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.
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.
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