the consultant orthopaedic surgeon as well as the 2 registrars I met last year. They were very pleased with all the equipment I had brought all the way from New Zealand and I am very grateful for this donation by the Southern District Health Board. The old pneumatic power tools (now replaced by battery operated ones) were lying idle in a drawer back in Dunedin and are very handy here as they mainly have to use hand operated drills. The external fixators which we are not allowed to resterilise in Dunedin again will find a use with the multitude of open fractures they have to deal with on a daily basis.
The registrar then took me to the ward for a ‘tour en salle” i.e. ward round and as usual there were mainly patients with lower limb fractures, tibia and femur, many with infected implants. I also saw patients with infected non unions and a man who had been in hospital for the last 6 months with a large skin and soft tissue defect of the distal thigh as a result of a supracondylar fracture of the femur and a complete lesion of the sciatic nerve. His fracture was ununited , shortened and in varus. Probably an above knee amputation will be the only solution considering the local conditions.
In the outpatient clinic I was greeted by the plaster technician who was disappointed that I didn’t manage to bring a plaster saw as he has to remove plasters using the blade of a hacksaw: and he is very skilled at it!!!
The patients were mainly fractures some having healed with significant deformity and others with chronic infections following internal fixation. There was one lady with finger contractions, amputations and muscle wasting of the intrinsic muscles of both hands and absent sensation and chronic ulcers of both feet. I asked whether there was leprosy in Haiti and they gave me the impression that they didn’t know but for me this was typical of advanced tuberculoid leprosy. Unfortunately there was very little we could offer this patient. Then there was a middle aged man with a long history of pain and a large swelling of the anterolateral aspect of the proximal tibia and Xrays showing destruction of the lateral condyle involving the joint. To me it looks like a giant cell tumour and he will have a biopsy at some stage. I did some teaching of the medical students and they seem to appreciate every tiny morsel of knowledge you give them which is very satisfying. The clinic finished at 2.00 pm and it was time for a late lunch.
Tomorrow is a theatre day.

Tuesday 25 October 2011

Walked to work his morning. Watching people in the street is fascinating. There are a lot of schoolchildren around at that time of the day. They are all dressed impeccably in their school uniform with their hair neatly pleated for the girls and the boys all wearing ties. As there are a many different schools here in Cap Haitien you get a sea of colours from the different school uniforms. Then there are the street vendors: food, clothes, groceries, shoes, phone cards, money changers anything really! I also pass in front of the shoe shine boys and I think I will need their services soon. Then I walk across the main square in front of the large Roman Catholic Cathedral and then on to the hospital. On the way there is a funeral parlour and because it is All Saints Day next week they have large signs outside announcing specials for funerals and 10% cash back deals. Well it sounds like this is a good time to die!
At the hospital I joined the teaching ward round: there were masses of doctors all gathered around the patient’s bed like a rugby scrum trying to absorb the knowledge dispensed freely by the orthopaedic registrar. Then it was off to theatre to sort out some of the instruments and implants I brought from NZ. I was privileged to be shown “Alibaba’s Orthopaedic Cave” in theatre where they keep hidden all the nice new orthopaedic implant sets and to my surprise there was a brand new shiny, never used, distal radius set as well as flexible reamers and other staff they obviously have never used. What is really required here is a cataloguing of all their equipment as nobody knows what is actually available. Before starting the operating I was told that one of the 2 operating theatres was out of action. The reason for it a ‘leaking roof”. I remembered from last year the peeling paint on the ceiling and even took a photo. Apparently they tried to fix the roof by adding some concrete but no success! Now they are waiting for what they told me is a special paint which is used in swimming pools: Yeah right!
In the meantime the theatre is used as a store room(see photo attached).
Anyway after this disappointing discovery it was time to start the list.
First case closed fracture of the femur midshaft 2,5 weeks old skin traction only. Now imagine doing this case with no fracture table, no image intensifier, no power tools, blunt rigid reamers with most sizes missing and a box of old nails of all different types, sizes most of which had already been used before. Well despite all of these challenges we managed to achieve an anatomical reduction and rigid fixation.
The next case was an infected femoral nail with a K rod in place and a draining sinus at mid thigh level. The fracture was a couple of years old and united. The nail proximally was around over an inch away from the end of the bone and we had to cut a trough to take it out. A second incision in the mid thigh revealed a large collection of pus which was drained. Lastly I noticed that there was a problem with his knee. You wouldn’t believe it but the knee was completely stiff as a result of the lack of physiotherapy services at the hospital. I therefore believe that the initiative by ‘Hands and Hearts for Haiti’ to establish a physiotherapy school here in Cap Haitien is a brilliant idea as a lot of these post operative complications are avoidable. I have already seen the change from last year in the sense that physios now visit the orthopaedic ward 3 times a week. That is excellent and the NZ physiotherapy team has to be congratulated for making this happen.
The last case was a young 14 year old with a 3 week old displaced distal radial fracture with 50 of posterior angulation. Xrays showed abundant callus formation and we carried out a ‘callotasis’ to correct the deformity followed by a plaster. After that the anaesthetist announced that she was very tired and called it a day. By this time it was 4.00pm.
As last year I have been bribing the theatre sister with my lunch and the effect was immediate!! So there is no risk of me putting on weight whilst working here.
Having managed to do these 3 cases in the circumstances was slightly short of a miracle.

I believe that small steps will lead to change and my aim is to teach the young registrars orthopaedic skills will hopefully result in improved quality of fracture care in the future. To that end I am organizing a fracture fixation workshop for the intake of young registrars. I have instructed them to get some beef femurs and tibias from the local butcher and I will run the first Haitien style AO Course. You have to think laterally all the time here in Haiti! And I feel I am getting good at it. My next project is to find some compressed air cylinders to run the pneumatic drills, reamers and saws in theatre. Wish me luck!

On the way back to Cap Haitien 22.10.2011

I have just checked in 2 heavy suitcases filled to the brim with orthopaedic equipment and a few underpants!!! I feel like travelling with an orthopaedic theatre in tow. Even my hand luggage has some external fixators in it which caused a little bit of curiosity at the security check. The chap who asked me to open my bag was very interested of what I was doing with all this equipment and we had a good chat about my work in Haiti.
The list of equipment required at the hospital in Cap Haitien was extensive and included a fracture table and image intensifier! Imagine trying to get those items through security! Anyway I have managed to get a lot of tools and implants which are no longer used by Dunedin Hospital but will make my work in Haiti so much easier. Having the luxury of a sharp drill and power tools will be a dream. The external fixators will be very handy to treat the daily open tibial fractures generated by the chaotic traffic in Haiti. I am sure the "tibia crackers" i.e. motorcycles are still operating in force in Cap Haitien.
The aim of my visit is to further develop the orthopaedic services at the hospital and provide training for the 2 young Haitien doctors Pierre and Cherubin. I will try to impliment some changes on the ward and in the operating theatre but this will require extreme diplomacy and probably some bribes! Wish me luck!
I am looking forward to the challenge and will keep you informed about my trials and tribulations.