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!