Thursday 3 November 2011


Early start today in the operating theatre:7.00 am. The first case was a young man who injured his knee 3-4 months ago in a car accident. He complained of a locked knee and giving out. Clinically he had some anterior cruciate ligament (ACL) laxity and in the absence of an MRI scan and arthroscopy the first part of the operation was an open arthrotomy which showed a deficient ACL and no obvious meniscal tear. I decided to do an ACL reconstruction and we had the compressor and pneumatic drill and saw all set up when the power went down. To my horror I had to resort back to the hand drill and it was hard work drilling the bony tunnels. The graft harvest was relatively easy because there was a super sharp small osteotome which obviously hadn’t been used before. The fixation of the graft required some lateral thinking but in the end things looked good.

After that our list was interrupted by a surgical case which led to a very long lunch break. The second case was the young boy with a very sore and swollen knee I referred to before in a previous post. On further reflection I got a chest Xray thinking of tuberculosis and bingo there it was: typical radiological findings of pulmonary TB!! I opened up the knee and found a completely destroyed knee joint with obliteration of the joint cavity, synovial hypertrophy , destroyed articular cartilage and very soft bone. The findings were typical of joint TB. The only thing I could do was removing the remaining cartilage in order to get the knee to fuse in a plaster. Because of the soft bone, internal fixation of the knee was not possible. He will now be given anti tuberculous medication and hopefully cured of the infection in 6 months. His knee, however, will be stiff for the rest of his life. The last case started at 5.00pm and was a removal of an infected femoral blade plate following a subtrochanteric fracture. I have never in my career seen so much hard fibrous scar tissue which even the scalpel didn’t manage to traverse and I finally had to resort to a chisel. I managed to get out of theatre at 6.00pm just in time to meet Robyn and Fiona and catch a taxi to a local hotel to meet Dr Moise from Port an Prince who is a rehabilitation physician working for Healing Hands which is an organization forming physiotherapy technicians, prosthetists and orthotists. We wanted to pick his brain in relation to the HHH Physiotherapy School project. The meeting was very informative and he is a good contact person to have. He also told me that if I had any patients requiring an artificial limb following amputation I could refer them to him and they would get their artificial leg fitted free of charge.


Friday 4 November 2011

After a teaching ward round it was time to start the outpatient clinic with the usual number of patients queuing up to be seen. There was nothing to much out of the ordinary as far as unusual pathology was concerned and I decided to do a bit of teaching of clinical examination. The doctors here are not used to examining patients. They take a quick history , then look at the Xrays and ask me what I would do. So we have been going over clinical examination technique and some of them seem to be getting the message. In the absence of investigations or scans available here clinical examination is very important and doesn’t cost anything. During the clinic I was called to the emergency department to see a patient with a nasty foot injury after a motorcycle accident. He had a complete degloving type injury to his heel and sole with avulsion of the tendo Achilles and bone loss of the calcaneal tuberosity. He also had a laceration of the posterior tibial artery and nerve and consequently no sensation on the remaining sole of the foot. We took him to the operating theatre urgently for exploration of his severe injury but unfortunately he had another fracture of the tibia and the only option was a below knee amputation.
Luckily I met Dr Moise the night before as I can now send this patient to Port au Prince to be fitted with an artificial leg and he will be able to walk again.
The sad part of the story is that this man was on the way to the hospital to see a doctor for epigastric pain and loss of weight. It looks like he might have some cancer somewhere.
Life is very though and unjust in Haiti! I feel for these beautiful people!