Orthopaedic Surgery in Haiti

2011-12-02T17:12:00.001-08:00

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!

2011-11-29T15:55:00.001-08:00

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!

2011-11-28T12:28:00.001-08:00

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.

2011-11-25T18:59:00.001-08:00

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.

2011-11-24T12:53:00.001-08:00

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.

2011-11-23T17:41:00.001-08:00

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!

2011-11-22T15:01:00.001-08:00

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!

2011-11-21T18:43:00.001-08:00

Weekend Saturday 19 Sunday 20 November 2011

Saturday was a very quiet day reserved for some retail therapy as Fiona was leaving after the weekend. We have a 14 year old girl called Lovely staying in our flat and the other day I asked her whether she had any books as I often see here sitting around doing nothing or watching TV. I was surprised when she told me that she has no books to read and that her school does not have a library (nor any computers for that fact). We therefore decided to find her some books and Fiona bought her a lovely illustrated dictionary which I am sure will help here with her French studies .I also was told by Lovely that some days the teachers just don’t turn up and the kids are left on their own at school without anything to do. Also kids don’t have any opportunities to play as there are no playgrounds nor any sporting facilities. The only time you see them on the streets is on Sundays when the neighbourhood kids take over the streets to play soccer using some very small locally made goals. Looking at them with my eyes as a retired soccer coach I must say they have very good skills.

On Sunday we were invited by Reuben’s wife, Jacqueline, for Sunday lunch which meant that we had to take a local Taptap to get to their place on the outskirts of Cap Haitien. We were squeezed like sardines in a tin and they managed to fit at least 20 people into a people mover which had not a single functioning shock absorber left. We got to our destination in one piece and had a lovely relaxing time followed by a nice lunch. Actually I spent most of my time entertaining a 5 year old boy called , Sebastien, who expected my full attention 100% of the time. I had to invite all sorts of games and make things from stuff lying around the garden to keep him entertained. We got a ride back into town from one of Robyn’s friends and as it was Sunday the day finished with an ice cream.

Monday 21 November 2011

After farewelling Fiona I walked to the hospital to join the ward round which had just started. There were only 2 admissions over the weekend one 1 year old child with a femur fracture appropriately treated with gallows traction and a closed tibial fracture in a young lady which had some lacerations which were sutured. The resident opted for application of a long leg plaster which I thought was a very good option as the fracture was reasonably aligned. All the other patients were doing well and a number were ready for discharge.I enquired about the little boy admitted last Friday with a very painful and swollen arm and I was told that he has been transferred to the paediatric ward but nobody could tell me whether he had improved or not.

Outpatient clinic was busy this morning and we saw about 20-30 people including some patients referred from ED. We sutured one thumb extensor laceration following a machete injury under local anaesthetic and saw as usual some interesting patients. There was one new born with an obstetric Erb’s palsy and another child with a high temperature and a swollen and painful thigh and knee on the basis of acute osteomyelitis of the femur.

Then there was an old man who complained of hip pain but Xrays were normal and the resident had not examined the patient. It turned out that he had a large lump overlying his hip possibly a lipoma, soft tissue sarcoma or TB of the bursa of the greater trochanter. I asked the resident to aspirate the lump but there was no fluid. He was referred to the general surgeons for an excision biopsy. Finally there was a young boy with severe burns to his upper limbs who has been on the ward for at least 6 months. He is under the care of the general surgeons who look after the burns and he has major contractures of his elbows and right wrist. He will require extensive Z plasties of his elbows and wrist to restore the movement of these joints. However that might not be enough as he probably has developed secondary tendon and joint contractures. Interestingly he got burned when dressed in newspaper for a play at school when another boy grabbed some matches and set him alight!

2011-11-19T06:47:00.001-08:00

Friday 18 November 2011

Today is a public holiday commemorating the Battle of Vertiere in 1803. From early in the morning we could hear the brass bands marching up the main street to the town square where the parade starts at the end of the official Te Deum held in the old catholic cathedral. So off we went to the square where there was a small crowd by Haitian standards waiting outside the church for the official party to leave and the parade to start. It was really hot in the sun and we had to shelter under some trees to get some shade. From our vantage point we could observe the preparations for the parade. There were quite a number of school brass bands in their colourful American style uniforms waiting patiently for the start of the activities. Most of the bands here also have a group of what is called ‘majorettes’ which basically are the equivalent of the New Zealand marching girls.

At some stage a small group of Haitians on horseback and dressed in period character clothes arrived carrying fake guns and wearing military hats modeled on the style worn by the French army in the 18th and 19th century. They looked quite fearsome with large rings dangling from their ears resembling more captain Jack Sparrow from Pirates of the Caribbean than General Jean Jacques Dessalines or Toussaint L’Ouverture who were the leaders of the revolt of the Haitians against the French.

I also noticed the presence of the UN troops all dressed up in their combat gear and armed to their teeth patrolling the area. I wasn’t sure whether that meant we were safe in case of trouble but they looked like they meant business. We were the only white people on the square and I hoped that the Haitians were not associating us with their French colonial masters of the past particularly on a day like this!!!

Anyway the parade eventually got on its way and it was great seeing all the bands marching past blasting their brass instruments and beating the drums with great gusto.

From the square they all walk all the way to Vertiere where there is a monument commemorating the famous battle. I guess it would take them at least an hour to get there fighting their way through the traffic and facing the blazing sun. I suppose that is a small sacrifice compared to those who were on the battlefield on 18 November 1803! Vive la Republique de Haiti!

2011-11-17T13:31:00.001-08:00

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!

2011-11-16T15:57:00.001-08:00

Tuesday 15 November 2011

Sadly the young man with the head injury died last night. In the absence of a CT scanner and neurosurgical expertise that’s unfortunately the outcome of many severe head injuries here in Cap Haitien. However overnight a young woman with multiple injuries 24 hours following a road traffic accident was admitted to the ward but poorly assessed by the resident on call. I was told that she had a fractured femur which was correct but it turned out that she had a head injury, fractured mandible, rib fractures and a haemothorax and a pelvic fracture. Nobody had taken the blood pressure since admission but was told that it was 90/60 when seen in the emergency department. This was an ideal opportunity to teach them about the basics of how to assess an unstable and multiply injured trauma patient. Then I was shown a patient who apparently had been on the ward for the last year as a result of a necrotizing infection of his leg under the care of the general surgeons. He had multiple skin debridement followed by skin grafts but no had a fixed equinovarus contraction of his ankle. Obviously his ankle wasn’t splinted and now he probably requires an arthrolysis of the ankle and tendo Achilles lengthening or perhaps an arthrodesis in a functional position. This complication was entirely preventable with proper splinting and physiotherapy.

The operating list started with a hiss and a roar and 2 orthopaedic theatres going by 8 am. I did an internal fixation of a displaced neck of femur fracture in a 47 year old with no fracture table, no image intensifier and nobody having a clue as far as the instrumentation was concerned which was basically a set of 7.0 AO cannulated screws. I did an arthrotomy through a lateral approach and the fracture was reduced open using one of the local residents who just had his breakfast to pull on the patient’s leg. The screws were inserted blind having gauged the length of the screws preoperatively on the opposite side. The fracture was stable after the insertion of 3 screws and the absence of grating on moving the hip in all directions confirmed that the screws had not perforated the femoral head and then it was time to close. The next case was an external fixator for a 4 week old open distal tibia fracture with the wound still open and the bone exposed .This might well be the first stage of a below knee amputation. After that I was told by the anaesthetists that there was no oxygen and that we could not continue with the list. I have the impression that sometimes the anaesthetists use this as an excuse if they don’t feel like doing another case. However they then did 2 Caesarian sections and we were allowed back into theatre in the afternoon to do an above knee amputation in a patient who had be on the ward for 5 months following a road traffic accident in which he suffered an open distal femur and distal tibia fracture as well as severe skin loss around the distal thigh and knee. When I first saw him when I arrived he had a complete sciatic nerve palsy with no active movement below the knee and basically a useless limb. An amputation was the only solution for this unfortunate young man!

In between cases I was asked to see a 17 year old girl with a large swelling of the distal thigh and a destructive lesion of the femur on Xrays consistent with an osteosarcoma. The prognosis for her is awful in the absence of chemotherapy and tumour surgery expertise she will probably have an amputation and die of metastases.

Although this might not sound like a lot of work for one day it was a great achievement by Haitien standards.

Wednesday 16 November 2011

The day started with a number of presentations by the house surgeons on aspects of the anatomy of the musculoskeletal system and today the topics were anatomy of the knee and ankle. As they have no data projectors about 20 people huddle in front of a laptop to get a view of the screen. The presentations were well done and were very comprehensive but they did not make the link with the clinical application of their anatomical knowledge.

The ward round followed and we saw 1 admission from the previous night with a severe grade 3b open tibial fracture and the resident on call had actually taken the patient to theatre, debrided the wound and applied an external fixator just as I taught him. That was very pleasing to see and I congratulated him for a job well done. Then I was shown a young man who had been on the ward for 2 weeks with a diagnosis of open tibial fracture. No Xray was available and when I asked the residents how old the fracture was they told me a couple of months. I asked them to open the bandage on his leg and there was a wound with a piece of white bone sticking out. I asked the resident to check whether the fracture was healed and it was pretty clear that there was no movement at the fracture site and obviously the bone had healed. I then asked him to take a forceps and tug at the bone as I suspected a sequestrum which is a piece of dead bone in chronic osteomyelitis. And surprise surprise a reasonably sized piece of tibia came out from the depth of the wound which will allow the wound to heal and the infection to settle down. He was discharged later in the day with antibiotics and advice to get his wound dressed regularly at the local hospital. Sequestrectomy on the ward round what about that?

Whilst one of the residents did a tibial nailing I helped out with the outpatient clinic which was very busy today. There were quite a number of new fractures and we did a manipulation of 2 distal radius and one supracondylar fracture in a child under local anaesthetic without to much teeth grinding! The sheer number of fractures and the lack of anaesthetic services forces one to reduce fractures in a suboptimal manner but there are unfortunately no other options.

Then I saw a 10 year old boy with a crouch gait as a result of cerebral palsy. I used him as a teaching case for the residents who knew very little of that condition. Finally I taught one of the new residents how to suture an extensor tendon injury in a young girl with a machete cut to the dorsum of the hand. By that stage everybody had left the clinic so I threw my backpack over my shoulders and walked home. Overall it was a very good day!

2011-11-15T15:40:00.000-08:00

Saturday 12 and Sunday 13 November 2011

On Saturday Robyn took us to a beautiful unspoilt beach called “Chouchou Bay” at 2 hours drive west of Cap Haitien. Although the distance was only about 50-60 kms it took us about 2 hours to get there because the road was pretty bad at times resembling more a riverbed than something for cars to drive on. The country side was spectacular with green mountains hugged by clouds, rivers and small settlements along the road. Once we left the main road the traffic was made up mainly of the odd motorcycle taxi loaded literally to the “gunnels”. You wouldn’t believe it but the Haitiens can fit the following on a motorcycle: 1 driver, 3 adult passengers, 1 baby and a 100kg bag of rice on the handle bars!!! Then imagine a road like a riverbed and you have the picture: the drivers are very skilled and must have a great sense of balance. Once we got to the beach we were amazed but the beauty of the place. A sandy and sheltered bay with clear water surrounded by trees and not a soul in sight apart from some local fishermen. After a picnic lunch it was time for a swim and the water was just perfect!

A local fisherman was weaving a net and he was so skillful with his hands it was a pleasure watching him: he told us that it takes him 2 weeks to finish a whole net! Another one played the guitar and the local children and Robyn started to sing and dance. We had a wonderful time and I hope that this place stays as it is and escapes development for the tourist industry!!!

Sunday was a day of rest and I had my weekly swim in the swimming pool at the Roi Christophe Hotel where we also had a nice brunch.

Monday 14 November 2011

The weekend at the hospital was busy for the orthopaedic department following a “taptap” accident about 2 hours out of town. Taptaps are the local taxis which basically are pick up trucks transporting people between cities and normally when fully loaded have 20 people on board. One of them came of the road and hit a rock face causing half a dozen of seriously injured passengers. So the orthopaedic ward was pretty full this morning during the ward round: 1 severe head injury, 1 patient with a dislocated hip and 2 wrist fractures of which one was dislocated and open, 1 fracture dislocation of the hip, 1 forearm fracture and some more minor injuries. The head injury patient is unconscious and lying on the ward and the family asked me to have a look at him. He has a severe head injury without any skull fracture and no other bone fractures. His neck and spine are clinically normal and he really needs a CT scan which is not available here. So the only thing we can do is to monitor him clinically and hope that he will wake up and recover the motor function of his limbs. Here in

Haiti

if you have a head injury you either die or you recover spontaneously because there are only a couple of neurosurgeons in Port au Prince. The patient with both wrist fractures and hip dislocation had his wrists redudec and plastered and his hip reduced under sedation. He was sitting in his hospital bed pretty happy.this morning. The other patient had a posterior fracture dislocation of the hip whichwe reuced under general anaesthetic today but the hip was very unstable and we had to put here into skeletal traction as a result. She will have to remain in traction for 6 weeks to allow the acetabular fracture to heal and the hip to become stable. Ideally she would require surgery in the form of fixation of the posterior wall but logistically I am not sure whether that is possible here.

The outpatient clinic was busy today with fractures from the weekend and follow ups. One 8 year old boy presented with a contracture of his middle, ring and little fingers as a result of an electrical burn 6 months ago. He climbed on the roof of a house and touch some live wires. He has skin contractures from burns and will require Z plasties and skin grafts to allow him to straighten his fingers again. Hopefully I can do his surgery before I leave at the end of the month.

At the moment we have 15 plus patients waiting for surgery and very little theatre time.

The orthopaedic residents told me that it is very difficult to get the anaesthetists motivated to do orthopaedic cases. They were saying that they have to beg them on their knees and probably whisper sweet things into their ears etc. I told the 2 residents that I have a perfect solution for the problem: I suggested to them that they marry anaesthetists and then their wives would be able to provide anaesthetic services for the orthopaedic department. They laughed and thought it was very funny! Well here in Haiti you have to think laterally at every level!

2011-11-11T15:55:00.000-08:00

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!

2011-11-08T15:49:00.000-08:00

Saturday 5 and Sunday 6 November 2011

After a leisurely breakfast we went to the hospital to have a look at the new Intensive Care Unit build by the Israeli Government. We were particularly interested in the lightweight modular building material which has been used for this construction. The unit is brand new and has already suffered water damage as a result of a leaking roof problem. We were able to see the water on the floor ourselves after a night of heavy rain. Quite a number of ceiling panels were water damaged in a building which was finished 4 months ago. This does not sound good for the future of the building and the electronic equipment inside. As this building material has been imported from overseas nobody knows how to fix the leaks: the lesson here is that you should use local building materials which can be repaired by local workers! When we looked at the building from the outside it was clear to our unprofessional eyes that the pitch of the roof was too small: Haitien rain is not like in New Zealand and when it rains here the skies open and it pours heavily for short periods of time transforming the streets into raging rivers. In the afternoon, whilst on our way to the market, we were caught out by the rain and had to take shelter in front of a shop for 1 hour to wait for the rain to stop and the waters to recede. As a result of the rain the temperature has dropped and I am now able to sleep without a fan going all night. Hurray!

Sunday started with a 3.5 hour church service which was interrupted by another downpour of rain as all the windows had to be closed. As it was the first Sunday of the month communion was served to 2000 people a truly amazing organizational challenge handled superbly by the church staff. After that I had my weekly swim in my private swimming pool deserted by Haitien and ‘Blancs’ i.e. Whites alike!
The rest of the day was catching up on emails and reading.

Monday 7 November 2011

The day at the hospital started with the registrar presentations followed by the ward round. The amputee from last week was doing well and so was the young boy with TB of the knee whose antituberculous treatment has been started and his pain is much better now that he is in a plaster. There was only one admission over the weekend in the form of a femoral shaft fracture from a motorcycle accident of course.

Outpatient clinic today was cut short by the fact that the only Xray machine had broken down. When I asked the registrars what normally happens in such a case they told me that some times this means no Xrays for a few days, weeks, or months! Well we could be in for a few challenges.
However I saw a middle aged lady with a marked , almost 75 degrees, deformity of the forearm after a fracture of the radius and ulna 4 months prior. The radius was plated but the plate removed prematurely for unknown reasons. After that a young man was brought to the clinic from ED wit a hand injury. He was assaulted with a machete following an argument over a cow! He lost most of his thumb unfortunately and the only thing I could do was showing the medical student how the clean the wound and stitch up the skin under local anaesthetic. Finally a mother brought her 5 day old baby boy with severe congenital malformations of both lower limbs. On the right side he had a complete absence of the tibia with agenesis ( non formation ) of the knee joint and the fibula attached to the back of the thigh. The foot was turned upside down and associated with an absence of the big toe. On the other side he had a partial absence of the tibia ( missing the distal third) and a clubfoot type deformity with a very small big toe and unstable ankle. I have seen such a case in New Zealand a couple of years ago and based on this I know that this boy will require an amputation through the knee on the right side and a reconstruction of the ankle and foot on the left. This surgery will not be able to be done before the age of 1 because of anaesthetic reasons. In the meantime I will splint the left leg to correct part of the deformity to prevent things from getting worse over the next 12 months. I wonder what the future holds for this young boy in Haiti where there is significant discrimination against people with physical disabilities.

2011-11-04T19:11:00.000-07:00

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!

2011-11-02T08:09:00.000-07:00

Weekend 29-30 October 2011

The Saturday started with a meeting regarding the Physiotherapy School Project which is being developed under the auspices of the Evangelical Church of Haiti and also sponsored by Hearts and Hands for Haiti. The success of the project is dependant on securing United Nations funding and being able to achieve long term sustainability through internal or external funding of the running costs.

After the meeting Robyn had organized for one of her friends ‘Shute’ to drive us to Fort Liberte, a small settlement at an hours drive from Cap Haitien. A few friends and friends of friends joined us as well as a little boy called Sebastien. So the car was pretty full but fortunately in Haiti there is no limit to the number of passengers one can squeeze into a car. Fort Liberte is a quaint little sea side town with a beautiful natural harbour and crystal clear water. It has ruins of an old fort built by the French in the 17th century with stunning views over the harbour and town. We visited a number of family members of our Haitien friends and had lunch prepared so generously by one of the families. It also gave me the opportunity to demonstrate my’ Kompa’ dancing skills with Sebastien in the main street of Fort Liberte to the amusement of the locals. Robyn couldn’t resist videoing the whole thing and is threatening to publish it on You Tube. It was a very pleasant and relaxed afternoon and on the way back we had to stop to buy some horsemeat on the side of the road at the insistence of the little boy Sebastien who on the way out had a tantrum and cried as he absolutely wanted his meat. I had to try it as well, of course, and must say that it was rather stringy and salty. Certainly not worth all the fuss made by our little friend.

Sunday as usual started with a 6.00 am church service and like last year I was introduced to the congregation by Pasteur Megy and had to go up to the stage to say a few words. The service was as usual except that the keyboard was so loud that it completely drowned the singing of the choir. After church we went to the local hotel Roi Christophe for brunch and a swim. The water in the swimming pool was just right but obviously to cold for the Haitiens and as a result I had the whole pool to myself. I remember that last year I didn’t enjoy the swim so much as the water was too warm. Finally in the late afternoon we picked up Fiona from the bus station and had an early bed.

Monday 31 October 2011

Work at the hospital started with a presentation by the medical students on the anatomy of the shoulder. As usual this was followed by questions and quizzing from the residents.
We then did the ward round and saw a little 10 year old boy with a very sore and swollen knee with significant quadriceps and leg wasting following a healed supracondylar fracture. Apparently his leg wasn’t right before the fracture and Xrays show a healed fracture and marked soft tissue swelling and a rotational problem at he level of the knee joint. The knee Xray shows an AP of the femur and lateral of the tibia. In the absence of MRI imaging the only way to make a diagnosis at the hospital here is a surgical exploration. I thought of TB, dislocation, tumour but I am not sure. There were quite a lot of empty beds on the ward which meant that the weekend was probably quiet although we saw a patient in ED with a closed femoral fracture, head and facial injuries but overall stable.
The outpatient clinic today was busy because the next 2 days are public holiday: Toussaint and Jour des Morts ( All Saints and All Souls day ). The resident reduced a couple of forearm and wrist fractures in children under haematoma block and even removed a protruding screw from a tibial plate in the plaster room. There were a couple of babies one with clubfeet and another with a healed fractured femur with marked angulation and shortening. The clubfeet were plaster and the baby with the healed broken femur sent on his way with explanations to his mother that the deformity will correct spontaneously over the next 12 months. Finally we saw a 12 year old boy with a localized kyphosis in the lower lumbar spine and a rather flat thoracic spine the cause of which is unclear to me.He has no pain and has no neurological deficit. Xrays presented to me were of poor quality and there appears to be an abnormality at the L5 level. Again I have been thinking of TB and we will carry out a few more investigations.
The clinic finished at 3.00 pm and after discussing the next operating list with the resident it was time to go home.

Tuesday 1 November 2011

Today is a public holiday so after sleeping a little bit longer I got up at 7.00 am for a leisurely breakfast including fried eggs, papaya, pineapple, bread, local cherry jam, yoghurt, local honey and Haitian coffee. Yummy! Then we went to visit a newly constructed hospital near Cap Haitien to meet with the Medical Director Dr Toussaint. I went there during my last visit and was impressed by the progress. There were a number of new buildings and the operating block is now completed but the theatres haven’t been fitted out yet. They are also in the process of building a small post anaesthetic unit. There is also a maternity, paediatric and rehabilitation unit including facilities for patients with spinal injuries. The project is funded by the Baptist Church and Haiti Hospital Appeal which is a UK based charity. Attached to the hospital is the biggest cholera treatment unit located in tents currently looking after 200 cholera patients. This was a very informative visit and Dr Toussaint kindly offered his hospital as a clinical placement for the future students of the HHH School of Physiotherapy.
We then returned home and I saw a few patients including a young man I operated on during my last visit for a chronic infection following a forearm fracture treated with plates and screws. He was very thankful that his infection was healed and he kindly brought us some oranges from his garden. He is a teacher at a school close to Cap Haitien and we had a good chat about issues related to education and teaching in Haiti. Class sizes are a big problem: although the limit is 50 I have been told that in some cases the can be as high as 150!! Also the attendance of teachers is very variable and a lot of the time classes do not happen because the teacher doesn’t turn up.
Finally we had another meeting of the Physiotherapy School Committee and the day finished with a wicked treat: icecream!!

2011-10-28T14:09:00.000-07:00

Wednesday 26 October 2011

Today is outpatient clinic day. After a teaching ward round on the assessment of a multiply injured patient we selected the patients for tomorrows operating list: forearm fracture 3 weeks old, fracture tibia, fracture femur and osteomyelitis foot. I am still trying to get the message through to the registrars that fractures heal without surgery and a closed tibia fracture is best treated in a plaster and that an external fixator is a safe way of treating unstable and open tibial fractures.
The outpatient clinic was busy and there are endless discussions between the patients and staff as to the payment of clinic fees, plaster, bandages, drugs and implants for the surgery. For example a patient who requires surgery for a forearm fracture has to pay for the blood tests, ECG, drugs, IV fluids, Xrays and implants. The cost is substantial considering that a lot of Haitians can barely afford clothes and daily food.
Overall patients are treated without respect and often fobbed off and asked to come back the next day.
I saw a number of interesting patients including a 5 year old boy with swelling of his left arm and deformity of the shoulder. Xrays showed what looked like osteomyelitis involving the entire bone and extensive periosteal new bone formation. The child was systemically well and was simply prescribed some blood tests and antibiotics. Then we saw a middle aged man who suffered a bimalleolar fracture dislocation of the ankle treated by closed reduction and plaster immobilization with a perfect result: fracture healed in anatomical position and of course no infection because the fracture wasn’t opened. There were other patients with all sort of different fractures, infected femoral fractures following plating, osteoarthritis of the knee etc. It is also interesting to listen to the discussions amongst the staff. Most are very unhappy with the mean salaries the government is paying them and the registrar I was working with this morning wants to go straight into private practice when he has finished his training but even better would like to work in France.
The stories you hear are amazing: the hospital ambulance is for the private use of staff to pick up their kids from school, the danger of being a soccer player ( you get beaten up by your fans if you lose the game ), poisoning somebody at a distance ( in a spiritual sense ) etc.
At the end of the clinic I visited the cholera ward where currently there are approximately 15 patient being rehydrated intravenously and lying on a wooden bed with a hole in the middle and a bucket underneath for obvious reasons. Finally I visited the new Emergency Department donated by the Israeli government. It has 2 resuscitation bays with modern monitoring equipment and a ward with 6 beds. Today it was empty and I was told it is reserved for patients with life threatening conditions only. It looks very nice and clean at the moment but I wonder what will happen to it over the next few years.

By that stage it was 2.00 pm and time for lunch before walking back home.

In the evening Robyn and I were invited by Dr Pierre Louis to welcome us back to Haiti and he had organized for the whole orthopaedic department to have a meal at a local restaurant. The evening was very pleasant and after a number of speeches and a bottle of champagne we had a nice meal of fish and chicken. It was great talking to everybody and we thanked them for their welcome and generosity.

Thursday 27 October 2011

Today was operating theatre day. I was told that we would start early at 7.00 am but I didn’t think I had to hurry with my cornflakes. I got there at 7.30 and the patient was on the table ready for the spinal anaesthetic. After that there was quite a long wait to see whether the spinal worked with the anaesthetist repeatedly stabbing the patient from the umbilicus down to the toes to check the sensory level. Eventually the decision was made the proceed to a general anaesthetic. The first patient was a grade 1 open fracture of the tibia 4 days old. The decision was to proceed to an open nailing. The reaming was laborious due to the lack of power tools and had to be done by hand. The registrar was struggling and I had to show him the proper reaming technique joking that his lack of power was due to the fact that he hadn’t eaten cornflakes that morning. Then we had to choose an appropriate nail of the without any way of accurately measuring the length except for some brilliant guesswork! The nail went down ok and the fracture nicely reduced and stable. In the absence of locking nail the patient will require a plaster for 4 weeks.
Whilst waiting for the second case I was trying to get the pneumatic drills from NZ going. Hand reaming and drilling is no fun I can tell you. The only electric drill they had last year is out of action as the battery charger has died. So I am absolutely determined to get these power tools going. Dr Pierre Louis, the local orthopaedic surgeon, told me that they had compressed air available which was not quite the whole story unfortunately. However he told me that he had an air compressor at home which was given to him by a friend in the past but that he hasn’t had any use for it since. So I asked him to bring it to the hospital so that we could try to connect the drill and see whether we could get it working. The compressor looked new but there was a problem with the connectors between the compressor and the drill. So at the moment I am working on getting the connection sorted. I think I have to visit a few mechanical repair workshops and hard ware stores this weekend.
After having tried out my mechanical skills it was back in the operating theatre for the second case: a middle aged lady with a 6 month old neglected angulated fracture of both bones of the forearm with severe stiffness of her shoulder, elbow, wrist and fingers. She obviously hadn’t moved her arm very much over that time. We managed to correct the deformity by shortening the bones by 1 cm and apply to plates which straightened here arm nice. However the drilling of the bone to insert the screws was laborious again due to the absence of power tools. In the end we got there and the fixation was solid.

The last case was a young man with a recurrent abscess over the anterolateral aspect of the foot and the registrars told me that he had osteomyelitis which was drained on a number of occasions. There was no Xray and after incision a large abscess was evacuated. I was looking for a piece of dead bone (sequestrum) which is often the cause of the chronicity and recurrence of the infection and when I saw it in the bottom of the wound I pointed it out to the medical students and when I retrieved it with a forceps I got a surprise: this was not a piece of dead bone but a piece of ‘jandal’ or sole of some sort of local footwear. Even the Haitiens were surprised and laughed whole heartedly. One of the doctors thought that it might have been placed there by a ‘Hougan” or Voodoo Doctors. Any way this was the highlight of the day and after that the anaesthetists refused to continue with the list which finished a 3.30 pm despite the fact that a patient with a 5 day old anterior shoulder dislocation had to be sent home and asked to come back tomorrow.

‘C’est la vie’ that’s life as the Haitiens would say.

Friday 28 October 2011

The day started with a presentation by the ‘internes’ or house surgeons on the anatomy of the gluteal region and the hand. The hand presentation didn’t get off the ground because one of the presenters was absent. The presentation was followed by a grilling session from the audience and the young doctors looked very sheepish when asked questions. The Haitiens are well trained at root learning but when it comes to comprehension there is a problem. I was very impressed this morning by the anatomy knowledge of the resident Dr Cherubin who was able to describe the anatomy of the brachial plexus perfectly in front of the students.

After the presentation we went on the ward round to check the post operative patients and those for theatre next week. Everybody was fine which was very pleasing.

Then it was off to the outpatient clinic for the usual mix of patients with fractures and other orthopaedic complaints. As the clinic was quiet today I took the opportunity to do some clinical teaching for the medical students and had a long teaching session with the new orthopaedic registrars.

Well the news of the day is that I managed to get the pneumatic drills working using a compressor. A friend of Robyn’s called “Major” is my hero as he was able to sort out the connection problem very professionally and quickly. The compressor works and next week I will try it in the operating theatre. It will have to be positioned outside the theatre block and I have an extension hose with will hopefully reach the operating room. If it works it will make such a difference to my work and that of the surgeons I work with.

So watch this space.

2011-10-25T17:59:00.000-07:00

Cap Haitien 2nd visit 23 October – 2 December 2011

Saturday 22 October 2011

Left Dunedin to Auckland, Los Angeles, New York, Santiago
( Dominican Republic)and then bus to Cap Haitien arrived on Sunday 4.30 pm local time.

Managed to get from the airport in Santiago to the bus station 2 minutes before the bus left for Cap Haitien. The taxi driver only spoke Spanish and didn’t know where the Caribe Tours bus depot was. Took me to the wrong place and then had to ask at least 5 times before we got to the right place. No problem getting a ticket at this late stage and after paying I asked for my passport back but was told that it would be taken care of by the bus ‘hostess” as they call the person who accompanies the driver on the bus. I was given a warm meal in a polystyrene container ( rice and chicken) and off we went. The border crossing was straight forward. You stay on the bus and the hostess takes all the passports and takes care of the paperwork if any. I didn’t have to get off the bus and the crossing was very quick as there was barely any traffic.
We stopped once more on the way to Cap Haitien for a luggage check. They look at the baggage but don’t open anything. Arrived in Cap Haitien at the bus station where a band played Haitien music on our arrival. As I was so efficient in getting from Dunedin to Cap Haitien in 48hrs Robyn wasn’t there to pick me up. So I got a taxi who had difficulties stowing my 2 heavy suitcases and as always he took 2 other customers who were confined to the backseat. He could only fit one suitcase in the boot and please the second one on the outside on top of the boot without tying it down. I wasn’t happy with it for obvious reasons and he then put it in the back seat asking the other two customers to ‘squeeze’ a bit!!! I got to rue 13 but the door to the house was locked. Fortunately there was an old patient of mine standing outside and so I asked him whether he had Robyn’s phone number. I had a phone number which Robyn gave me but unfortunately the number had been reallocated to somebody else since last time when Robyn was here.
Then a white Landcruiser stopped in the street and a young man got out asking whether we were looking for Robyn. We said yes and without any hesitation got his cellphone out of his pocket and rang Robyn. She then appeared on the balcony instantly and was very surprised to see me not expecting my arrival until the next day.
We had dinner in the form of toasted sandwiches and it was an early bed for me after we set up the traditional mosquito net, as I want to avoid catching malaria or dengue fever.

Monday 24 Octobre 2011

I had a fantastic sleep despite the heat and humidity and didn’t wake till 7.00 am to the usual street noise and thought I had slept in. After a hearty breakfast Robyn and I dragging a heavy suitcase with orthopaedic instruments and implants went to the money changer around the corner who now lives in a fortified office as he has been attacked and robbed a few times. There is a tiny slot in a wall and you can talk to the person behind a one way darkened glass and the only thing you see of him is his hand which crawls out of the slot to take your money and then to return with your Haitien gourdes which is the local currency. There is no paperwork or any record of transaction and really very hassle free!!!
We then took a taxi to the hospital and first had to meet the medical superintendent Dr Coq whom I had met on my previous visit and he was very welcoming and he said that it was OK for me to work at the hospital without any further forms to be filled out. We were then joined by Dr Pierre Louis who is the consultant orthopaedic surgeon as well as the 2 registrars I met last year. They were very pleased with all the equipment I had brought all the way from New Zealand and I am very grateful for this donation by the Southern District Health Board. The old pneumatic power tools (now replaced by battery operated ones) were lying idle in a drawer back in Dunedin and are very handy here as they mainly have to use hand operated drills. The external fixators which we are not allowed to resterilise in Dunedin again will find a use with the multitude of open fractures they have to deal with on a daily basis.
The registrar then took me to the ward for a ‘tour en salle” i.e. ward round and as usual there were mainly patients with lower limb fractures, tibia and femur, many with infected implants. I also saw patients with infected non unions and a man who had been in hospital for the last 6 months with a large skin and soft tissue defect of the distal thigh as a result of a supracondylar fracture of the femur and a complete lesion of the sciatic nerve. His fracture was ununited , shortened and in varus. Probably an above knee amputation will be the only solution considering the local conditions.
In the outpatient clinic I was greeted by the plaster technician who was disappointed that I didn’t manage to bring a plaster saw as he has to remove plasters using the blade of a hacksaw: and he is very skilled at it!!!
The patients were mainly fractures some having healed with significant deformity and others with chronic infections following internal fixation. There was one lady with finger contractions, amputations and muscle wasting of the intrinsic muscles of both hands and absent sensation and chronic ulcers of both feet. I asked whether there was leprosy in Haiti and they gave me the impression that they didn’t know but for me this was typical of advanced tuberculoid leprosy. Unfortunately there was very little we could offer this patient. Then there was a middle aged man with a long history of pain and a large swelling of the anterolateral aspect of the proximal tibia and Xrays showing destruction of the lateral condyle involving the joint. To me it looks like a giant cell tumour and he will have a biopsy at some stage. I did some teaching of the medical students and they seem to appreciate every tiny morsel of knowledge you give them which is very satisfying. The clinic finished at 2.00 pm and it was time for a late lunch.
Tomorrow is a theatre day.

Tuesday 25 October 2011

Walked to work his morning. Watching people in the street is fascinating. There are a lot of schoolchildren around at that time of the day. They are all dressed impeccably in their school uniform with their hair neatly pleated for the girls and the boys all wearing ties. As there are a many different schools here in Cap Haitien you get a sea of colours from the different school uniforms. Then there are the street vendors: food, clothes, groceries, shoes, phone cards, money changers anything really! I also pass in front of the shoe shine boys and I think I will need their services soon. Then I walk across the main square in front of the large Roman Catholic Cathedral and then on to the hospital. On the way there is a funeral parlour and because it is All Saints Day next week they have large signs outside announcing specials for funerals and 10% cash back deals. Well it sounds like this is a good time to die!
At the hospital I joined the teaching ward round: there were masses of doctors all gathered around the patient’s bed like a rugby scrum trying to absorb the knowledge dispensed freely by the orthopaedic registrar. Then it was off to theatre to sort out some of the instruments and implants I brought from NZ. I was privileged to be shown “Alibaba’s Orthopaedic Cave” in theatre where they keep hidden all the nice new orthopaedic implant sets and to my surprise there was a brand new shiny, never used, distal radius set as well as flexible reamers and other staff they obviously have never used. What is really required here is a cataloguing of all their equipment as nobody knows what is actually available. Before starting the operating I was told that one of the 2 operating theatres was out of action. The reason for it a ‘leaking roof”. I remembered from last year the peeling paint on the ceiling and even took a photo. Apparently they tried to fix the roof by adding some concrete but no success! Now they are waiting for what they told me is a special paint which is used in swimming pools: Yeah right!
In the meantime the theatre is used as a store room(see photo attached).
Anyway after this disappointing discovery it was time to start the list.
First case closed fracture of the femur midshaft 2,5 weeks old skin traction only. Now imagine doing this case with no fracture table, no image intensifier, no power tools, blunt rigid reamers with most sizes missing and a box of old nails of all different types, sizes most of which had already been used before. Well despite all of these challenges we managed to achieve an anatomical reduction and rigid fixation.
The next case was an infected femoral nail with a K rod in place and a draining sinus at mid thigh level. The fracture was a couple of years old and united. The nail proximally was around over an inch away from the end of the bone and we had to cut a trough to take it out. A second incision in the mid thigh revealed a large collection of pus which was drained. Lastly I noticed that there was a problem with his knee. You wouldn’t believe it but the knee was completely stiff as a result of the lack of physiotherapy services at the hospital. I therefore believe that the initiative by ‘Hands and Hearts for Haiti’ to establish a physiotherapy school here in Cap Haitien is a brilliant idea as a lot of these post operative complications are avoidable. I have already seen the change from last year in the sense that physios now visit the orthopaedic ward 3 times a week. That is excellent and the NZ physiotherapy team has to be congratulated for making this happen.
The last case was a young 14 year old with a 3 week old displaced distal radial fracture with 50 of posterior angulation. Xrays showed abundant callus formation and we carried out a ‘callotasis’ to correct the deformity followed by a plaster. After that the anaesthetist announced that she was very tired and called it a day. By this time it was 4.00pm.
As last year I have been bribing the theatre sister with my lunch and the effect was immediate!! So there is no risk of me putting on weight whilst working here.
Having managed to do these 3 cases in the circumstances was slightly short of a miracle.

I believe that small steps will lead to change and my aim is to teach the young registrars orthopaedic skills will hopefully result in improved quality of fracture care in the future. To that end I am organizing a fracture fixation workshop for the intake of young registrars. I have instructed them to get some beef femurs and tibias from the local butcher and I will run the first Haitien style AO Course. You have to think laterally all the time here in Haiti! And I feel I am getting good at it. My next project is to find some compressed air cylinders to run the pneumatic drills, reamers and saws in theatre. Wish me luck!

On the way back to Cap Haitien 22.10.2011

2011-10-22T00:11:00.000-07:00

I have just checked in 2 heavy suitcases filled to the brim with orthopaedic equipment and a few underpants!!! I feel like travelling with an orthopaedic theatre in tow. Even my hand luggage has some external fixators in it which caused a little bit of curiosity at the security check. The chap who asked me to open my bag was very interested of what I was doing with all this equipment and we had a good chat about my work in Haiti.
The list of equipment required at the hospital in Cap Haitien was extensive and included a fracture table and image intensifier! Imagine trying to get those items through security! Anyway I have managed to get a lot of tools and implants which are no longer used by Dunedin Hospital but will make my work in Haiti so much easier. Having the luxury of a sharp drill and power tools will be a dream. The external fixators will be very handy to treat the daily open tibial fractures generated by the chaotic traffic in Haiti. I am sure the "tibia crackers" i.e. motorcycles are still operating in force in Cap Haitien.
The aim of my visit is to further develop the orthopaedic services at the hospital and provide training for the 2 young Haitien doctors Pierre and Cherubin. I will try to impliment some changes on the ward and in the operating theatre but this will require extreme diplomacy and probably some bribes! Wish me luck!
I am looking forward to the challenge and will keep you informed about my trials and tribulations.

Visit to the citadelle and my last week in Haiti

2010-07-11T08:06:00.000-07:00

Last weekend we went to visit the famous citadelle built by Roi Christophe, the king of the first independent black government of Haiti, to defend his country against the French and Napoleon in particular. This well preserved fortress is situated on top of a 900 meter high mountain which dominates the northern plain around Cap Haitien and was linked to a whole series of other forts along the coast line. The construction is an engineering master piece built around 1804-06. Apparently 20.000 people died during the construction and all the building materials had to be carried up the hill by human labour. The fortress was fitted with over 300 canons some of which are well preserved and beautifully decorated with french and english symbols. The view from the top was breathtaking and although we had to walk uphill for about 45 minutes in the intense tropical heat once on top it was nice and cool:the inside was naturally air conditioned and we really enjoyed the cool air!!!At the bottom of the hill was the ruined palace called "Sans Souci" where Roi Christophe lived with his wife and 2 children as well as his many servants. He eventually committed suicide but his burial place remains unknown to this day.

I have been very busy at the hospital over the last week teaching the residents and operating on the many acutes who present everyday. Cap Haitien is the capital of the compound tibia fractures. The reason is the many motorbikes circulating here in a chaotic traffic: the bikes are real tibia crackers!!! I have been able to achieve some changes in the management of the fractures and I am pleased with that. However I am concerned that the residents will go back to their old habits particularly if the orthopaedic surgeon in charge at the hospital is not endorsing what I have been teaching.

There are also many spinal injuries here mainly as a result of people falling from trees trying to collect certain fruits.Two days ago I was shown a patient who had fallen from a tree and was paraplegic. He was lying on the floor in the emergency department and when I enquired why he was not in a bed I was told that he had fallen out of bed. There was this poor chap lying in his own urine and nobody cared about him. I asked the residents whether they had a spinal board but they said there was none. However after a short period of time one of them turned up with exactly what was needed. This gave me the opportunity to teach the doctors how to lift a patient with a spinal injury safely and we all carried him to the surgical ward. The treatment for these patients is basically inexistant and they are left lying in bed with very little active management. The problem here is that the nurses only give injections and sit around in their impeccably white uniforms and matching white stockings doing very little. They don't want to get their uniform dirty and as a result it is the house surgeons who have to do all the dressings and even take charge of the pressure sore prevention. Yesterday I operated on this patient with a T9-T10 fracture dislocation using an old Hartshill rectangle I brought with me and fortunately they had some wires which I could use. The hospital was on generator power and as a result the airconditioner didn't work so it was hot like hell!! In addition there were about 10-12 doctors wanting to watch the operation which further contributed to the heat. I was dripping with perspiration after about an hour and had to have a change of clothes. Also in the tropics your hands sweat profusely when wearing surgical gloves and the sweat accumulates during the operation and when things start to overflow you have to put on a new pair. Anyway I got through the operation OK and the patient is doing well although I suspect that his paraplegia is permanent. I will try to get him into a spinal unit run by the Baptist church on the outskirts of Cap Haitien for his ongoing care. There is a great need for an orthopaedic surgeon with spinal expertise and I hope that in the future I will be able to teach some basic spinal surgery to one of the residents.

Tomorrow is my last day at the hospital and everybody wants me to come back next year which is very encouraging. I have also given the residents a small research project and I will set up a website so that I can do some distance teaching and provide them with teaching materials. I however think that yearly visits are required to teach them new surgical skills and help them to get access to better orthopaedic equipment and trauma implants. But one thing they desperately need is somebody who can fix their image intensifier for intraoperative Xray imaging so that they can treat the fractures by closed methods. This will also allow the surgeons to get post operative films which currently are difficult to obtain as the patients have to pay for them and they are not cheap in Haitien terms. Without post operative films they residents don't get any feedback on how they are performing and they will not be able to learn.

Finally I want to talk briefly about the Haitien food. I have been looked after very well by Robyn and Bernadette who has been cooking for us. Breakfast is quite substantial and normally has fresh food like papaya ( my favourite), pineapple, mango, grapefruit, and banana as well as cornflakes, yoghurt, toast, jam, peanut butter and eggs. And then there is the fantastic Haitien coffee! I will miss this when I have to return to my bowl of cornflakes and milk! Evening meals normally have meat or fish, bean sauce, fried plantain babanas, igname or sweet potatoes and salad. The meat here is mainly goat which is delicious and the other day I had "tete de cabri" which is goat's head and it was delicious. However I was not brave enough to eat the eyes! There is also very good 'free range chicken', pork and beef. I love their fresh juices and they have lemon, orange, grapefruit, orange etc. I certainly haven't lost any weight despite all the water which has gone through my sweat glands over the last 3 and a half weeks.

Well this is my last blog and on Friday I will head back to the Dominican Republic to fly to Auckland via Miama and LA. I can't imagine what it will feel like experiencing a temperature difference of over 30 degrees Celsius. I might have to buy an extra woollen jersey in Auckland!

I hope you enjoyed my blog and many thanks to those of you who left comments. I enjoyed reading them!

So it is au revoir from Haiti and I guess I will have to turn up at work next Monday.

The weekend: beach, church and Roi Christophe hotel

2010-07-05T17:53:00.000-07:00

Saturdays are reserved for local excursions and everybody is looking forward to that day. There are very nice beaches around Cap Haitien but the problem is the access. The roads are bad and often the only way to get there is by boat.

The other problem is the pollution. As soon as there is human presence the sea is being used as a giant waste disposal system. Here in Cap Haitien the beaches are littered with millions of plastic bottles and domestic rubbish. When it rains the streets are transformed into raging rivers and all the rubbish is flushed out to sea. All the city sewers also drain into the sea. There are no water treatment plants as far as I can tell and the pollution here in the city is anenormous problem. as soon as one drives to the rural areas where the population concentration is less it looks relatively clean and there is less rubbish in the streets.

So we went toa small fishing village called Labadie, at an hours drive west of CapHaitien over a rather rutted road.The beach of Labadie is famous the large cruise ships as the water is very deep allowing them to get very close to shore. The beach has now been fencedoffand canonly be used by the tourists who get off the boat for the day to enjoy watersports. Haitiens are not allowed in and as a result we decided that this was true apartheid and that we would get a local boat to go to Labadie village situated in the next bay.

As soon as we arrived we saw most of the villagers gathered around a TV in the village square watching the Argentina Germany game. All the Bresil supporters were yhoping for Argentina to loose and they had a ball!!!. The end of the game was followed by great celebrations and even a mock funeral with a coffin carried through the streets.

We found a nice beach next to an old lodge restored by its owners and run as a bed and breakfast. Inside there were beautiful old pieces of Haitien furniture as well as a number of antiques. A great place to stay for the weekend and relax. The swimin the sea, in fact the Atlantic ocean rather than the Caribbean sea as I first thought, was pleasant but not very refreshing as the water was rather warm: it felt like being in a bath at home.

After our swim we had a small picnic followed by a walk through the picturesque village. We saw people cleaning fish caught the same day and came across a very odd looking specimen which turned out to be a puffer fish. Now this brought back some memories from 30 years ago when I was studying tropical medicine in France.: we learned about poisonous tropical fish and one of them was the puffer fish. We asked the locals but they said it was safe to eat.

A lot of the locals dive to catch fish using a spear gun but seem to get only small fish. They also catch crayfish, octopus, and what they call 'conch' here which is a large shell fish which has a beautiful shell which is sold to the tourists. Unfortunately there are no fisheries regulations here and the locals take everything irrespective of size.We bougth some crayfish and crabs to take home and some of it is in my lunchbox today.

Sunday starts very early with a church service at 6am. The Haitiens dress up in their best clothes for church. Ladies in beautifully colored dresses and hats which in NZ would be worn for weddings or goingtothe races. gentlemen wear suits, collar and tie despite the intenseheat. I wore a white shirt and tie last Sunday but dropped the tie this timefor personal comfort reasons!
The church service is attended by 2-3000 people which are crammed like sardines in a tin. The service is in Creole and French and takes 2-3 hours. I had to address the congregation in French last Sunday but this time I was off the hook. They have many choirs here and Haitiens love singing. The sermonisnormally very long and the minister sometimesgets very passionate about things and starts shouting and gesticulating letting out some strange high pitched sounds.It is all very entertaining although I don't follow Creole very well yet. I understand some words and occasionally I follow parts of the sermon. They have communion once a month which means the service takes an extra hour. You wouldn't believe it but they manage to serve bread and wine to over 2000people! Amazing really.

After church our routineis to go to the local Roi Christophe hotel which is like a green oasis in the centreof town.We have a nice breakfast there with local fruit like pineapple, mango, papaya followedby eggs and a big glass of freshly squeezed juice. The other attraction is that the hotel has wirelessinternet. Sowe allgetourlaptopsout and do our emails, check whats happening in NZ and I often use this time to write my blog. The hotel was built last century and has been restored nicely keeping the old features including a number of antiques. It is a peaceful haven in the middle of the dusty and dirty streets of the city. The largeoldtress in the garden provide the shade and coolness we enjoy and the day is spent there relaxing and using the pool!!!

After having dinner we return home refreshed for another week's work.

Finally I want to give you a brief account of the heat here in Haiti. Most days the temperature is around 33-35 degrees Celsius with a humidity of around 80% andat night it drops to30-31 degrees. This means that you sweat continously and your clothes stick to your skin permanently including whatever you wear at night. It feels like being in a sauna with your clothes on! There is no air conditioning at the hospital except in the 2 operating theatres. At home we use fans which are left on at night to cool things down. During the day I drinkabout 3-4 litresof fluids and as soon as I finish a bottle of water half of it has already come back out through my sweat glands.

Here in Haiti its drink or die!!

Miss Ro Mother Theresa of Cap Haitien

2010-07-04T09:19:00.000-07:00

I want to dedicate this post to a very special person without whom our stay in Haiti would not have been possible: you guessed right it is Robyn. I have been here just over 10 days and have observed her in action and I also know that she operates invisibly in the background to make things happen miraculously. She has an endless circle of friends here in Cap Haitien but also across Haiti and having the right contacts here is so important. She speaks the local Creole language which immediately opens doors and hearts.

We were in Port au Prince last weekend having lunch when a person approached her remembering her from so many years ago. Then we had the routine which kicks in when Robyn meets old friends: big hug, kissess, excitment, jumping up and down, followed by a long chat. You walk around Cap Haitien with Robyn and she knows so many people that you have to stop every couple of 100 meters for a chat.It is wonderful to see how she relates to the Haitiens.

She is an amazing person who has spent her whole life serving others and in the process has helped so many people here in a spiritual and material sense. She is so generous of her time and the words no and impossible are not part of her vocabulary. Robyn is full of energy but some days she overstretcches herself and we have to tell her to slow down and rest.

Robyn's skills are exceptional and I will try to describe them although I know the list is endless. She is a manager, organiser, accountant, travel agent, catering manager, automatic cash machine, interpreter, cook, driver, personal assistant to the team, call centre, coach, counsellor, nurse, mother to Enoch and many others, guide, patient advocate etc.

She is an exceptional person who has achieved so much in this country and iI believe she deserves more recognition for what she has done and continues doing here. Haiti needs an great army of Robyn like soldiers to get this country back on its rails and achieve the social changes which will lift Haiti out of this mess. I guess it will take generations to achieve any visible changes and it is the seeds planted by Robyn which will grow into great big trees bearing the fruits of her labour.

I would like to take this opportunity to thank Robyn for all she has done for the team and to express my appreciation for her constant care about our material and spiritual needs.

Thank you for everything Robyn!

A day trip to hell

2010-06-29T18:13:00.000-07:00

Last weekend we went to Port au Prince to get an idea of the scale of the devastation caused by the massive earthquake which struck the Haitien capital on 12 January 2010. In order to do this as a day trip we decided to fly using the Haitien domestic airline called Tortug'air. and after a short flight of 25 minutes we arrived in Port au Prince.
Already before landing we were able to see large blue tent cities spread across the city which were put up after the earthquake as temporary shelter but 6 months later they seem to have become a permanent accomodation for thousands of people who lost everything in the earthquake. A friend of Robyn's picked us up and drove us around the city for about half a day.
We were all shocked and couldn't believe what we saw: the extent of the devastation caused by the quake and the misery and suffering of the Haitien people was heart breaking. The most striking feature was that the city looked as if the earthquake had hit the previous day: there was no evidence of any reconstruction and during the time we spent there I only saw 2 bulldozers!!! Basically people have no means to reconstruct their houses and the government hasn't done anything apart from identifying the houses which have to be demolished. Property here is not insured and if your house is destroyed by an earthquake in the abscence of government help you have to finance the rebuilding yourself.
Most people in the affluent areas live in tents in front of their collapsed houses whereas the poor have been placed into tent cities where the living conditions are appalling: no running water, no electricity, crime and rape are rampant and I am sure that the risk of cholera and other infectious diseases is extreme. The tents are really cramped and the space between them is less than half a meter. However there seems to be some sanitation in the form of portaloos.
The pattern of destruction of the city is interesting. The destruction is worse in some areas compared to others and you can find a completely destroyed building next to one standing without any damage. I believe that the reason is the poor construction of modern houses as Haiti has no regulation of the building industry. Often the older houses built with a wooden frame were still standing whereas the use of concrete combined with poor building standards as well as the lack of earthquake resistant building technology was probably the main reason why so many buildings collapsed. Entire churches were standing there with toppled spires and some ripped open by the violence of the tremor. Some multi storey buildings simply crumbled and were reduced to a single level. The Presidential palace collapsed like a stack of cards and most of you probably have seen photos in the press.
The centre of the city was worse affected with complete streets wiped out. Driving through this area was for me the worst human suffering I have ever seen. It was like hell. The dust, the dirt, the smell, possibly of decomposing bodies left inside the buildings, the despair and misery was out of this world. It was like a nightmare and I felt nauseous. However despite the destruction life continues amongst the ruins. People have reestablished their businesses as best as possible trading on the side of the road or outside the damaged buildings. These people are tough and despite all the calamities they keep going: it is a struggle of survival!
As far as the reconstruction is concerned there was no sign of it. I saw people with pick, shovel and sledge hammer working here and there and a lot of rubble in the streets often completely blocking the traffic. In the presence of such destruction and in the context of the lack of resources in Haiti where do you start? The task is huge and it will probably take years to rebuild the city and I am not at all convinced that Port au Prince will ever recover.
At the end of the day we felt all overcome by the destruction and human suffering as we climbed back into the plane to fly back to Cap Haitien. It was a day in hell indeed!

The curse of western style orthopaedic surgery

2010-06-25T13:48:00.000-07:00

I have now had 2 days working as part of the orthopaedic team at St Justinien Hospital.As opposed to general surgery we rely much more on technical equipment most of which is not available here. To do a hernia or a laparotomy only basic surgical instruments are required but for orthopaedics we rely heavily on implants, mainly for trauma here in Haiti, and intra operative Xrays. Plain radiographs are available in the hospital but patients have to pay: if they have no means one has to forgo the post operative or follow up Xrays. The same applies for blood tests, IV fluids, bandages etc.

In theatre there are some implants mainly plates and screws, K wires, some old nails and some external fixators. There are no pneumatic tourniquets and mostly I have to use Esmarch bandages until they run out and then I have to think of something else. The choice of implants is very limited and they do not come in all sizes. Often you are given a handful of all sorts of different plates, some Sherman plates 40 plus years old, which are meant to cover all options from a forearm to a femur. As they haven't got srcrews covering all the sizes they have to be cut to length using large bolt cutters. Drills are mainly hand driven although apparently there is one battery operated electric drill of the type you would buy at Mitre 10.

However the most frustating is the lack of intra operative imaging and scrub nurses!

There is an image intensifier parked in the theatre corridor but apparently it doesn't work and nobody knows how to fix it. So it sits there accumulating dust and nobody cares. This means that all internal fixations of fractures have to be done open in an environment where sterility is doubtful. The consequence, as you can imagine, is that the post operative infection rate is very high! Yesterday I saw an 8 year old boy who had a tibia fracture, probably open, a couple of months ago which was internally fixed and he now presents with a serious infection with skin defects, exposed metal, non union, and an ankle that is deformed and stiff. He is at risk of loosing his leg and I believe that if he had been treated in a closed fashion with an external fixator or simple plaster he might not be in this situation.

Now the abscence of scrub nurses. I do not know why this is the case but I will try to find out and see if this can be changed. However I guess nothing will change as the staff here have a very fatalistic approach to life and there is a complete lack of initiative amongst Haitiens who accept their fate as given. Normally there is one circulating nurse who's job it is to dish out instruments and disposables for 3 theatres and the first year resident acts as scrub nurse. To give you an idea of what an operating list is like here at Justinien Hospital I encourage you to read Ross Pettigrew's blog at http://www.rosspet.blogspot.com/. It is worth reading and I recommend it to you.

Now let me take you back to my first post in relation to the closed treatment of fractures as described by John Charnley. This is exactly what is required in the Haitien environment. I strongly believe that all fractures should be treated closed using either plaster of Paris, traction, pin and plaster or external fixation. Plaster is readily available but unfortunately there is no traction equipment, except for some skin traction, and they have a limited number of external fixators. Open fractures are very common here and they normally wash out the wound and then the patient is admitted to the ward splinted or plastered. A week or two later the fracture is then openly internally fixed even if the skin is not healed. Often the fracture is shortened when it comes to the definitive treatment which makes things worse. So you can imagine the possible disaster if it gets infected.
There is a lot of neglected trauma here either because people don't come to the hospital because they have no money or they go and see the witchdoctor first. Apparently they apply oils and herbs on the fracture and if that doesn't work they will eventually come to the hospital months later with severe deformities, infections and stiff joints. Some of the cases here are very challenging and would be so even in the NZ environment.
So for me there is a dilemma: should I teach the residents the western style fracture treatment using the shiny metal or the safer closed method as described by Charnley. I know the answer but I have noticed already that the residents want to learn how to operate on fractures and as soon as I carry out a closed manipulation of a fracture in theatre they seem to disappear and loose interest. My challenge is to get the message through that closed fracture treatment is safe and that open surgery should only be carried out if conservative management fails or is not possible like femoral fractures in adults.
The curse of the shiny metal is a reality here in Haiti . I must say that I have seen this in the past when I was working in Africa where western technology is introduced without taking into account the local environment.
As far as my dilemma is concerned I believe I need to do both: teach them the concept of non operative treatment of fractures and the principles of safe surgery.
My challenge next week is to get through 15 patients with serious limb fractures and my goal is to convince the Haitien doctors to treat at least half of them without the knife. Wish me luck.

2010-06-23T12:49:00.000-07:00

I arrived in Cap Haitien yesterday after a 5 hour drive which was, in Haitien terms, uneventful although the border crossing was interesting. All was done through a middle man who takes away your passport and gets all the formalities done for a small fee. The Haitien immigration office was situated inside a container and everything was handwritten into a book, left hand side when you enter and right hand side when you leave. How they track people entering and leaving the country is anybody's guess.

Once in Cap Haitien I caught up with the other members of the team including Ross Pettigrew and everybody was happy to read the Otago Daily Times from last Saturday which I had slipped into my luggage. The we had a little farewell lunch for Dale one of the of physiotherapist who was finishing her stint here and in the evening we were invited for dinner at one of the local hotels. Most of us had goat stew and the meat was very tender and tasty.

I am staying with Ross in a private house which at the moment hasn't got any running water as the pump is broken. So we have to get the water from a well in front of the house and the shower is very simple:you stand in a baby bath, poor water over yourself using a container and the water is recycled and used to flush the toilet. That's it very simple and nothing can go wrong.

I had a reasonable night sleep under my mosquito net and luckily there was no power cut which meant that the fans were going all night yeah! This morning after we all had the great haitien breakfast in the form of spaghetti and then we were off to the hospital to meetthe membres of the orthopaedic department.

The only orthopod Dr Pierre Louis is a very nice man of my age (actually he was born in December 1952 just a week before myself) and we found him watching soccer in the operating theatre (the attached photo shows the TV and the arial is a used diathermy cord!!!). He showed me around the orthopaedic outpatient clinic where he introduced me to his registrars who currently are 2 first year trainees. After that we went on a ward round and saw only fractures: mainly tibias, including a nasty open pilon fracture, but also an elderly lady with a neck of femur fracture and some kids with upper and lower limb fractures.

The wards are very crowded without sense of hygiene: no hand washing facilities, no gloves, the windows have no glass ( shutters only) and open onto a central courtyard with flies on soaked dressings etc. There are a number of cases who require surgery and my challenge for tomorrow is to help the residents with an operating list as Dr Pierre Louis is away. I have no idea what implants they have but one thing I know is that the image intensifier parked in the corridor is not working. So all the internal fixations will have to be done open in an environment where the infection risk is very high. Well we shall see how things go but I will have to think out of the square, think Haitien and constantly remind myself that things are different here.

I spend a short period of time with Ross in the general surgery clinic and then attended some sort of medical round mainly for residents and nurses. Ross was asked to give a talk and he spoke about his research from 30 years ago with myself acting as simultaneous translater.

In the afternoon there is nothing happening at the hospital apart for the occasional emergency case and we normally go home at 2.00pm. This timetable would be a great opportunity for me to learn to play golf if only there was a golf course.

This gives you an idea of the local circumstances and our challenge is to find a way for us to contribute for the benefit of the local doctors and patients. We will certainly not be able to significantly change the system which basically lacks all the basic infrastructure and administrative organisation. If only we could send some of our managers here as they would be very useful in establishing basic organisational structures.

However every little step counts and when they are added up in the end I hope that we will be able to make some lasting contribution.

2010-06-21T16:18:00.000-07:00

Well I have arrived in the Dominican Republic this morning after crossing the whole Pacific and then the North American Continent followed by a little escapade down south to the Carribean. The highlight of the long travel was being told just before landing in LA that the All Whites had drawn with Italy. The whole plane cheered when the pilot announced the result.
Travelling all that way will in the end have been quicker than going across the border to Haiti.
Let me explain. I arrived at 11.00am expecting to be picked up by Ruben a friend of Robyn's.Unfortunately he fell into the claws of the local constabulary and was taken to the police station because he had a missing rear vision mirror. He had to get it replaced, pay a fine of 50$ and return to the station so that they could check that it was fixed. By that stage most of the day had vanished.
As Ruben wasn't at the airport when I arrived I waited for a few hours and tried to contact Robyn. However my cellphone didn't work and anyway I didn't have her phone number. However I had the numbers of one of her friends so I bought a cheap local cellphone (18$) and tried to ring. Well when you get a new cellphone it is difficult at the start to navigate around until you get used to it and you can image what it would be like if it is all in Spanish! In the end after the advice, in fast Spanish, from quite a number of locals things didn't work out and I gave up.

I waited for about 3 hours and then decided to get a taxi and book into a hotel in town. Well to my surprise they had free WIFI and so I was able to contact Robyn by email. After a series of email exchanges I was told that Ruben had been delayed and that he would contact me at the hotel. By the time he reached the hotel it was to late to leave for Haiti. He told me the story and we had a good laugh.

Now the plan is to leave tomorrow morning at 7.00 am.

So by the time we reach Cap Haitien more than 24 hours will have passed which is more than the flying time from Dunedin.

Now it's time to put my feet up and have an early night.

2010-06-19T00:37:00.000-07:00

Well my bags are packed and as always it was done with military or surgical precision one might say. Going to the tropics or a developing country always requires a bit more thinking to make sure that all the essentials are packed including mosquito net, malaria tablets, small first aid kit, Swiss army knife, sun protection etc. Looking at all the surgical stuff I have packed it feels like I am travelling with a mobile operating theatre in a suitcase. It might sound like something out of James Bond but it will hopefully make my work at the hospital in Haiti more effective.
Now its just a question of spending 24 hours in the plane and stepping onto the tarmac in Santiago, Dominican Republic, for the Haitien adventure to begin.

2010-06-13T20:29:00.000-07:00

As you can see I have been reading John Charnley's book on 'The closed treatment of fractures' third edition 1968 in preparation of my posting at the Justinien Hospital in Cap Haitien. This is an excellent description of fracture treatment before the advent of the shiny metal implants and I recommend it to any orthopaedic trainee or anybody working in developing countries. This book was given to me by the late Bruce McMillan and it was purchased in Edinburgh at a price of 50 shillings.

2010-06-13T17:14:00.000-07:00

Haiti here I come! I am in the process of getting myself organised before leaving for Haiti this coming Sunday 20 June. This means sorting out my work to make sure everything is taken care off over the next month and the biggest challenge is to clear my desk! Despite all the information I have received from Robyn and via Ross' and Steve's blogs I feel that I am going into the unknown.Over the weekend I finally managed to sit down and write a list of what I think I should take. I have been to the warehouse and have bought torches, a headlight and a supply of batteries for the power cuts, have taken my first dose of chloroquine ( although a bit late) and have been gathering old surgical instruments and used orthopaedic equipment donated by Dunedin Hospital. As the need in Haiti is so great it all feels to me like a drop in the ocean. However anything will come in handy I think and even if it benefits only one patient it will have been worthwhile.
I have also been reading the local Haitien newspapers on line to find out what is happening with the post earthquake reconstruction and also to get a sense of the political situation. I even managed to listen to some Haitien music for a short period of time until the family thought that I had used up their patience.
Well this is my first post on my first ever blog and I will try to keep it updated with interesting information and photos over the next 5 weeks. If you enjoy it please send me some feedback.