Tuesday 8 November 2011
Today is orthopaedic operating day. I was told we would start at 7.00 am but when I got there the theatre was empty. I found the registrars on the ward doing a teaching ward round. They informed me later that the starting time was changed to 8.00 am but they failed to inform me. The first case on the list was a neglected elbow dislocation which is now about 4 weeks old. This patient has been cancelled a few times and this morning the anaesthetists cancelled her again because of high blood pressure. The second case was a young man with a grade 2 open tibial fracture which had been on the ward for 2-3 weeks. The fracture was quite comminuted and involving the distal third. I felt an external fixator would be the best option although some of the senior registrar felt a plate would be better. I applied a fixator despite significant equipment issues. As usual I was presented with a big box full of all sort of different types of fixators and nothing fitting with each other!! However the outcome was satisfactory. My plan is to carry out a major inventory of all the orthopaedic equipment and sort everything into different boxes as well as cataloguing everything in a book. This will be my project for the next week.
The last case was a lady with a midshaft closed femoral fracture as well as a distal radius and thumb fractures. The injury happened about 4 weeks ago and she had been in skin traction since. I let the senior registrar do the operation and he struggled a bit with some bleeding from the perforating arteries but the reaming of the femur worked well using the compressor which I operated in the next room. There are still issues with equipment and registrar understanding of the nailing technique for the femur and tibia and more teaching is required. I intended to operate on the patient’s wrist under the same anaesthetic but was told that the anaesthetist decided that it was unsafe to continue because she felt the patient had lost too much blood. By the way there is a blood bank here in Cap Haitien but the family has to donate an equivalent amount of blood units as is required for the patient before the blood is released. Well that was the end of the operating list and my day at the hospital.
Wednesday 9 November 2011
The day at the hospital started with a teaching ward round by the senior registrar which covered everything from fractures to antibiotics, and inflammatory pathway to neck of femur classifications. Interestingly the senior registrar is also a lawyer so he talks like the legal profession does and he also disappears from the hospital regularly to defend cases in the local court. He also runs an office in town. I have noticed that the teaching is mainly didactic covering anatomy and physiology but clinical examination in not taught nor practrised. I keep reminding them that clinical examination of the patient is very important and a recent case demonstrated this very well.
A patient in his 40’s was involved in a road traffic accident car versus motorcycle. He was seen at a local hospital and referred to the Emergency Department of Justinien Hospital were he was attended to by the orthopaedic resident. He complained of thigh and knee pain and Xrays of the knee and femur did not show any fracture and he was sent home. Obviously nobody examined him properly and he came back to the outpatient clinic 3 weeks later walking with crutches and unable to weightbear. When I examined him it was clear that he had a hip problem and an Xray of the pelvis showed an anterior hip dislocation. He had all the typical clinical findings and even in the absence of CT and MRI imaging clinical examination will lead to the diagnosis,
The outpatient clinic was busy as usual and the first patient was a lady in her 50’s whom I noticed at church last Sunday sitting in the row behind me with a markedly deformed forearm: almost bent at a right angle! She had surgery 4 months ago in the form of plating a fracture of both bones of the forearm and apparently she developed a post operative infection which resulted in early removal of the ulnar plate. She then had physiotherapy and her arm gradually became more and more deformed and because the doctors disn’t do anything further she accepted her deformity and got on with life. Fortunately her hand and elbow function is excellent. Xrays show a broken plate on the radius and a ffibrous mal union of both bones. She will require surgery to straighten her arm by rebraking the bone and reapplying 2 stronger plates.
A lady in her 60’s was stretchered into the clinic with a long leg plaster following a femoral nailing for a midshaft fracture and an associated tibia fracture. She apparently was brought all the way from home on a stretcher in the back of a truck. After removal of stitches we gave her a pair of crutches and taught her how to walk with the plaster and she was off home. hen there were the usual machete injuries some of which lead to open fractures. Tendon injuries are poorly managed in Haiti and often the wound is closed and the tendons apparently are repaired later. However I have never seen a tendon repair in theatre so far. As a result outcomes of hand injuries are very poor.
At the end of the clinic the patient with the 3
week old hip dislocation turned up and after completing the blood tests he was taken to the operating theatre for a closed reduction under a general anaesthetic. Unfortunately despite a combined Kiwi Haitien show of strength the hip didn’t budge and we had to abandon the attempt at closed reduction. He was then woken up and placed on the operating list for an open reduction the next day.
I was completely soaked after this attempt at reduction and as it was the end of the day
I went home to get changed before attending another meeting of the HHH Physiotherapy School Project.
Thursday 10 November 2011
There were 4cases on the operating list today: neglected 4 week old elbow dislocation cancelled many times, 3 week old open tibial fracture for an external fixator, above knee amputation for a patient who has been on the ward for 5 months and the hip dislocation. The ward round as usual involved the usual teaching and I was pleased to see that the patient with the below knee amputation was doing well moving his knee freely without any pain. He will be started on crutches today and is awaiting a gastroscopy for his epigastric pain which could well be as a result of gastric cancer which I am told is very common here in Haiti.
The residents decided to start with the hip dislocation and I went off to theatre to be told that there was no water. We had to wash our hands with alcohol and got on with the operation. The hip was really jammed and I had to put a pin into the neck of the femur and perform the ‘corkscrew manoeuvre” to extract the femoral head and reduce it back into the socket. I am sure the patient will be pleased that his hip has finally been reduced!
After that we were told that the rest of the operating list was cancelled because of the lack of water. I saw a few patients in outpatients including a young woman with a 7 month old unreduced shoulder dislocation. She had pain but a reasonable range of movement and Xrays showed a deformed and dislocated humeral head. Unfortunately there was very little I could offer her except for a fusion of the shoulder joint. As she had minimal pain and reasonable movement we decided to leave things as they were.
After my usually shared lunch with the residents and some heated discussion with Dr Cherubin about life in Haiti and its politics it was midday and time to go home.
Friday 11 November 2011
Teaching today was on the anatomy of the forearm and hand. The house surgeons, called ‘internes’, normally give a powerpoint presentation on different topics and are then grilled by the residents. After that we did the ward round and the problem we have currently is a lack of access to the operating theatre: at the moment there are 10 inpatients and 10 outpatients waiting for surgery and orthopaedics is only allocated 2 lists per week which corresponds to 6 cases. You can do the maths for yourself and will realize that there is a problem similar to the one we have in Dunedin. By the way water has been restored at the hospital but no orthopaedic cases done today.
The clinic was smaller than usual which is normal on a Friday. I saw a couple of interesting cases including a young girl with a neurological condition and signs of an upper motor neurone syndrome. It is very difficult to get a clear history from Haitian patients and I was told that she was hospitalizes in paediatrics for 2 months and that she was epileptic. There was also a history of eye surgery. The father told me that she was fine before coming to hospital but that since she has had difficulties walking, unsteadiness on her feet and unable to talk. I told the residents that there was no orthopaedic problem and that she must have a brain lesion of some sort explaining her symptoms. As there is no CT scanner at the hospital she will have to travel to the Dominican Republic at huge expense which will probably ruin the family and in the end there might not be any treatment available for her.
Then there was a 6 year old with a neglected thumb fracture and a non union of 12 months duration. He will 
require a surgical correction and fixation with wires to restore the length and stability of the thumb. The question is when. Finally an 8 year old was referred with an equinus contracture of the ankle after he he had been in hospital for a cellulitis of the dorsum of the foot. He spent some time in hospital and was treated with antibiotics but it was unclear whether any surgery was done. Clinically he had only a jog of movement in the ankle which was fixed at 25 degrees. Xrays showed sclerosis of the talus and narrowing of the ankle joint space probable as a result of osteomyelitis and/or septic arthritis of the ankle. He will require a surgical arthrolysis in order the place his foot in a better position but in the long term he will end up with a fused ankle joint.
In the afternoon I did some teaching on clinical orthopaedic examination to the new residents. They have a lot to learn indeed!
Today is orthopaedic operating day. I was told we would start at 7.00 am but when I got there the theatre was empty. I found the registrars on the ward doing a teaching ward round. They informed me later that the starting time was changed to 8.00 am but they failed to inform me. The first case on the list was a neglected elbow dislocation which is now about 4 weeks old. This patient has been cancelled a few times and this morning the anaesthetists cancelled her again because of high blood pressure. The second case was a young man with a grade 2 open tibial fracture which had been on the ward for 2-3 weeks. The fracture was quite comminuted and involving the distal third. I felt an external fixator would be the best option although some of the senior registrar felt a plate would be better. I applied a fixator despite significant equipment issues. As usual I was presented with a big box full of all sort of different types of fixators and nothing fitting with each other!! However the outcome was satisfactory. My plan is to carry out a major inventory of all the orthopaedic equipment and sort everything into different boxes as well as cataloguing everything in a book. This will be my project for the next week.
The last case was a lady with a midshaft closed femoral fracture as well as a distal radius and thumb fractures. The injury happened about 4 weeks ago and she had been in skin traction since. I let the senior registrar do the operation and he struggled a bit with some bleeding from the perforating arteries but the reaming of the femur worked well using the compressor which I operated in the next room. There are still issues with equipment and registrar understanding of the nailing technique for the femur and tibia and more teaching is required. I intended to operate on the patient’s wrist under the same anaesthetic but was told that the anaesthetist decided that it was unsafe to continue because she felt the patient had lost too much blood. By the way there is a blood bank here in Cap Haitien but the family has to donate an equivalent amount of blood units as is required for the patient before the blood is released. Well that was the end of the operating list and my day at the hospital.
Wednesday 9 November 2011
The day at the hospital started with a teaching ward round by the senior registrar which covered everything from fractures to antibiotics, and inflammatory pathway to neck of femur classifications. Interestingly the senior registrar is also a lawyer so he talks like the legal profession does and he also disappears from the hospital regularly to defend cases in the local court. He also runs an office in town. I have noticed that the teaching is mainly didactic covering anatomy and physiology but clinical examination in not taught nor practrised. I keep reminding them that clinical examination of the patient is very important and a recent case demonstrated this very well.
A patient in his 40’s was involved in a road traffic accident car versus motorcycle. He was seen at a local hospital and referred to the Emergency Department of Justinien Hospital were he was attended to by the orthopaedic resident. He complained of thigh and knee pain and Xrays of the knee and femur did not show any fracture and he was sent home. Obviously nobody examined him properly and he came back to the outpatient clinic 3 weeks later walking with crutches and unable to weightbear. When I examined him it was clear that he had a hip problem and an Xray of the pelvis showed an anterior hip dislocation. He had all the typical clinical findings and even in the absence of CT and MRI imaging clinical examination will lead to the diagnosis,
The outpatient clinic was busy as usual and the first patient was a lady in her 50’s whom I noticed at church last Sunday sitting in the row behind me with a markedly deformed forearm: almost bent at a right angle! She had surgery 4 months ago in the form of plating a fracture of both bones of the forearm and apparently she developed a post operative infection which resulted in early removal of the ulnar plate. She then had physiotherapy and her arm gradually became more and more deformed and because the doctors disn’t do anything further she accepted her deformity and got on with life. Fortunately her hand and elbow function is excellent. Xrays show a broken plate on the radius and a ffibrous mal union of both bones. She will require surgery to straighten her arm by rebraking the bone and reapplying 2 stronger plates.
A lady in her 60’s was stretchered into the clinic with a long leg plaster following a femoral nailing for a midshaft fracture and an associated tibia fracture. She apparently was brought all the way from home on a stretcher in the back of a truck. After removal of stitches we gave her a pair of crutches and taught her how to walk with the plaster and she was off home. hen there were the usual machete injuries some of which lead to open fractures. Tendon injuries are poorly managed in Haiti and often the wound is closed and the tendons apparently are repaired later. However I have never seen a tendon repair in theatre so far. As a result outcomes of hand injuries are very poor.
At the end of the clinic the patient with the 3
week old hip dislocation turned up and after completing the blood tests he was taken to the operating theatre for a closed reduction under a general anaesthetic. Unfortunately despite a combined Kiwi Haitien show of strength the hip didn’t budge and we had to abandon the attempt at closed reduction. He was then woken up and placed on the operating list for an open reduction the next day.I was completely soaked after this attempt at reduction and as it was the end of the day
I went home to get changed before attending another meeting of the HHH Physiotherapy School Project.
Thursday 10 November 2011
There were 4cases on the operating list today: neglected 4 week old elbow dislocation cancelled many times, 3 week old open tibial fracture for an external fixator, above knee amputation for a patient who has been on the ward for 5 months and the hip dislocation. The ward round as usual involved the usual teaching and I was pleased to see that the patient with the below knee amputation was doing well moving his knee freely without any pain. He will be started on crutches today and is awaiting a gastroscopy for his epigastric pain which could well be as a result of gastric cancer which I am told is very common here in Haiti.
The residents decided to start with the hip dislocation and I went off to theatre to be told that there was no water. We had to wash our hands with alcohol and got on with the operation. The hip was really jammed and I had to put a pin into the neck of the femur and perform the ‘corkscrew manoeuvre” to extract the femoral head and reduce it back into the socket. I am sure the patient will be pleased that his hip has finally been reduced!
After that we were told that the rest of the operating list was cancelled because of the lack of water. I saw a few patients in outpatients including a young woman with a 7 month old unreduced shoulder dislocation. She had pain but a reasonable range of movement and Xrays showed a deformed and dislocated humeral head. Unfortunately there was very little I could offer her except for a fusion of the shoulder joint. As she had minimal pain and reasonable movement we decided to leave things as they were.
After my usually shared lunch with the residents and some heated discussion with Dr Cherubin about life in Haiti and its politics it was midday and time to go home.
Friday 11 November 2011
Teaching today was on the anatomy of the forearm and hand. The house surgeons, called ‘internes’, normally give a powerpoint presentation on different topics and are then grilled by the residents. After that we did the ward round and the problem we have currently is a lack of access to the operating theatre: at the moment there are 10 inpatients and 10 outpatients waiting for surgery and orthopaedics is only allocated 2 lists per week which corresponds to 6 cases. You can do the maths for yourself and will realize that there is a problem similar to the one we have in Dunedin. By the way water has been restored at the hospital but no orthopaedic cases done today.
The clinic was smaller than usual which is normal on a Friday. I saw a couple of interesting cases including a young girl with a neurological condition and signs of an upper motor neurone syndrome. It is very difficult to get a clear history from Haitian patients and I was told that she was hospitalizes in paediatrics for 2 months and that she was epileptic. There was also a history of eye surgery. The father told me that she was fine before coming to hospital but that since she has had difficulties walking, unsteadiness on her feet and unable to talk. I told the residents that there was no orthopaedic problem and that she must have a brain lesion of some sort explaining her symptoms. As there is no CT scanner at the hospital she will have to travel to the Dominican Republic at huge expense which will probably ruin the family and in the end there might not be any treatment available for her.
Then there was a 6 year old with a neglected thumb fracture and a non union of 12 months duration. He will 
require a surgical correction and fixation with wires to restore the length and stability of the thumb. The question is when. Finally an 8 year old was referred with an equinus contracture of the ankle after he he had been in hospital for a cellulitis of the dorsum of the foot. He spent some time in hospital and was treated with antibiotics but it was unclear whether any surgery was done. Clinically he had only a jog of movement in the ankle which was fixed at 25 degrees. Xrays showed sclerosis of the talus and narrowing of the ankle joint space probable as a result of osteomyelitis and/or septic arthritis of the ankle. He will require a surgical arthrolysis in order the place his foot in a better position but in the long term he will end up with a fused ankle joint.In the afternoon I did some teaching on clinical orthopaedic examination to the new residents. They have a lot to learn indeed!
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