Tuesday 29 November 2011

Today was my last operating list. When I arrived in the operating theatre at 7.30 am there was dead silence. Nothing had started for the day. I thought that was a bad omen.

I found the residents outside the theatre calling ‘orthopedie, orthopedie, orthopedie …’ to alert the anaesthetists that we were here and ready to go. As there was no action we went to the ward to see a 67 year old lady with a displaced neck of femur fracture who requires a hemiarthroplasty. They have uncemented Moore prostheses here but not in all sizes and sometimes the Haitien patients have small femoral canals which makes the fitting of the prosthesis challenging and sometimes impossible. The only other option then is a resection arthroplasty.

There were 4 orthopaedic cases on the list today: non union proximal phalanx thumb in a 5 year old, patellectomy, femoral nailing and plating of a distal tibial fracture. The patient with the tibial fracture jumped the queue because he is a friend of the medical director and normally would have to wait for a couple of weeks for his surgery. The first case took about 20 minutes operating time and then a patient of the senior registrar, not on any list, was taken into theatre for a general surgical procedure out of the blue without discussion. Whilst waiting I had a look at the store room to see whether there was any useful orthopaedic equipment hidden away in old dusty cartoons and I found 2 brand new US Army pneumatic tourniquets with a bicycle pump which was what I was trying to find in NZ and here there were 2 and nobody knew about them. I tried them with the residents and they work perfectly well even if there is no power!!!

The second patient on the orthopaedic list was called for at 11.30 but as his blood pressure was slightly elevated he was cancelled by the anaesthetist. Then we were told there was a C section and at that stage I went to have some lunch with the residents. As Robyn and I had an appointment with the Director General of Health I had to leave the hospital at around 1.30 pm. I will see tomorrow whether the residents managed to do the femoral nailing and the tibial plating.

The meeting at the Ministry of Health was straightforward and after that we visited a patient who had a hemiarthroplasty for a neck of femur fracture 2 months ago and when we got to the house she was in bed. She had been told by the local orthopaedic surgeon that she was not allowed to walk for 3 months. She didn’t have any crutches but was given a wheelchair. Her hip felt fine to me and I advised her to go and see the surgeon next week and to get some crutches.

The paraplegic patient which I was told would be transferred from another hospital from the central part of Haiti is now apparently being flown here tomorrow which is my last day. I told the referring hospital that I cannot guarantee that I will be able to do the surgery before I leave but they said they take the chance as there is no other option available to them. The patient has a C6C7 dislocation and my plan is to do an open reduction through a posterior approach, sublaminar wiring and fusion. We shall see what tomorrow brings!

Saturday 26 Sunday 27 November 2011




This weekend we had a visit from Pauline Penney who is a Kiwi living in Port au Prince and working for the UN. We had the opportunity to discuss our physiotherapy project with her and her input was very helpful indeed. We showed her around Cap Haitien and she really enjoyed her time away from Port au Prince.

It rained a lot on Sunday and the temperature was nice and cool which meant I had a great sleep and for the first time didn’t require the fan. Don’t forget it is wintertime here and temperatures drop to around 23 degrees at the most.



Monday 28 November 2011

 
The day at the hospital started with the final presentations by the interns who are leaving the department in the next couple of days. The presentations went from 7.00 to 11.00 and were followed by morning tea consisting of sandwiches, cup cakes and soft drinks preceded by speeches. It was a nice touch by the interns thanking everybody for the teaching they received over the last 4 to 6 weeks .

The patients attending the clinic had to wait patiently outside and once the party was over the clinic started with a hiss and a roar and finished at 1.30. We saw a closed fractured tibia which was put into a long leg plaster and sent on his way followed by a young man with a dislocated elbow. The resident gave him some diazepam IV and reduced the dislocation on the spot. After application of a back slab he also was sent on his way. There were lots of other smaller injuries and towards the end of the clinic a young woman was brought in who had been injured in the Dominican Republic 3 months prior. She suffered a segmental fracture of the tibia and a complex distal humeral fracture with intra articular extension. Both fractures were treated in a plaster after closed reduction and she was sent back to Haiti. She has a very stiff and deformed elbow which is beyond salvage and a clinically united tibial fracture with some external rotation and shortening. The resident told me that Haitien are treated very badly in the Dominican Republic and that they are treated like animals rather than human beings. I must say that after the cases I have seen recently he is probably right.



Today was also the initiation day for the new intake of nurses called ‘jour des bleus’. This is when the new recruits dress up in funny clothes with multi coloured bows in their hair, brightly coloured socks and a pair of footwear which doesn’t match. They looked really funny to the great delight of the interns and residents.

Friday 25 November 2011




The ward round this morning was very relaxed and there was a lot of Haitian humour and bursts of laughing. There was one admission last night and guess what: a motorcycle accident. The patient suffered a heel fracture and a posterior hip dislocation on the same side. This is the 4th hip dislocation I have seen over the last 4 weeks and probable double the number of femoral fractures. The hip dislocation was reduced by the resident last night and the patient sitting up in his bed very happy. Then we saw a 12 year old boy with an angulated proximal femoral fracture in a long leg plaster slab unreduced with obvious angulation of the proximal thigh. The junior resident was told off in no terms that this was not an appropriate way of treating femoral fractures and he looked very sheepish indeed. The other patients were all fine including a little boy with osteomyelitis of the femur who looked very happy this morning.

We then went to the medical ward to look at a patient with a spontaneous compression fracture of the thoracic spine with a history of convulsions, improving paraparesis and a mild fever. He had been improving on antibiotics and I thought that the most likely diagnosis ,by exclusion, was osteomyelitis. However you never know here in Haiti!



The outpatient clinic was steady today with the usual interesting patients. There was a young child with congenital elevation of the scapula (Sprengel’s shoulder), an elderly man with a non union of the humerus and a complex intra articular fracture of the proximal tibia treated in a long leg plaster and Mammon, the plaster technician reduced a Colles fracture without anaesthetic: he likes to play doctor!

Finally I saw the sad case of a young man who was involved in an altercation in the Dominican Republic which ended up him loosing his arm from a single very sharp machete blow. He put his arm in front of his face to protect himself but the machete sliced through his forearm including bone resulting in a surgical guillotine amputation. In New Zealand this would have been a perfect indication for a reimplantation with a number of surgical teams reattaching the amputated arm. However in this part of the world this is not possible and this young man is now one handed which is a significant disability. The residents told me that these machete incidents are very common in the Dominican Republic were the Haitian are treated very badly. There is in fact a lot of animosity between the 2 countries. I said to the residents if the Dominican machetes are that sharp we should send our theatre instruments there for sharpening as they are all dead blunt!



To finish off the day I helped one of the residents to drain a chronic osteomyelitis of the humerus and then it was time to go home.

Yesterday I have been contacted by the Baptist Convention Hospital regarding a patient with a C6C7 dislocation and spinal cord injury who is somewhere in the centre of Haiti and I have been asked to see whether I can stabilise his neck here at Justinien Hospital before I leave next week. I said that I am happy to help if they can get the patient here over the weekend. We shall see what happens.

Thursday 24 November 2011




There were 3 cases on the operating list today: non union forearm fracture, fracture radius and ulna 4 weeks old and a femoral nailing. The morning started with a below knee amputation which wasn’t on the list but was a patient of the local orthopaedic surgeon who obviously manages to get his cases done whenever he wants! The next case was a non union of the radius and ulna with a broken radial plate and a previously removed ulnar plate for sepsis. The angulation of the forearm was gross and we carried out a replating and bone grafting from the iliac crest. The next case was the forearm fracture and I showed the senior resident how to do an open nailing using old fashioned Rush nails. The residents thought it was a good technique and I am sure they will use it many more times considering the mountains of Rush nails I have seen in the famous ‘Alibaba’s Cave’ which is the cupboard in theatre where all the orthopaedic implants are kept.

The last case was cancelled because theatre staff had run out of steam!

I popped over to the outpatient clinic to see a few patients. An adolescent boy whom I saw at the beginning of the week with a history of osteomyelitis of the humerus and multiple surgical operations in the past came back with a pointing abscess over the lateral aspect of the distal arm and Xrays showing a cavity in the distal humerus with periosteal new bone formation consistent with a Brodie’s abscess. He will require to have that drained tomorrow and the bone curetted out. Then I saw a 10 year old girl with bilateral genu valgum, short stature and a swollen abdomen consistent with Kwashiorkor (malnutrition). Her father was saying that she wasn’t eating very well and that he had a lot of other kids which probably means that he can’t feed his children properly. I asked the resident to get some blood tests, an Xray of her knees( to exclude rickets) and a paediatric consultation. We shall see what the investigations will show!

That was the end of the day and when I got home Robyn had bought a great big tin of yummy Belgian chocolate biscuits. What a great way to finish another great day in Haiti.

Wednesday 23 November 2011




The ward round this morning was very low key. There were no new admissions and the remaining patients were fine. There are still 3 femur fractures waiting for intramedullary nailing, 1 forearm fracture, 1 distal femoral malunion for an osteotomy and an older man with a supracondylar fracture of the femur on one side and a tibial fracture on the other which seems to have been abandoned. The little boy with the osteomyelitis looked much happier today and his temperature was normal this morning. I asked to see the temperature chart but was told there was none but that they could get one from paediatrics. I shall see tomorrow whether the chart has appeared!

Outpatients were very quiet today but we saw a young boy with a femoral fracture treated non operatively in the Dominican Republic with a healed fracture and good alignement but 3 cms shortening. As he is only 5 years old this should remodel with growth. Then a young adult presented with an ankle and foot problem which he said was troubling him since last Monday. Clinically he had marked wasting of his left upper and lower limbs with signs consistent with a spastic hemiplegia and I pointed out the spontaneous Babinski sign to the residents. Haitien patients don’t tell the truth the residents keep telling me and they are right: on further questioning he admitted that he had problems with his leg since he was a child!!!

I left the clinic early today to go to an opening of a new rehabilitation centre on the outskirts of Cap Haitien. This centre is part of a hospital which is being built by the Baptist Convention of Haiti with the help of a number of overseas aid organizations and when finished will have a maternity, paediatric ward and an operating theatre is being completed currently. The opening ceremony was a typical Haitian event with a lot of speeches, prayers, singing and followed by some food. There were representatives from the United Nations, Haiti Hospital Appeal, Swiss Paraplegic Foundation etc. One of the Swiss representatives spotted my Citroen hat and asked me whether I liked French cars. It turned out that he is the past president of the Swiss Citroen Club and owns 3 vintage Citroen Tractions. When I found out that he was working at the National Swiss Paraplegic Centre in Nottwil I asked him whether he knew Niklaus Aebli who works in the same place and was my PhD student in Dunedin for 3 years. He did indeed and we had a great chat about Citroens and the work the Swiss Paraplegic Foundation is doing in Haiti and other countries. The world is a small place indeed and you never know who you will meet around the next corner. Amazing really!

Our driver was keen to get back to Cap Haitien as he wanted to watch the Barcelona versus Milan soccer game. Haitians are soccer fanatics and all the way home we could see crowds of people lined up outside shops with TV’s and standing on motorcycles to get a good view. That was the end of a great day!

Tuesday 22 November 2011

Today’s operating list: malunion radius and ulna, biopsy tumour proximal tibia, 4 week old fracture midshaft radius and ulna and intramedullary nailing 3 week old fracture femur with 5 cms of shortening. I was told as usual that we would start at 7.00 am but when I arrived about 7.30 the operating was very quiet and they told me that there was no oxygen and that the only thing on offer was spinal anaesthesia for lower limb operations only. So that meant the 2 forearms were cancelled and they sent for the patient with the tumour.

In the meantime we saw a few patients on the ward including the child with fever and a swollen thigh from yesterday. He was afebrile this morning but still not very well with ongoing pain in his thigh. An aspiration of the midthigh down to bone did not reveal any collection of pus. I asked about the blood results but they hadn’t been done yet. However he was on IV antibiotics. An elderly lady was admitted last night with a painful hip and Xrays showed a fracture of the base of the neck and the greater trochanter with early callus formation and on questioning the residents further it turned out that the injury was 6 weeks ago. She was given crutches, told to remain non weightbearing for another 4 weeks, and discharged with an outpatient appointment.

The first patient in theatre was eventually ready. He had a swelling of the anterolateral aspect of the leg below the knee with bone destruction of most of the lateral tibial condyle sparing the fibula. To me it looked like a giant cell tumour or chondroblastoma as the subchondral bone was involved. There is no pathologist in Cap Haitien and all biopsies have to be sent to Port au Prince. Apparently it takes 3-4 months to get the results back and the residents thought that would be just in time for my next visit!!!

The second case a femoral rodding was done well by one of the residents despite a crucial reamer missing off the tray, a difficult reduction and a small butterfly fragment cause when passing the nail across the fracture. However the patient had a completely stiff knee at the end of the procedure as a result of the quadriceps shortening and he will require intensive physiotherapy which again is not easy to achieve here.



Unfortunately that was the end of our list as we were told that here were no nurses to wash the instruments. Before I left I saw one of the residents and the interns standing at the sink cleaning the instruments from the previous case. Yes that is Haiti!

To finish off the day I was told that we did not have any electricity at home because the owner of our flat hadn’t paid the electricity bill. However after pulling a few string somebody from the electricity company came and reconnected us and everybody was happy!

Weekend Saturday 19 Sunday 20 November 2011

Saturday was a very quiet day reserved for some retail therapy as Fiona was leaving after the weekend. We have a 14 year old girl called Lovely staying in our flat and the other day I asked her whether she had any books as I often see here sitting around doing nothing or watching TV. I was surprised when she told me that she has no books to read and that her school does not have a library (nor any computers for that fact). We therefore decided to find her some books and Fiona bought her a lovely illustrated dictionary which I am sure will help here with her French studies .I also was told by Lovely that some days the teachers just don’t turn up and the kids are left on their own at school without anything to do. Also kids don’t have any opportunities to play as there are no playgrounds nor any sporting facilities. The only time you see them on the streets is on Sundays when the neighbourhood kids take over the streets to play soccer using some very small locally made goals. Looking at them with my eyes as a retired soccer coach I must say they have very good skills.

On Sunday we were invited by Reuben’s wife, Jacqueline, for Sunday lunch which meant that we had to take a local Taptap to get to their place on the outskirts of Cap Haitien. We were squeezed like sardines in a tin and they managed to fit at least 20 people into a people mover which had not a single functioning shock absorber left. We got to our destination in one piece and had a lovely relaxing time followed by a nice lunch. Actually I spent most of my time entertaining a 5 year old boy called , Sebastien, who expected my full attention 100% of the time. I had to invite all sorts of games and make things from stuff lying around the garden to keep him entertained. We got a ride back into town from one of Robyn’s friends and as it was Sunday the day finished with an ice cream.





Monday 21 November 2011

After farewelling Fiona I walked to the hospital to join the ward round which had just started. There were only 2 admissions over the weekend one 1 year old child with a femur fracture appropriately treated with gallows traction and a closed tibial fracture in a young lady which had some lacerations which were sutured. The resident opted for application of a long leg plaster which I thought was a very good option as the fracture was reasonably aligned. All the other patients were doing well and a number were ready for discharge.I enquired about the little boy admitted last Friday with a very painful and swollen arm and I was told that he has been transferred to the paediatric ward but nobody could tell me whether he had improved or not.

Outpatient clinic was busy this morning and we saw about 20-30 people including some patients referred from ED. We sutured one thumb extensor laceration following a machete injury under local anaesthetic and saw as usual some interesting patients. There was one new born with an obstetric Erb’s palsy and another child with a high temperature and a swollen and painful thigh and knee on the basis of acute osteomyelitis of the femur.

Then there was an old man who complained of hip pain but Xrays were normal and the resident had not examined the patient. It turned out that he had a large lump overlying his hip possibly a lipoma, soft tissue sarcoma or TB of the bursa of the greater trochanter. I asked the resident to aspirate the lump but there was no fluid. He was referred to the general surgeons for an excision biopsy. Finally there was a young boy with severe burns to his upper limbs who has been on the ward for at least 6 months. He is under the care of the general surgeons who look after the burns and he has major contractures of his elbows and right wrist. He will require extensive Z plasties of his elbows and wrist to restore the movement of these joints. However that might not be enough as he probably has developed secondary tendon and joint contractures. Interestingly he got burned when dressed in newspaper for a play at school when another boy grabbed some matches and set him alight!

Friday 18 November 2011

Today is a public holiday commemorating the Battle of Vertiere in 1803. From early in the morning we could hear the brass bands marching up the main street to the town square where the parade starts at the end of the official Te Deum held in the old catholic cathedral. So off we went to the square where there was a small crowd by Haitian standards waiting outside the church for the official party to leave and the parade to start. It was really hot in the sun and we had to shelter under some trees to get some shade. From our vantage point we could observe the preparations for the parade. There were quite a number of school brass bands in their colourful American style uniforms waiting patiently for the start of the activities. Most of the bands here also have a group of what is called ‘majorettes’ which basically are the equivalent of the New Zealand marching girls.

At some stage a small group of Haitians on horseback and dressed in period character clothes arrived carrying fake guns and wearing military hats modeled on the style worn by the French army in the 18th and 19th century. They looked quite fearsome with large rings dangling from their ears resembling more captain Jack Sparrow from Pirates of the Caribbean than General Jean Jacques Dessalines or Toussaint L’Ouverture who were the leaders of the revolt of the Haitians against the French.



I also noticed the presence of the UN troops all dressed up in their combat gear and armed to their teeth patrolling the area. I wasn’t sure whether that meant we were safe in case of trouble but they looked like they meant business. We were the only white people on the square and I hoped that the Haitians were not associating us with their French colonial masters of the past particularly on a day like this!!!



Anyway the parade eventually got on its way and it was great seeing all the bands marching past blasting their brass instruments and beating the drums with great gusto.

From the square they all walk all the way to Vertiere where there is a monument commemorating the famous battle. I guess it would take them at least an hour to get there fighting their way through the traffic and facing the blazing sun. I suppose that is a small sacrifice compared to those who were on the battlefield on 18 November 1803! Vive la Republique de Haiti!

Thursday 17 November 2011

Today was not such a good day! Although there were 5 cases on the operating list we only got to do one before the theatre was taken over by general surgery and of course the obstetricians for C section after C section. The one and only case was a middle aged woman with a neglected 4 week old elbow dislocation. This is a very disabling condition as the patient is unable to bend the arm and I told the residents that a straight arm is a useless arm because most activities of daily living require elbow flexion. So we did an open reduction of the elbow dislocation through a lateral approach followed by plaster immobilization in flexion. She will have to remain in plaster for 3 weeks followed by physiotherapy. Hopefully she will recover a functional range of movement.

That was the end of the operating list.

We then went to the outpatient clinic and saw an 18 month old child with a very swollen arm, elbow and forearm which according to the mother was the result of a fall. Xrays were normal but he had a fever of 39 degrees Celsius and to me it was clear this was an infection either septic arthritis of the elbow or osteomyelitis. He was admitted to the ward for blood tests and IV antibiotics. In the absence of any other possible investigations he will be followed clinically and if he improves with antibiotics in the next couple of days that will be fantastic but if he remains febrile with spiking temperatures he will require surgery to drain the elbow or subperiosteal abscess somewhere!!!

 Then a young adolescent showed up complaining of pain in his arm following multiple operations over the last 4 years. He had marked wasting of his arm proximally and swelling and tenderness distally with multiple scars. Xrays showed sclerosis and remodeling of the humerus consistent with chronic osteomyelitis. There is a lot of sickle cell disease here in Haiti and these individuals affected have a high incidence of osteomyelitis. He probably has a flare up of osteomyelitis and he was sent for updated Xrays and blood tests.The next patient was a young adult who had a closed distal arm fracture after somebody “threw a rock at him”. I find it very difficult to get a clear history from Haitiens as they are very poor historians! Often they tell you the most unbelievable stories and you can’t always believe everything they tell you. Anyway this chap had a plaster applied and then was sent on his way. Post reduction Xrays are only occasionally done as the patients can’t afford them. The last case was a 13 year old with a displaced Salter Harris 1 fracture of the wrist which was reduced under haematoma block and placed into a plaster.

Later on we did some dressings on the ward including a patient who had an external fixator applied for a grade 3b open tibial fracture. There was some concern regarding the viability of the skin flaps and I told the residents that I had very little experience assessing skin viability as far as Haitiens are concerned and that black skin in the white population is bad news!!

In between these cases there was a lot of down time and I spent some time reading and the rest chatting to the residents. The main topic of discussion today was about tomorrow’s commemoration of the battle of Vertieres (on the outskirts of Cap Haitien ) on 18 November 1804 when the Haitiens under General Capois la Mort won a decisive battle against Napoleon Bonaparte which ended the French Colonial period in Haiti. I told the residents that New Zealand has also beaten the French but more recently and at rugby!

Tuesday 15 November 2011

Sadly the young man with the head injury died last night. In the absence of a CT scanner and neurosurgical expertise that’s unfortunately the outcome of many severe head injuries here in Cap Haitien. However overnight a young woman with multiple injuries 24 hours following a road traffic accident was admitted to the ward but poorly assessed by the resident on call. I was told that she had a fractured femur which was correct but it turned out that she had a head injury, fractured mandible, rib fractures and a haemothorax and a pelvic fracture. Nobody had taken the blood pressure since admission but was told that it was 90/60 when seen in the emergency department. This was an ideal opportunity to teach them about the basics of how to assess an unstable and multiply injured trauma patient. Then I was shown a patient who apparently had been on the ward for the last year as a result of a necrotizing infection of his leg under the care of the general surgeons. He had multiple skin debridement followed by skin grafts but no had a fixed equinovarus contraction of his ankle. Obviously his ankle wasn’t splinted and now he probably requires an arthrolysis of the ankle and tendo Achilles lengthening or perhaps an arthrodesis in a functional position. This complication was entirely preventable with proper splinting and physiotherapy.

The operating list started with a hiss and a roar and 2 orthopaedic theatres going by 8 am. I did an internal fixation of a displaced neck of femur fracture in a 47 year old with no fracture table, no image intensifier and nobody having a clue as far as the instrumentation was concerned which was basically a set of 7.0 AO cannulated screws. I did an arthrotomy through a lateral approach and the fracture was reduced open using one of the local residents who just had his breakfast to pull on the patient’s leg. The screws were inserted blind having gauged the length of the screws preoperatively on the opposite side. The fracture was stable after the insertion of 3 screws and the absence of grating on moving the hip in all directions confirmed that the screws had not perforated the femoral head and then it was time to close. The next case was an external fixator for a 4 week old open distal tibia fracture with the wound still open and the bone exposed .This might well be the first stage of a below knee amputation. After that I was told by the anaesthetists that there was no oxygen and that we could not continue with the list. I have the impression that sometimes the anaesthetists use this as an excuse if they don’t feel like doing another case. However they then did 2 Caesarian sections and we were allowed back into theatre in the afternoon to do an above knee amputation in a patient who had be on the ward for 5 months following a road traffic accident in which he suffered an open distal femur and distal tibia fracture as well as severe skin loss around the distal thigh and knee. When I first saw him when I arrived he had a complete sciatic nerve palsy with no active movement below the knee and basically a useless limb. An amputation was the only solution for this unfortunate young man!

In between cases I was asked to see a 17 year old girl with a large swelling of the distal thigh and a destructive lesion of the femur on Xrays consistent with an osteosarcoma. The prognosis for her is awful in the absence of chemotherapy and tumour surgery expertise she will probably have an amputation and die of metastases.

Although this might not sound like a lot of work for one day it was a great achievement by Haitien standards.



Wednesday 16 November 2011



The day started with a number of presentations by the house surgeons on aspects of the anatomy of the musculoskeletal system and today the topics were anatomy of the knee and ankle. As they have no data projectors about 20 people huddle in front of a laptop to get a view of the screen. The presentations were well done and were very comprehensive but they did not make the link with the clinical application of their anatomical knowledge.

The ward round followed and we saw 1 admission from the previous night with a severe grade 3b open tibial fracture and the resident on call had actually taken the patient to theatre, debrided the wound and applied an external fixator just as I taught him. That was very pleasing to see and I congratulated him for a job well done. Then I was shown a young man who had been on the ward for 2 weeks with a diagnosis of open tibial fracture. No Xray was available and when I asked the residents how old the fracture was they told me a couple of months. I asked them to open the bandage on his leg and there was a wound with a piece of white bone sticking out. I asked the resident to check whether the fracture was healed and it was pretty clear that there was no movement at the fracture site and obviously the bone had healed. I then asked him to take a forceps and tug at the bone as I suspected a sequestrum which is a piece of dead bone in chronic osteomyelitis. And surprise surprise a reasonably sized piece of tibia came out from the depth of the wound which will allow the wound to heal and the infection to settle down. He was discharged later in the day with antibiotics and advice to get his wound dressed regularly at the local hospital. Sequestrectomy on the ward round what about that?

Whilst one of the residents did a tibial nailing I helped out with the outpatient clinic which was very busy today. There were quite a number of new fractures and we did a manipulation of 2 distal radius and one supracondylar fracture in a child under local anaesthetic without to much teeth grinding! The sheer number of fractures and the lack of anaesthetic services forces one to reduce fractures in a suboptimal manner but there are unfortunately no other options.

Then I saw a 10 year old boy with a crouch gait as a result of cerebral palsy. I used him as a teaching case for the residents who knew very little of that condition. Finally I taught one of the new residents how to suture an extensor tendon injury in a young girl with a machete cut to the dorsum of the hand. By that stage everybody had left the clinic so I threw my backpack over my shoulders and walked home. Overall it was a very good day!

Saturday 12 and Sunday 13 November 2011

On Saturday Robyn took us to a beautiful unspoilt beach called “Chouchou Bay” at 2 hours drive west of Cap Haitien. Although the distance was only about 50-60 kms it took us about 2 hours to get there because the road was pretty bad at times resembling more a riverbed than something for cars to drive on. The country side was spectacular with green mountains hugged by clouds, rivers and small settlements along the road. Once we left the main road the traffic was made up mainly of the odd motorcycle taxi loaded literally to the “gunnels”. You wouldn’t believe it but the Haitiens can fit the following on a motorcycle: 1 driver, 3 adult passengers, 1 baby and a 100kg bag of rice on the handle bars!!! Then imagine a road like a riverbed and you have the picture: the drivers are very skilled and must have a great sense of balance. Once we got to the beach we were amazed but the beauty of the place. A sandy and sheltered bay with clear water surrounded by trees and not a soul in sight apart from some local fishermen. After a picnic lunch it was time for a swim and the water was just perfect!

A local fisherman was weaving a net and he was so skillful with his hands it was a pleasure watching him: he told us that it takes him 2 weeks to finish a whole net! Another one played the guitar and the local children and Robyn started to sing and dance. We had a wonderful time and I hope that this place stays as it is and escapes development for the tourist industry!!!

Sunday was a day of rest and I had my weekly swim in the swimming pool at the Roi Christophe Hotel where we also had a nice brunch.

Monday 14 November 2011

The weekend at the hospital was busy for the orthopaedic department following a “taptap” accident about 2 hours out of town. Taptaps are the local taxis which basically are pick up trucks transporting people between cities and normally when fully loaded have 20 people on board. One of them came of the road and hit a rock face causing half a dozen of seriously injured passengers. So the orthopaedic ward was pretty full this morning during the ward round: 1 severe head injury, 1 patient with a dislocated hip and 2 wrist fractures of which one was dislocated and open, 1 fracture dislocation of the hip, 1 forearm fracture and some more minor injuries. The head injury patient is unconscious and lying on the ward and the family asked me to have a look at him. He has a severe head injury without any skull fracture and no other bone fractures. His neck and spine are clinically normal and he really needs a CT scan which is not available here. So the only thing we can do is to monitor him clinically and hope that he will wake up and recover the motor function of his limbs. Here in Haiti if you have a head injury you either die or you recover spontaneously because there are only a couple of neurosurgeons in Port au Prince. The patient with both wrist fractures and hip dislocation had his wrists redudec and plastered and his hip reduced under sedation. He was sitting in his hospital bed pretty happy.this morning. The other patient had a posterior fracture dislocation of the hip whichwe reuced under general anaesthetic today but the hip was very unstable and we had to put here into skeletal traction as a result. She will have to remain in traction for 6 weeks to allow the acetabular fracture to heal and the hip to become stable. Ideally she would require surgery in the form of fixation of the posterior wall but logistically I am not sure whether that is possible here.

The outpatient clinic was busy today with fractures from the weekend and follow ups. One 8 year old boy presented with a contracture of his middle, ring and little fingers as a result of an electrical burn 6 months ago. He climbed on the roof of a house and touch some live wires. He has skin contractures from burns and will require Z plasties and skin grafts to allow him to straighten his fingers again. Hopefully I can do his surgery before I leave at the end of the month.

At the moment we have 15 plus patients waiting for surgery and very little theatre time.

The orthopaedic residents told me that it is very difficult to get the anaesthetists motivated to do orthopaedic cases. They were saying that they have to beg them on their knees and probably whisper sweet things into their ears etc. I told the 2 residents that I have a perfect solution for the problem: I suggested to them that they marry anaesthetists and then their wives would be able to provide anaesthetic services for the orthopaedic department. They laughed and thought it was very funny! Well here in Haiti you have to think laterally at every level!