Wednesday 30 November 2011

There were quite a lot of admissions overnight mainly femoral and tibial fractures. I also saw a patient who had a varus deformity of the distal femur, a very stiff knee, and a short leg following a fracture 4 months ago. The Xray revealed the problem where a distal tibial plate was used for the distal femur. This unfortunate young man obviously will require an osteotomy with an extensive arthrolysis or maybe a knee fusion. The ward round was quick today as we had a visit from an orthopaedic professor from Marseilles in France. He gave an uninterrupted lecture of 3 hours on different orthopaedic topics some of them not really relevant to the Haitien context.



The out patient clinic was reasonable busy and we saw an 18 month old girl with a genu valgum with an unclear history. Xrays did not show any abnormality and I wonder whether she had an undisplaced metaphyseal fracture which sometimes can develop a valgus deformity. Hopefully it will remodel spontaneously. Then a 5 day old baby presented with a varus deformity of the distal tibia on one side and a recurvatum deformity of the femur on the other. Otherwise the baby was normal and Xrays showed some bony sclerosis but no fracture. This looked like congenital bowing and again I told the residents to follow up the child regularly to see whether the deformity corrects spontaneously.

At around midday the tetraplegic patient arrived and was dropped off outside the clinic on a spinal board. She was a tiny thin lady in her sixties who 2 weeks earlier had fallen from a bridge and dislocated her neck. After assessment by the anaesthetists she was taken to theatre for surgery. The dislocation was reduced and the C6C7 level wired and fused. It is unlikely that she will recover the use of her legs and arms.



In the evening we had a very pleasant fare well dinner at the Roi Christophe hotel with Dr Pierre Louis, the residents and the visitors from France.

Thursday 1 December 2011



Well my suitcase is packed and I have eaten my last delicious Haitien breakfast prepared as usual by Robyn. I am taking the bus to Santiago in an hour where I have to stay overnight to catch an early morning flight to Miami. Then it’s a non stop trip to Dunedin via Los Angeles, Auckland and Christchurch. My family will be pleased to see me again after 6 weeks of absence and I am very grateful to them for allowing me to come to Haiti for such a long time. Their sacrifice has contributed to everything that I have been able to achieve here and everybody I have spoken to has asked me to specially thank them for this.



A very special thanks also goes to Hearts and Hands for Haiti who have made this trip possible and your support and prayers have helped the success of my work here.

Finally a very big thank you to Robyn who, as usual, has been outstanding in making my stay here in Cap Haitien so exciting and rewarding. She has looked after me so well by preparing yummy lunches everyday, even bought me Belgian chocolate biscuits, and basically has been in the background organizing things in the most masterful way. We had a wonderful time and I will never forget the games of domino we played on a number of evenings: that was great fun! Thank you Robyn.



Thank you also to Bernadette for the exquisite Haitien food and for your beautiful smile.



So in the end I would like to say: Haiti I love you from the bottom of my heart and au revoir!

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!