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!