Saturday, December 18, 2010


Dec 9

Today was another day of rioting and burning, shooting and general violence in the city.  It is quiet on the hospital compound, but we can see smoke a few blocks away and occasionally hear what sounds like the odd gunshot.  Needless to say, we continue to be confined to the compound.   Several of my patients came for their elective surgery.  We  have virtually no empty hospital beds since hardly anyone wants to be discharged and leave the hospital compound.  That means that we can only do same day surgery.  I wound up doing an arthroscopy, a foot/ankle procedure and a skin graft with the resident.  The TSF case required C-arm so that had to be postponed since the machine is STILL not working.  Since we had some extra time, we cleaned out the ortho clinic rooms and got the painter to come in and repaint them.  That is a job that has needed to be done for a long time.

Jim Matiko emailed the Linvatec rep who works with them.  Jim’s group recently switched to Linvatec for their equipment.  Jim told him that I needed more and newer arthroscopy equipment.  He responded right away and said he could get us nearly anything we need.  He is interested in coming down as well.  I sent him a nice long wish list and apologized for it looking like I was greedy.  I am starting to run low on the 3 liter irrigation bags.  Lucia is trying to work out some irrigation system that will work that will not be so expensive.  I am really glad that Jim came down.  He spent a long time today teaching Jean Joel how to suture and what are the names of many of the instruments we use in surgery.  Jean Joel is a quick learner.

Dec 10

Terrific news!  The C-arm is fixed.  Greg is a volunteer biomed tech specialist who came several days ago from the Pacific Northwest. He had been working on it all week.  Thurs night he prayed for Divine assistance and at 3 am he awakened and felt inspired to once again test some circuit boards.  He discovered a small etched area on the mother board.  Then by trial and error he tried soldering from different points and after 7 or 8 hours he found the right combination. Luck? Cosmic karma?  I prefer to think that God had a major part in the whole process.  Maybe it was something that we needed to learn.  Did I learn something?  Maybe to be more patient and depend more on Him.  For sure, my prejudging the tech guy that did the repair as incompetent was totally wrong.  Clearly, God can use people to accomplish important things even though they may SEEM and perhaps even BE incompetent.  Needless to say, he fixed the machine and I didn't.  Maybe someone else needed to learn something.

I am having a great time doing cases with Scott and his friend, Jim Matiko.  Scott and I are hoping that Jim might be the person to replace me.  I think he would do a great job here.  In spite of the unrest in the streets many of our patients for elective surgery continue to show up.  We did a raft of good cases today including  a CP with severe planovalgus feet.  We did calcaneal-cuboid-med cuneiform osteotomies.  Lat column lengthening/medial shortening with Gastroc lengthening.  Also hamstring lengthening.  Very elegant surgery.  We've done 5 TSFs and have another tomorrow.  The trauma cases continue to come in.  Scott brought a resident with him from LLU.  It has been great having him.  How I wish I could have a resident here to help with the work load on a regular basis.  I believe the experience would be invaluable for him as would the help for me. Scott did a T spine fracture and I assisted him.  It went well.  I then had a hip fracture that the resident assisted me on.  It also went well.  We used the C-arm on a femur fracture and on a major bilateral foot reconstruction.  Now if things settle down in the streets, we can get really rolling.  Many nurses and other hospital staff are still unable to make it in to work.  The tap-taps are not running yet either and many of our patients use them to get here and back home again.  The airport remains virtually closed.  Several more volunteers have had to delay their returns home and several who were coming on Sunday are now unable to come.

Dec 11

Today was not a good day even though it was the Sabbath.  We did several cases that Scott and I considered urgent and they all went well including another TSF.  However, during the day we started getting word that we were going to be asked to evacuate the country.  Indeed, when we finished surgery after 8pm we met with Nathan and he informed us that the SDA church leaders had asked that all expatriots be out of Haiti before the government announces their decision about the election recount on Dec 20.  Nathan would like for all of us to leave by this coming Wednesday, Dec 15.  He is planning a convoy with several other organizations that will be leaving then. There are rumors that violence will increase this coming week in anticipation of the announcement.  This will mean that the surgeries that Scott and I were planning to do so that I could get more familiar with the instruments and types of cases will not get done.  We are still going to try to do a few cases tomorrow and Monday, but since nurses and therapists will not be here to give necessary care to our post-op patients, many will have to be postponed.  I will try my best to give good care to everyone who comes here.  I may have to be less aggressive in doing certain types of cases given my lack of experience.  Jeannie and I decided to watch a movie last night.  Scott and I also met with Brian, the architect who is here for several months.  We went over the plans he has developed for the new addition to the hospital and other structures that will be added in the future.  There is so much more that could be done here if the structure and infrastructure could be improved.  I am confident that the necessary changes will occur and I am going to do my best to help it happen.  I hope that some of the important changes can be made in the next few months so that we can attract more paying patients and improve the hospital’s financial situation.

Dec 12 – 13

I write these words with a heavy heart.  It is 2:30 am and a patient of mine just died. He was 19 years old.  He crashed his motorcycle 4 days ago and was taken to the hospital in Petit Goave where he was kept for 2 days.  He had very comminuted fractures of his femur.  I operated on him with the resident and Dr Matiko yesterday.  He apparently had a massive pulmonary embolism just after we finished fixing his femur fractures.  His pressure dropped to 60/30 and his respiratory rate went to almost 50 and stayed there until a little while ago.  We lost a lot of blood during the case but were able to transfuse him 3 units postoperatively.  Scott and I even went to the blood bank downtown to procure more blood in case it might help him improve.  He very slowly deteriorated with his O2 saturations slowly dropping from the 90s down to the low 70s.  He finally had a cardiac arrest at 1 am.  In spite of prompt intubation and resuscitation, I pronounced him dead at 1:30.  He was a nice young man and a perfect physical specimen.   I can hear the wailing chants of the mother downstairs even now.  She wailed to God for her loss and repeatedly asked ‘why did he ride the motorcycle when I told him not to.’  How I long for the day when sickness and death will be a thing of the past.  As much as I love orthopedic surgery, this kind of experience robs my work of much of its specialness.  I have gone over in my mind several times the sequence of care that I gave this patient.  I have talked with both Scott and Jim Matiko about it.  Should I have done something differently?  It is a tough call when resources are limited.  I tried to get through to the University of Miami field hospital in the hour before he died.   They have an intensive care unit and specialists in treating these kinds of problems.  I got no answer from them  before my patient died.  Perhaps I should have tried sooner.  I feel so sorry for the family.  It has been almost 2 years since I have had a patient death.  They happen so infrequently in my practice that each one hits me hard.

Dec 13 – 14

We had a huge clinic on Monday.  I couldn’t help as much as I wanted to because I had a long meeting with Nathan about the volunteer situation.  He has been directed by church leaders to evacuate all the ex-patriots by Wednesday Dec 15.    Even though there are no demonstrations at this time, they  believe that there will be more when the election council announces its final decision next Monday Dec 20.  American Airlines has resumed flying and all is quiet everywhere.  A couple of the volunteers want to keep their original travel plans and not leave early.  That is a problem for Nathan and he wanted my opinion.  I told him that I have patients in the hospital that wouldn’t be adequately cared for by Wednesday and I would need to delay my departure until at least Friday.   He understands that patients cannot be abandoned by their doctors and has granted me permission to stay the extra 2 days.  Even if the violent demonstrations resume, the hospital compound will undoubtedly be a safe place.  It is really only dangerous to try to get to the airport or bus station if there is violence.  If need be, I can stay here through the holidays until it is safe for everyone to return.  There is a possibility that might not be until after the runoff election the middle of January.  The really bad news today is that BOTH c-arms won’t work.  Our elation when Greg got them both running has now turned to distressful feelings.  So many of the cases we do can be done so much better and faster with intra-operative fluoroscopy.   Scott is going to call a c-arm technician that has helped him in the past.  The man lives in Puerto Rico.  He might even be able to come here and work on the machines.   We had several cases as well on Monday including another TSF.   It would have been nice to have c-arm for aligning things perfectly.  I learned some more on that case.  I calculated the deformity and the mounting parameters without Scott’s assistance and he checked them and found them correct.  It’s great to know that I am making some progress on that front.  I wish that he could stay for another week or two.  He has decided to keep his original travel plans and leave on Friday.  Of course, that doesn’t fit with Nathan’s mandate from the church leaders to evacuate all ex-patriots.  I hope that bit of friction doesn’t create problems for Scott back at Loma Linda.  I am grateful for the extra two days I will have with him to learn as much as possible so that I can be more effective in caring for the Haitians.  After all, that is why I am here.

Jim Matiko left today after changing his flight to Delta. He is a really great surgeon to work with.  I am fortunate to have him for a friend and supporter. He has been extremely generous with his financial support of this project.  I wish he could stay here also since many of the upper extremity cases are complex and well beyond my capabilities.  I am confident that he will be able to help recruit other upper extremity specialists to come down periodically.  I can save the tough cases for them.  Most aren’t urgent.  I just hate to put things off and let them pile up.  It is VERY inconvenient for patients as well since some come from hours or even days away.

I saw 2 patients today that need total hips and have the resources to go to the Dominican Republic.  I contacted Dave Mehne and will try to work it out so that they can get their hip replacements there on the next trip to Los Alcarrizos.   That will probably be in March.  I’ll try to go over to the DR for a couple of days and do some cases with the young Dominican orthopedist that I am teaching to do arthroscopy.

Today, Tuesday, we had a bunch of cases and another huge clinic.  Everybody is returning now that the violence has subsided.  One interesting case was a little girl with congenital band syndrome of the leg.  The tibia and fibula were rotated at the band and her foot pointed almost straight backward.  She walked and ran with hardly a limp.  I assisted Scott as he did three osteotomies of the tibia and fibula and then pinned the fragments in shish kebob style.  Her foot now is correctly oriented in her cast..  The biggest concern is for the circulation of the foot.  It has looked very good so far.  We’ll do a cast change in a couple of days before she goes home.  Several cases that I had scheduled for Matiko showed up.   Scott and I will try to do them tomorrow.  A patient with a fresh dislocation of the lunate came in also.  Scott and I studied up for that case until about midnight tonight so we hopefully can do a good job on it tomorrow.  The pathology here is just amazing!  We have seven cases on for tomorrow.  Tomorrow is clubfoot clinic as well.  Scott had arranged for several clubfoot patients that he had taken care of to come in.  Tomorrow could be the mother of all work days here.  The ortho resident, Ray, was able to help us a lot today but he will be leaving early tomorrow with the rest of the expats.

Wed Dec 15

The ex-patriots including my precious Jeannie left at 6:00 this morning to meet with two other groups to caravan to Santo Domingo per orders of the church leaders.  I hope and pray they will have no difficulties on the way. .  There have been no reports of any violence in the entire country for several days and all seems very quiet this morning.  Of course, when the official results of the election are announced next Monday there will probably be ‘unrest.’

 Staying behind until Friday are Scott and Dr Adrian, anesthesiologist, and Lucia.], OR nurse specialist.   Both of them are from Santo Domingo and have been with Scott on many of his trips to Haiti in the past.  I first met them when I went with Scott to Cap Haitian 2 years ago.  They are both extremely good at what they do.  Jeannie has learned a lot from Lucia in the past 11 days.  She is VERY organized and a very hard worker.   She believes that Scott walks on water.  His surgical skills are truly enormous.

  We had an even bigger clinic as well as seven surgical cases today including the upper extremity cases I mentioned above.  A displaced fracture of the distal radius that occurred 3 weeks ago in a 22 y/o was supposed to come in last week for Jim to do.  He was my biggest challenge since he had lots of callus.  It took time to free it up and get it reduced out to length and then fixed with a volar plate and multiple screws. I am certain that Jim could have done it much better and would probably have made it look easy in the process.  I helped Scott with the dislocated lunate.  It went well.  We put in several pins after reducing the bone.  We didn’t have c-arm but did bring in the portable x-ray unit.  Our educated guesses on pin positions and angles turned out to be close to perfect.  They required very little adjusting.  We also took out a large submuscular lipoma from the forearm.  After talking to the c-arm tech in Puerto Rico, Scott went to work on the unit.  I hung around to see if I might learn something.  After working on things for a while, we were clearly stymied so we hung it up for the night and headed off to bed about midnight.  Scott wants to talk to the guy in Puerto Rico again before throwing in the towel.  We would really like to get it working again.  We have the 69 y/o blind man with the subtrochanteric fracture that should be surgically fixed.  Jessica was finally able to get an echocardiogram done per Dr Spendey’s recommendation.  She had to take him out of traction and put him on a stretcher and taken him to the cardiologist’s office.  He has a normal ejection fraction so no one can say he isn’t a reasonable surgical risk.  The risks are actually greater if surgery is not performed.  The team that admitted him prior to my arrival decided that he was too high a surgical risk.  They placed a tibial traction pin and wanted him to be placed in a body cast after 6 weeks.  I don’t think he would survive that kind of treatment.  He would be impossible to manage with a cast.  In addition, it would be a horribly uncomfortable existence even if he did survive.  Scott and I will fix his fracture tomorrow even if we have to do it in the old style using the portable x-ray machine in the OR.  The fluorscope would make it much easier and more accurate and less risky by decreasing operative time.

Thursday Dec 16

Once again the clinic was very busy although a bit less so than the last several days.  Scott went to work there after rounds and I began with the surgical cases.  They were all smaller cases except for the last one.  They all went well including Clodia.  She is the little girl with the leg infection from her cholera treatment.  We were able to take her wound vac off and place wet to dry dressings without anesthesia.  That means that Jean Joel will be able to do here dressing changes while I am gone and she should do well. While I was doing a case, I heard a yelp of joy from the next room.   Scott had gotten the c-arm working.  Given the error code that the machine was giving us, he followed the advice of the technician from Puerto Rico and took the cover off the collimeter.  He found some screws that were very loose and the collimeter was not being held in place properly.  Tightening the screws and adjusting the collimeter got it going again.  What a miracle!  I put everything back together with his direction so that I might be able to work on it if the need arises.  I don’t have Scott’s boldness nor confidence that I can trouble shoot this kind of equipment.  If the tech from Puerto Rico is available to give me guidance, it might work.

 I saw an amazing patient in the clinic in the afternoon.  He is a 53 y/o farmer with a wife and children ages 5 to 15.  He came from 3 hours away by vehicle.  He grows rice and beans on his little farm.  He has no mechanical or animal assistance to till the ground.  He produces just enough to feed his family.  There is no surplus to sell.  He has terribly problematic knees.  He has severe knock knees that are also very unstable.  The lateral compartments are completely worn of articular cartilage and very painful.  He walks very hunched.  He has thick calluses on his knees apparently from working a lot on his knees.  It could also possibly be from spending a lot of time in prayer but I doubt it.  It will be a major challenge to solve the deformity/instability problem and give him good durable knees that will be satisfactory for his farm work.  I took a video of him walking.  Perhaps it can be used to help raise funds for the care of patients like him with virtually no financial margin.

 The old man with the femur fracture was our last case and it went well.  He finally has the fracture fixed and we can start getting him out of bed.  He and his family are so grateful.  Scott and I had a good meeting with Madam Clotaire.  We discussed the training program for orthopedic technicians and some hospital plant/grounds issues.

We were able to finally get together with Hans Larsen, the president of the Haitian Orthopedic Society.  He suggested we meet for dinner at a restaurant in Petionville.  He was a half hour late.  The food was tasty and was a nice change from our daily hospital food.  We talked about his experiences taking care of earthquake victims in the hours and days after Jan 12.  We discussed the state of orthopedics in Haiti and the role that I might be able to play in training programs.  He was especially interested in the ortho tech program that we are starting.  He is a likable, engaging person.  He invited me to call him to play tennis when I return in January.

Scott and I got stopped by hospital personnel as we returned to the hospital at 10 pm to see a patient in x-ray.  She had been in an MVA and had an unstable pelvic fracture.  She is moderately obese.  Scott thought she should be fixed surgically so we woke up Lucia and Maria and started the case after 1:30 am.  Three hours later she had an anatomically fixed parasacral iliac fracture with 2 long iliac wing screws and a contoured iliac plate with multiple screws and two fluoroscopic-ally placed SI screws that were in perfect position.  Scott gets more amazing all the time.   He made it look quite easy.  The lady had a head on collision on her way to the airport to go see her husband in Palm Beach Florida.  The hospital could certainly bill her the going stateside rate for the terrific care she received in the middle of the night.  She initially was taken to Medicin Sans Frontier hospital and was told she would have to stay at bedrest for 3 months.

Now as I write these words, I am leaving Haiti per orders of leadership.  What will happen if any of these patients have complications during their recovery?  The patients who have fractures and dislocations will either be taken care of at MSF, Medishare or General Hospital or will get no treatment.  We will probably be faced with patient complications from treatment or from no treatment.

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