Last days!

The Monday outpatient clinic was very busy as a result of the long Easter weekend and things were more chaotic than usual. There is no appointment system here in Haiti and people just turn up. There is only one consulting and one plaster room and often 2 or 3 people are being seen in the same room: the concept of privacy doesn’t feature highly here!

Before

 

 

And after

 

My first patient was a follow up from an operation I did 2 years ago. This lady had a very deformed forearm following a plating of the radius and ulna which had failed. She was very pleased to show me her arm which was now straight and functional. There were a whole range of cases: tibial non union, acromioclavicular dislocation, unreduced shoulder dislocation, septic arthritis of the knee in a young child, valgus knees in children, arm and fore arm fractures etc.

After the clinic visited the local orthotic and artificial limb centre and was taken for a visit by the manager who is from Togo and who has been working in developing countries for many years. As I worked in Togo for a year 35 plus years ago we had a great chat about Togo and the current state of affairs of this tiny West African nation. They have a very good workshop and they make all sorts of plastic splints ( note the black colour of the plastic!!) and above and below knee artificial limbs. A great team doing an excellent job with support from outside Haiti of course.

My last operating list started with a patient of Ogedad’s who had a large intramuscular lipoma seated deeply inside the leg which had been increasing in size over many years. Xrays showed a marked thinning of the fibula from the chronic pressure effect. I helped Ogedad do the operation and I was impressed by his surgical skills. The next case was a child with a congenital pseudarthrosis of the tibia but when I got to the operation room they had called for another case with a forearm fracture which was a friend of the medical director of the hospital. Here in Haiti there is no fairness in the system! You need to know people in high places to get anything done: they call this ‘piston’.

I was really disappointed that nobody even cared to talk to me about this and as a result I was unable to show the residents how to do this procedure. As it was early afternoon there was no way that this child would be done that day. He will be sent home and probably be left with a severely deformed leg which will be ignored by the orthopaedic surgeons here because they have no knowledge of how to deal with these problems. I decided it was time to call it a day.

Milot hospital

Ogedad doing the ward round

 

Robyn picked me up from the hospital and we drove to Milot where Ogedad is currently doing a locum. Sacre Coeur Hospital in Milot is run by Catholic Nuns and much better equipped  and organised than Justinien Hospital in Cap. I sat in Ogedad’s outpatient clinic and after that he took us around the hospital. The wards looked much cleaner and less crowded and the orthopaedic equipment excellent including an image intensifier. They have surgical teams flying in from the States every week and this week it was urology. They bring their whole team and take over the operating theatre. They don’t do any teaching and basically do not contribute at all to the development of the Haitian surgical workforce! When Ogedad wanted to book some acute cases he was told by the anaesthetic nurse in no certain terms that only Caesarean sections were done out of hours. So there you go again!

Future ITTP building

Indonesian MINUSTAH contingent

Today on my last day I did some teaching at the Institute for Technicians in Physical Therapy. We first checked out the progress of the building being done up by the UN. We were very pleased with the progress and noticed that all the ceilings inside had been lined with plywood and that they were waiting for the windows and doors. The Indonesian soldiers were extremely pleasant young men and one of them spoke good English. There were also 3 Chilean soldiers there who were responsible for the security of the site and they didn’t appear so welcoming. However after we spoke to them in broken Spanish they started smiling a little!

 

 

 

The teaching session was well received by the students and they asked very good questions. I taught on fractures and went through some of the cases I had seen in the clinic here at the hospital over the last month. The students showed their appreciation by singing a song of thanks at the end of the teaching session.

 

 

At the end of the day I attended an ITTP School Committee Meeting where a was thanked for my contribution to the school and teaching of orthopaedic surgery at Justinien Hospital.

Well my time here in Cap Haitien has come to an end and I am off to Santiago by bus and back to NZ via the States on Friday. I must say that despite all the frustrations I am pleased by the progress which has been made since my last visit. I enjoyed teaching the orthopaedic residents and it was very satisfying to see what a skillful surgeon Ogedad has become. He is indeed one of the future orthopaedic leaders of this country.

Ogedad, his wife Christna and myself

 

My greatest thanks as always have to go to Robyn who has been outstanding. Without all her background organisation, her contacts, her Creole language skills and her great sense of humour my stay wouldn’t have been the same. Also many thanks to Bernadette for her very tasty Haitian cooking and for her happy smile! Thanks to Steve, Lorraine , Jo and Claire for their wonderful company.

Couscous prepared by Bernadette

Miss RO the shining light

I am also very grateful to the United Nations and the Indonesian contingent of the MINUSTAH in Cap Haitien for their work on the school building in Riviere Salee. They have done a great job!

Finally thanks to Hearts and Hands for Haiti and all the sponsors and supporters of our project. Without your help and prayers we wouldn’t have been able to get this project off the ground!

Au revoir Haiti. I will miss you until I return!

Easter Sunday Haitian style

After attending the 6.00 am Easter Service at our church and saying good bye to the congregation we were picked up by Pasteur Ruben who took us to his congregation which is in a rural area 1 hour out of Cap Haitien and at the foot of the world famous Citadelle. On the way we picked up the preacher of the day and his pregnant wife as well as Jacqueline, Ruben’s wife, and her cooking team. All the cooking gear was placed on the back of the truck as well as myself and 3 of the younger passengers as the cabin was packed full with 6 people.

 

 

 

 

 

 

 

 

The trip was dusty and bumpy and we had to cross a couple of rivers which fortunately were very low as it hasn’t rained here since December last year. We eventually arrived at Ruben’s church where the service had already started. We were introduced to the congregation and I was asked to say a few words which I did diligently.

 

 

 

 

As the service was going for another 2 hours we were allowed to leave and have a look around the local village which has fantastic views of the Citadelle ( Fortress) perched on the top of a nearby hill.

 

 

As we were waiting for the service to finish and the food to be cooked I entertained the Sunday School children who looked rather interested by our presence. I taught them in English how to count to ten, the months of the year and days of the week and I must say they learnt it very quickly! We had a good chat in French and I enquired about their names, age, whether they had any brothers or sisters etc. They were really lovely kids and very keen to learn all about myself and New Zealand. They even asked me to sing so I gave my best rendition of ‘ Pokare Kare Ana’ and I had the impression they were impressed with my vocal talents!!!

 

 

The service eventually finished and had a yummy lunch of chicken, rice balls, fried plantain bananas, potatoes, and vegetables accompanied by fresh pineapple juice. By the time we had finished eating it was 4.00 pm and time to head home. I jumped back on the truck and off we went.

This was such a special Easter Sunday which I will always remember!

Easter Weekend

Good Friday is when our church here does the baptisms. They are adult baptisms and they used to do them on the beach here in Cap Haitien but the water is so polluted now that they had to build a font and today 80 people were baptised in a 3 to 4 hour ceremony.

 

 

We spent the day with all the physiotherapy students at Chouchou Bay which has a lovely sandy beach 2 hours from Cap Haitien. The road is pretty bad and Robyn had organised the school bus to take us there. After a delayed start due to some engine trouble we set off with our picnic picking up students all the way: it felt like a school trip with all the noise and loo stops!

The swim in the sea was very refreshing and everybody had a great time. There was a lot of singing on the way back and we were all pretty tired after a full day in the sun.



Mount John with white cross viewed from Cap Haitien

 

 

Easter Saturday started very early for me as Ogedad and the other residents were taking me up Mount John (716 m above sea level) above Cap Haitien which is dominated by a big cross. To avoid the heat of the day we set off at 6.00 am before sunrise. The start of the climb was going up roads which to me were steeper than Baldwin Street and this was followed by a goat track which led to the summit through banana plantations and mango orchards. Some of the residents were struggling up the hill and wondered why I was able to climb up so easily despite being twice their age! I told them I was a goat in my previous life.

 

Anyway we got to the top where we enjoyed the view of Cap Haitien and its surroundings as well as a packed breakfast. Once everybody had gathered some strength we started the descent which was a real quadriceps endurance test. We went past quite a number of houses with children calling out ‘blanc’ (meaning white) and then running away. I am told that Haitian parents tell their children if they don’t behave the ‘blanc’ will come and eat them! People also ask for money as they think that all white people are very rich. Sometimes I feel like a walking ATM!

We made the trip in 5 hours and everybody was pretty tired at the end.

 

Back in Cap

Had a great time in Guadeloupe but I almost didn’t get there. At the airport in Port au Prince they had never seen a New Zealand passport which caused some confusion. They asked me whether it was part of Europe and when I told them it was near Australia they stared at me as if I was from out of space! They then told me that I needed a visa to enter Guadeloupe which wasn’t correct as I had checked this before leaving NZ. Another person standing in the queue to check in then took over the discussion and he rang the Immigration Department in Guadeloupe who informed me that unless I was from the Cook or Tokelau Islands I needed a visa. I knew immediately that it was the other way round but couldn’t do anything other than wait for my fate to be decided: will they let me on the plane or not? After some time I was told I was allowed to board and that they would sort out the visa issue on arrival in Pointe a Pitre.

After a 2.5 hour flight I got to the island of Guadeloupe which is actually part of France and the Immigration Officer stamped my passport without blinking an eye and let me through no questions asked. Shortly after I was greeted by the immigration officer I had spoken on the phone who apologised saying that he got this wrong and that New Zealanders did not need a visa unless they were from the Cooks or Tokelau. He shook my hand and said welcome to Guadeloupe!

After a short 2 day visit I was back on the plane to Haiti. All went well until it came to the flight between Port au Prince and Cap Haitien. As there are no announcements or departure screens you never know when the plane is leaving! I had noticed that the plane had arrived and that there was quite a lot of activity around it. The next thing I saw was somebody with a spare wheel and jack: in no time was the plane jacked up and a wheel change carried out. Shortly after we took off for a short 20 minutes flight across the mountain range and back home.

I went back to work the next day after a house call from a mother and her child who had severe contractures of his knees and feet (on the basis of arthrogryposis). He had been operated on by a visiting orthopaedic team from the US a couple of years ago but unfortunately his foot deformities had recurred and his knees were still bent preventing him from walking. He will require further surgery but unfortunately I won’t be able to do his operations before I leave as access to the operation theatre here is almost impossible. He will have to wait until I return in year or two.

 

 

The outpatient clinic was busy as usual and I saw another child with Duchenne muscular dystrophy: he had the classic signs and the weakness of his muscles was quite advanced including his arms. He was barely able to get up from the floor but just managed to stand and walk! My guess is that he will be wheelchair bound in a few years and die of respiratory complications in his teenage years. Unfortunately there is no treatment for this genetic disease.

There was also a young girl with marked shortening of her left arm. X-rays showed destruction of the proximal humeral growth plate from previous trauma or infection and as she had no pain and almost full function surgery was not required.

 

 

 

 

 

 

 

 

 

 

 

 

The afternoon was spent teaching the residents and I saw that the hospital has a videoconference unit which is used for video links with France. The anaesthetists use this regularly but the operating theatre comes to a still stand every time they have a teaching session or a meeting! This means that operating lists often don’t start before 11.00 am. We have a unit in Dunedin and I think this could be an opportunity for ongoing teaching of the orthopaedic residents here in Cap Haitien. The only issue is the time difference between Haiti and NZ.

Yesterday my operating list started around midday and I was able to do 2 quick procedures on twins with severe knock knees and that was it. They are very slow at putting patients asleep and as there are no scrub nurses the orthopaedic residents have to set up for the procedure themselves. Nobody knows where things are and the whole thing is a very painful experience for the surgeon I mean.

Between cases I go to outpatients to help them and Thursdays is normally reserved for the clubfoot clinic. I showed them how to do Achilles tendon releases under local anaesthetic and checked on the progress of the Ponseti casting. Overall the service provided by the clubfoot nurse is very good but she requires support from the orthopaedic team.

There were quite a lot of children waiting for plasters and one of the girls was desperate to go to the loo. As there are no toilets the only way to relieve yourself is by using an empty plastic soft drink bottle and proceed in full public view!

 

 

At around 4.30 pm I returned to the operating theatre where the residents had started a tibial nailing. For one reason or another everybody in theatre gets catheterised and as they don’t always have urine bags they use a surgical glove instead: I thought that was great lateral thinking. They now have the SIGN nailing system available which allows them to lock the nails but in the absence of an image intensifier this means that the nailing has to be done open or blind. The resident proceeded with a blind nailing after reaming using non cannulated hand reamers. He managed to insert the solid nail into the distal fragment but the distal locking wasn’t easy and I am not sure whether the screw was actually in the nail or not. However despite this at least he did not open the fracture and I have noticed that they are using very few plates now which has reduced the complications and the outcome of tibia and femur fractures has improved since the introduction of this nailing  system. As the locking allows them to mobilise patients earlier there is less risk of post-operative ankle and knee stiffness. I am looking forward to seeing the post-surgery X-ray if the patient has the means to pay for it.

In the evening there was a Passover Service at the church below our apartment and this provided us with live singing for 3 hours. There were about 3 to 4000 people attending  the service which were all given food in the form of Kasava bread, meat, lettuce and a drink. I was told that they killed 5 head of cattle for the occasion. In the morning they distributed about 500 parcels of food for the poor. An amazing achievement indeed!

Port au Prince 4 years later

After an early quick flight to Port au Prince I was picked up by Dr Ogedad and taken to the venue for the 2^nd Haitian Annual Assembly for Orthopaedic Trauma which is organised by the SIGN Group and sponsored by Partners in Health, Project Hope Haiti/USAID Haiti. The SIGN Company was formed some years ago in the US to develop low cost trauma implants for countries with limited resources like Haiti which could not be sold in the States to avoid price inflation. They have developed a  locked nailing system which does not require image intensification and can be inserted easily without the sophisticated equipment, as for example a fracture table and power tools, which most orthopaedic surgeons take for granted.

 

 

I believe this is a great initiative and I have already seen the improved management of long bone fractures at Justinien Hospital. The meeting is mainly aimed at education of Haitian trainees and they are encouraged to present papers and participate in the discussion on difficult cases. Dr Ogedad gave a very good presentation on correction of post traumatic deformities and I have to say that he is amongst the top senior trainees in the country. I believe the support from HHH has helped him significantly to get to a very high level of surgical expertise which he will pass on to other young local doctors based on his teaching skills and enthusiasm. Listening to what is being done around the country is very interesting and to me it is clear that those hospitals supported by outside aid are much better off when it comes to equipment and implants compared to the situation in Cap Haitian where I work. One of the risks of this approach is that you get pockets of excellent orthopaedic care and others of basically no care at all! I think the country needs to improve its universal orthopaedic care before some groups launch themselves into very expensive treatments for what looks to me like minor cosmetic deformities.

Driving through Port au Prince 4 years after the earthquake is encouraging as most of the tent cities and fallen down buildings, I saw during my first visit in 2010, have disappeared and been replaced by construction sites. The city has returned to what is normal in Haiti: chaos!

And life goes on!

My day started with a teaching ward round where the residents teach the medical students. This is mainly based on revision of the relevant anatomy to the clinical case and their knowledge of anatomy is reasonable compared to our students. We saw 2 post-operative patients from yesterday and they were both progressing well.

                                                                      

 

After seeing a patient in ED with a serious machete injury to his forearm it was time to head to the outpatient clinic. There I saw another young child with severe bilateral knock knee with no underlying bony abnormality and this is the 3^rd case in ten days! This seems to be a very common problem here although the residents told me they hadn’t seen many cases in the past. The rest of the patients were routine trauma cases including some follow up of femoral fractures. Since my last visit the hospital has been equipped with the SIGN nailing system which allows locking of the nail without image intensification and has been specifically designed for developing countries. It has hand reamers and the procedure can be done entirely without requiring power. However the nailing has to be done open. This is certainly a step forward and clinical outcomes are good

One size fits all

As the clinic wasn’t very busy there was time for teaching. I gave them a presentation on congenital pseudarthrosis of the tibia, having seen 3 cases since I arrived, and a talk on neurological conditions presenting in an orthopaedic clinic, of which I also have seen a couple. I finished the session with some clinical cases. I must say all the Haitian doctors are very keen to learn and appreciate any teaching I provide them with. As the pathology here is quite different here compared to New Zealand I have to adjust the teaching topics to what is relevant here. There is no point me talking to them about hip and knee replacements as arthritis is rare and that type of surgery is not done here at the hospital.

Tomorrow I am off to Port au Prince for a meeting on Fracture Treatment in Haiti organised by the SIGN group from the United States. On Saturday I will fly to Guadeloupe which is a French Island to visit some very good friends which I haven’t seen for 25 years. Guadeloupe is not too far from here (about the same distance between Dunedin and Auckland) and it takes about 2.5 hours by plane.

I am looking forward to my little adventure!

New week: what's in store?

 07 April 2014

When I arrived at the hospital today Dr Cherubin was giving a talk to all the residents of what was expected of them in relation to how to look after the ward patients, organisation of operating lists and management of acute patients. This was as a consequence of a general concern that some residents were not doing their job properly.

Then there was a talk on Duchenne muscular dystrophy by Dr Martineau following on from a case we saw a week prior. The doctors here know very little about neurological diseases and it was a good session which allowed me to give them the basic skills to at least recognise these conditions which can present in an orthopaedic clinic.

After that we went to see the acute admissions from the weekend and they were all still in the emergency department. No 6 hour rule here!!! There was one compound tibia, one septic knee and pyomyositis of the thigh, one closed femur fracture and humerus, and a couple of soft tissue injuries.

After a quick ward round I attended the outpatient clinic which had mainly trauma cases.

As far as the acute cases were concerned only the compound tibia got to theatre in the evening and the resident on call applied an external fixator.

During the day the operating theatre was mainly empty as the anaesthetists had their teaching.

Access to the operating theatre is a big issue here! Since I came last time they have introduced an operating theatre charge of 80 US $ for acute and elective procedures. And apparently you have to pay upfront. For most Haitians this is a huge amount of money they don’t have and so things do not happen. The other issue is the anaesthetic department which drags the chain constantly. There is always a reason why they can’t do the case. This is extremely frustrating and there is nothing I can do unfortunately. However I suggested that all the residents, who are still single, should marry an anaesthetist to solve this issue once and for all!

08 April 2014

Today is the operating day for orthopaedics. However there is no anaesthetist to be seen. Apparently they are all attending a videoconference teaching session from France! I am sure they will be taught a whole range of things which are not relevant to Haiti or can’t be done because the drugs or equipment is not available.

 

  

 

 

In the mean time I have been attending the outpatient clinic where there is a constant stream of patients to be seen. I saw 2 interesting paediatric cases: one hip dislocation in a 2 yaer old most likely as a result of a septic arthritis and another congenital pseudarthrosis of the tibia in a 5 year old with 5 cm leg shortening. For the dislocated hip one could of cause carry out an open reduction and spica immobilisation but in the circumstances it is probably best to leave the hip out as the joint is not painful although the child will limp and have a short leg.

 

Around 11.30 am I was told that the anaesthetists had returned from teaching and were ready to start the list. Shortly after the residents informed me that the first 2 cases ( twins with severe knock knees) were cancelled because they had the flu. Yeah right! They then called for a child with a 45 degree knee contracture following an osteomyelitis of the distal femur. They did a spinal anaesthetic and my plan was to first manipulate the knee to see how much extension I was able to obtain. As I push on the knee a copious amount of pus squirted out from a small sinus in the thigh. This precluded any operative procedure but it was possible to correct the knee to about 20 degrees which was held with a plaster. He will require further procedures after the infection is healed.

The next patient on the list was a child with an unreduced elbow dislocation despite surgery in the past. Again I was told the same story: patient is coughing so that one was cancelled as well. The last case was the child with chronic osteomyelitis and complete necrosis of the tibia. He had eaten I was told and when I asked the residents later to put him on the list for tomorrow they informed me that the parents had left the hospital with the child trying to  seek help from somewhere else: understandable considering the child had been in hospital for the last 2 weeks. Again that’s Haiti I am afraid to say!

Well that was my operating list for today.

At last the weekend!

On Saturday we were allowed to sleep in which was great as I had a busy week and a lot of late nights. After lunch we went to a new hotel with a fantastic swimming pool and we just relaaaaaaxed.

 

As we were close to the School of Physical Therapy Technicians I was taken on a guided tour by Jo and Claire. First we visited the temporary building which was built using 2 containers on both sides and a roof placed across. This houses two class rooms for lectures and practical classes. There are 40 students taking the course and due to the success of the current teaching programme an increase in student intake is necessary to keep up with the demand. We than had a look at the progress on the new school building, which has temporarily stalled, to find out that the inside had already been vandalised as somebody had removed the electrical wiring from some of the rooms. The problem is the windows and doors haven’t been installed yet which means there is no security. However the United nations have promised that they will complete the project within the next 2 weeks. Yeah  right!

 

In the evening we had a nice farewell party for Jo who was returning to NZ the next day after 2 months teaching at the school.

On Sunday, as usual, I got up at 5.15 am to attend church. Well as we are living on top of the church we didn’t have to go very far: just down one flight of stairs. It is not every day that one has an in-house church service! I was asked to speak to the congregation and as I am teaching on paediatric orthopaedics at the hospital my short address was centered around children. On the wall behind the pulpit is written:” You can achieve anything if you believe in it”. As I work mainly with physically challenged kids I told them the story of my famous patient Adam Hall. He was born with spina bifida and achieved a gold medal at the Paralympic  Games in Vancouver 4 years ago. In Haiti disabled persons are still being discriminated again and I wanted to convey the message that children with disabilities sometimes achieve more in life than those born with an able body.

After church we went for lunch to the Roi Christophe Hotel for internet access, more relaxation and a swim.

 

On the way I met a chap who told me that I was operating on his son’s leg next Tuesday. A novel way of being informed what’s on your operating list! A bloc further down the road we were stopped for a street consultation. A young woman had problems with her right shoulder following a motorcycle accident 6 months prior. I examined here there and then on the side of the road and concluded that she had a sterno clavicular dislocation (joint between the collar bone and breast bone). This didn’t require surgery and after giving her some advice we walked on.

So there you go that concludes my first week.

Some orthopaedic registrars in trouble!

Friday today. Quite a long outpatient clinic with mainly trauma cases. I was told that there were some issues with some of the registrars not performing i.e. not looking after the patients on the ward, being arrogant, not attending outpatients etc. This resulted in a stern talk by the head of department to the offenders and in Haiti a stern talk from a superior is something you want to avoid at all cost: it consists in being shouted at in the most demeaning manner often in earshot of other people and the only thing you can do is to retreat with your tail between your legs!

 

 

 

 

 

 

 

 

After that was sorted I finished the day with seeing a few kids including one with a tibia deformity  on the basis of an untreated congenital pseudarthrosis of the tibia (see photo) and another with a hand deformity (see photo). This child had undergone an amputation of the thumb and index finger in the past for what I was told was an infected IV line. The child’s current problem was a skin contracture interfering with extension of the wrist. This can easily be fixed with a Z skin plasty.

 

I also came across a few oddities (see photos).

Very elegant plaster jandal

Thoraco brachial plaster

Figure of 8 plaster

 

 

 

 

 

 

 

 

 

 

The day ended with teaching the interns and residents.