Haiti Never Ceases to Amaze

Nov 2
I felt like running when I woke up at 5 o’clock.  I started out on the uphill a bit faster(not quite as agonizingly slow?) as usual.  The gas was pretty well gone before even getting to the more level section at the top.  Pushing on was not fun but there was still some hope that today might be the day.  The more flat section decreased the negative sensations a lot and the timed spots seemed to come a bit sooner than usual.  The more flowing feeling on the descent turned the whole experience into something actually positive.  27’ 10” My best time yet.  To think that my goal after doing this run several times when I first started was to break 30 minutes.  Now I’m nearly 10% under that.  If I can keep up the improved times I will logically reach 0 minutes and 0 seconds.  Then time will begin to go backwards and every time I run I will get a little younger.  It took for me to spend a year in Haiti to discover the secret of eternal youth.  What an awesome year this has been.

Dr Alexander operating with Dr Nau

I concentrated on the clinic while both Ian and Mario got our cases going.  Several more patients with frames came in and they almost always take a while to make sure everything is going well.  One patient with bilateral PonseTaylor frames for severe clubfoot is doing quite well.  I checked all of her strut settings and a couple of them were way off.  The mom said the strut was hard to turn so she just stopped.  They live quite close by.  I don’t know why she didn’t come to get help before her appointment.  We got it straightened out and changed a couple of struts that needed it.  A patient of mine that I put a TSF on for a tibial malunion came in.  He looked a bit overcorrected and the xray confirmed he is in a bit of varus as well as more distraction than I had programmed.  I discovered that he has been adjusting his struts to try to get one of the rings way from his skin.  All of the struts but one were totally off. 

Huge cyst in the talus bone

I programmed a residual for him that will take a few days.  I’ll check it next week before we leave.  The orthopedist at Medishare called to ask if we could take a couple of hip fractures.  Apparently they have limited Carm capabilities.  His name is “Bull” Durham and he is from Tuscon Arizona.  He came over along with the neurosurgeon and I showed him around.  This is his 4th time working at Medishare.  He is getting to the point where he feels they are regressing in their capabilities.  He also feels frustrated that they are not allowed to get out in the community at all because of security concerns.  He wants to come here next time.

An ORIF of the ankle

A neurosurgeon at Medishare called and asked to bring a patient with a C6 spinal injury for surgical stabilization.  He had jumped facets and complete quadriplegia.  I told him it was fine to bring the patient and I would help him with the case.  We started it about 5:30 and finished before 8 pm.  I passed sublaminar wires and we bent a rod and wired C4 to L1 and fused him.   He was reduced and nicely stabilized when we finished.  Derek gave the anesthesia and was a pretty tired guy by the time I got him to the hotel.

Nov 3
Our surgery schedule was lighter than the usual Thursday.  That was ok because Ian had heard about the Hotel Olafson and the really good food there.  He wanted to take the whole team there because today was Mario’s last day.  We had several smaller cases, another diabetic foot that needed a transmetatarsal amputation and a 10 y/o with severe neglected clubfeet.  I assisted Mario with the clubfeet.  The first side was easier and he got a good correction.  The second side was limited by both medial skin contracture and the neurovascular bundle.  It will require a second stage procedure.  Dr Durham from Medishare called back to see if he could bring a case over to do tomorrow.  Their C-arm apparently quit working yesterday.  We have two cases for the C-arm tomorrow but it should be available in the afternoon.

With our cases wrapped up before 5 o’clock, we headed off to the Olafson in the pickup.  The traffic was absolutely terrible.  The jams appeared to be related to the road work that is being done on the main road through the city.  Roosevelt helped us find the hotel.  It is a decades old Victorian building and very photogenic.  The long  veranda wraps around the end of the three story building.  Overhead fans keep the air moving.  There was a classic looking hotel bar just inside the front door.  Many of the tables on the veranda had people sitting at them smoking cigarettes. It was much like a scene out of the movie “Casablanca.”  We had a really good time telling stories.  I toasted the whole team and especially Mario for all of their help and hard work.  Most of us had sandwiches for which the hotel is well known.   Derek really enjoyed the rum punch which is also a house specialty.   After several of them,  he decided to take a swim in the pool which he said was delightful.  We explored the rest of the old building before leaving.  The traffic was all gone by the time we returned home.

Nov 4
I expected the clinic might be larger than usual because of the holiday on Wednesday.  It was.  Quite a few new patients came in including one young man with a history of chronic infection in a distal femur fracture.  He was last operated on at the navy ship for a debridement.  He continues to have significant purulent drainage from just above the knee.  He has just a jog of motion in his knee.  I explained the options and recommended amputation.  He would need at least 3 more operations and likely more to clear up the infection.  If the process were successful, he would still be left with a short leg with virtually no knee motion.  He had already been thinking about this possibility and fairly quickly agreed.  We’ll try to work him in in a  timely fashion this coming week.  The power went off for quite a while during clinic.

The patient with the hip fracture from Medishare is 98 years old.  She was quite active and not demented before her fall a couple of weeks ago.  I had Ramon Rivera evaluate her when she got here yesterday and he cleared her for surgery.  We tried to get things going in the OR as quickly as possible hoping to finish in time to go back to Petionville to look for some paintings and carvings.  Ian wants to try to have a fund raiser in his church in Ohio with the Haitian art work.  Unfortunately, things went very slowly.  The hip fracture, using the hillbilly fracture table went nicely.  Lilly helped me and drilled several holes and put in screws and did some suturing.  She has been great to have here.  A patient with a tibial nonunion for a SIGN nail was supposed to be next but we had several smaller cases that each needed Derek.  That slowed the whole process down and we didn’t get the tibial case started until nearly 2 pm.  I helped Dr Durham from Medishare do that case and by the time we finished it was after 4 o’clock.  The power went out during the procedure and would only come on for a few seconds every half hour or so. It was very maddening.   After finishing the tibia the clinic was still going but almost done.  I couldn’t leave Dr Durham alone to do his distal radius fracture and Jeannie was the only one left to help circulate.  We eventually finished with everything by around 7 pm.  Petionville would have to wait.  Ian and Sue and Derek leave tomorrow morning so we’ll have to go to plan “B” with that one.  Jeannie and I will try to get what they want before we leave on Wednesday and take it with us.  We can ship a box to them when we get back to Appleton.  Ian is really excited to try this fund raising for Haiti.  If it works, he wants to come back and get more art and do it on a regular basis.  Jeannie and I took Lilly to the Auberge and we spent a couple of hours with them reprising some of our interesting times during the last two weeks.  Scott and team arrive tomorrow.

Haiti is Beautiful!

Haitian Metalwork, a local folk art form

Oct 29
The Alexander/Adames team all wanted to do something this weekend.  Some wanted to go to the mountains and others to the beach.  Some wanted to do both.  We decided on the mountains today and the beach tomorrow.  The group was ten strong and we filled both the cab and the back of the pickup.  We stopped on the road to Petionville and looked for souvenirs.  We also found some great citrus that was very sweet and juicy.  We also got a large watermelon for lunch.  The paintings, metalwork small decorative boxes, and wood and stone carvings were even better in Fermathe, the little town where Ft Jacques is located.  We all thoroughly enjoyed the fort.  It is very picturesque and has such a great view of Port au Prince and the bay far below.  We got lots of pictures sitting on the cannons and climbing around.  A woman in the parking lot was selling some just picked raspberries.  We bought a bag full of them and Jeannie plans to have them with waffles.  It was a very relaxing day for everyone to get away from the intensity at the hospital.  Ian and Sue found some nice metal work and a couple of paintings that they liked.

Oct 30
Jeannie and I made rounds early.  We changed all of the dressings that needed it.  All of the patients seem to be doing well.  They lady with the bilateral femur fractures that rode here on a motorcycle for several hours is all smiles whenever we come in.  Her right side was definitely the most painful and now that it has been fixed with a SIGN nail, she is able to get out of bed with no pain.  The left side is now nealy healed even though it is malunited.  She is several centimeters short on that side.  Her hemoglobin remains too low to do any further surgery right now.  She would have to be transfused first as well as have more blood ready for an open reduction and fixation.  She has no resources and all of the volunteers that are able have already donated.

Mario Negotiating

We had only one translater with us today so the back of the pickup wasn’t quite so crowded on the way to the beach.  Kaliko Beach resort is quite nice.  The beach itself is smooth pebbles and rocks but there is a wide sandy area between the beach and the buildings.  Some small sea grape trees provide shade for much of the area.  There was a small rowboat hanging out just off the beach.  It said “taxi # 13” on the side.  I asked Ian and Mario and Derek if they were interested in going out for a ride.  Only Ian wanted to go so we negociated with the guy, Fritzner, and out we went along with Roosevelt.   The guy is a fisherman who fishes three days a week.  On good days he can make more than $50 US.  He keeps all four of his kids in school even though he says the fees are high.  I tried rowing on the way back but was pretty much a failure.  I don’t think I made any headway into the breeze.  The oars as well as the boat were handmade.  They were quite heavy and I struggled.  Fritzner took over again and we made it back in short order.

Lunch was next on the agenda.  It costs $30 US per person to access the resort for the day but that includes a great buffet lunch as well as 5 tickets for drinks.  The salads were very fresh and there was a lot of rice, beans, chicken, meat, potatoes and other vegetables.  We were all thoroughly stuffed.  The rest of the afternoon was a total enjoyment in the pool and looking for shells on the beach.  I had a great time talking with both Ian and Lilly.  We started out for home later than we should have and it got dark about halfway back.  I am very reluctant to drive at night because bicyclists and many motorcycles have no lights or reflective devices.  It  is also way harder to identify the potholes.  Thankfully it was an uneventful return.  We will have another big clinic tomorrow I am sure.

When we got back to the hospital, we found our good friend, Ramon  Rivera.  He is an internist who lives and practices in Puerto Rico.  He and I worked together at Hospital Bella Vista more than 30 years ago.  He has a real heart for Haiti and has been here on two different occasions.  The first was before the earthquake.  He came and worked in Cite Soliel for 2 weeks.  After the earthquake, he responded and rented a pickup in Santo Domingo and drove here, caravanning with another vehicle.  He would like for the Adventist hospital in Puerto Rico to be involved as a sister institution with HAH.  He will be able to help us a lot the next week and a half.  We have a lot of patients with comorbidities, especially the diabetics.

Oct 31
The Monday clinic was a typical large one.  I got taken away for part of it by a fairly long phone call from an orthopedic surgeon at Medishare.  His name is John Durham and has been called “Bull” since he was a child.  He has been to Medishare 3 times previously.  He practices in Flagstaff, Arizona.  He doesn’t have a fracture table and doesn’t want to try to do intertrochanteric hip fractures without one.  He also has a patient with a femoral neck fracture and has no hemiarthroplasty implants.  He also wants to borrow some plates and screws to fix a distal radius fracture.  With all three of us seeing patients steadily we finished by about 2 pm.  We had 4 smaller cases to do and finished with everything by about 6 pm.  Our last case of the day was the lady that I had treated for a malunited tibia with a TSF and osteotomy.  She had been lost to followup for a while and developed an equinus contracture of her ankle.  We treated it surgically with a gastroc slide and then immobilized it by extending her frame to her foot and putting in metatarsal wires.  She had healed well and her foot was plantigrade when we removed the lower part of the frame and the metatarsal wires two weeks ago.  Upon going home, she apparently made no effort to prevent another equinus contracture.  She came in to the clinic today with the same fixed equinus she had before.  I was sure we could do a manipulation and get her foot plantigrade.  Ian suggested making a foot plate orthosis to attach to her TSF so Jamison did that while we were waiting for her stomach to empty.(she ate spaghetti at 9 am)  Sure enough, the manipulation was successful.  She is now in a little bit of dosiflexion, held by her custom foot plate tied up to her TSF.  During a break in the afternoon, we celebrated Mario’s 41st birthday.  Jeannie made brownies and we had ice cream and the fresh raspberries that we bought up at Ft Jacques on Sunday.

Lunch with a hopeful Haitian Dog, a common occurrence

We had a tremendous thunder and lightning storm that hit suddenly.  The wind blew very hard and I heard a loud crash outside.  I carefully opened the door to our balcony and found my cool banana plant laying on the floor as though someone had shot and killed it.  It was still raining hard.  I’ll try to resuscitate it tomorrow.

Nov 1
We had a big day scheduled – 4 cases for the c-arm.  Two of them were cases that Dr Bernard Nau had sent.  One was a lady with a SIGN nail and femoral nonunion.  The other was the patient he sent a few days ago with a painful swollen ankle.  The joint crunched a lot when it moved.  The xray showed the talus(ankle bone) was riddled with cysts.  There was hardly any bone left.  Dr Nau had arranged to come for both of the cases.  Ian did the case with Ben assisting.  The huge cysts in the talus were impressive.  Meanwhile, Derek was already next door getting a 3 year old ready for a bilateral posteromedial clubfoot release.  I assisted Mario on them and they went well.  Ian finished the tibio-talar-calcaneal fusion with a large distal femoral locking plate.  Ben then came in and watched while we finished the second clubfoot.  Ben and I then did the lady he had sent me with the femoral nonunion.  We took out the distal locking screws and a third “blocking”? screw.  The knee was very arthrofibrotic and required a big incision to mobilize the

Terry at the Fort with Derek, Ian, & Mario

patella to get the retrograde SIGN nail out.  We reamed her to 11 mm and then put in a larger 9mm SIGN nail that was 20 mm longer and locked it both proximally and distally after impacting it.  Ben got bone graft from the iliac crest and I exposed the nonunion and cleaned it up and made a good bed for the graft.  The case went very well.  It was a pleasure working with Ben.  We were able to give the patient an additional 30 degrees of knee flexion as well.  The last case was really interesting.  The patient had a history of a fracture dislocation of the ankle that got infected after surgery.  Eventually the infection got cleared up but the patient was left with a very painful ankle.  Ian decided to fuse her tibia, talus and calcaneus with a SIGN nail.  He did the case with both Mario and Bernard assisting.  He did a beautiful job.  He is really a master surgeon.  He had never seen a SIGN nail before coming here.

Alexander Team Arrives

The Alexander Team with Jeannie & Terry

Oct 24
The Ian Alexander team arrived yesterday.  He is a foot and ankle subspecialist from Ohio.  He is sponsored by the Foot and Ankle Society.  His trip here is to help the leadership of the Society decide if their involvement here will be an ongoing program.  They want it to be a teaching program as well as a help for the local orthopedic surgeons.  He has his wife, Sue, with him.  She is a pediatrician.  He also has a peds foot and ankle specialist from Brazil.  Mario Adames practices in the Southern Brazilian city of Florianopolis.    It is largely on an island and has 42 beaches.  It is well known for its surfing.  He says they do a lot of windsurfing and kiting also.  Sue is an OR tech with them.   She is extremely good at orthopedics.  She sets up the room as if she has been working at HAH for years.  Derek is a great anesthesiologist.  He is from Ohio but will be moving to Virginia in a few months.  He grew up in Lake Tahoe, Nevada and studied in Arizona.  We are lucky to have him.  He loves to do blocks.

The clinic  was made all the more challenging by three diabetics with foot infections.  One had an entirely infected and dead foot.  Another had a dead fourth toe.  Everyone in the hall was wearing a mask to deal with the odor.  We  were able to take the patient with just the toe involved and debride her foot.  The other patient had a very low hematocrit and needed transfusion first.  I hope we can get blood so we can do her surgery tomorrow.

I was able to schedule several cases.  The little boy with the TSF being treated for short tibia came in again with infection around several of his pins.  He has had several trips to the OR already for similar problems.  He still needs his frame since the new bone still isn’t strong enough.  I’ll take him back again tomorrow for revision of his frame.

The final path result finally came back today on Katiana Paul.  It is a fibrosarcoma.  I emailed Dr Bibiloni and Dr Mehne with the results to see if they might have any connections that can get her adequate treatment.  Dr Larson answered that the only possibility in Haiti would be a hip disarticulation.  That wouldn’t address the pelvis that appears to be locally invaded.

Both teams enjoyed a pizza dinner at the Auberge hosted by Frank and Kaye.  I got to know Ian better during the meal.  He has been a business man also, developing and selling software.  The “peekleez” was a hit with most everyone, especially Steve.

Oct 25
We had a big list of cases on the board and didn’t finish until after 9 pm.  Ian and I did a takedown of a malunited tibia and placement of SIGN nail.  Ian enjoyed learning the nuances of the SIGN system.  The case went well.  A 20 y/o came into the ER after being hit by a car.  He had a puncture compound very comminuted distal femur fracture as well as an unstable fracture of L2 without neurologic deficit and a deep abrasion on the back of his hand.  Frank put in a SIGN nail and then cleaned up the wrist abrasion.  We’ll have to plan the spine surgery.  He will need to have blood available.  Mario did some of the peds cases.  I showed Ian the book while we had a bit of time in between cases.  He was very impressed with the quality and the content.  I explained the opportunity that we have to establish this program with satisfactory funding.  He immediately mentioned that he has a very wealthy patient that he is sure would give a large donation and that he is going to give her that opportunity.  I’ll sign a book for her that Ian can give her.

The Whitney/Mulder team leaves tomorrow.  Jeannie made a great spaghetti and salad meal for their team and we had a late dinner.

Oct 26
Jeannie and I bid the team goodbye.  Frank said that he and Kaye were seriously considering taking over for me.  After working with him for the last week and a half, I am sure that he would do a great job.  After they left, I went for my run.  I had my best run yet 27’ 40”  even though I was still a bit stuffed up with a cold.  We made rounds and after finishing, Ian was very excited to tell me some ideas.  He said that he had been brainstorming about getting exposure for the book.  He wants to arrange for a booth at the American Academy of Orthopedic Surgeons annual meeting in San Francisco in February.  For more than two months I have been trying to figure out how I could make the right contacts to see about having a display there.  Ian has done it many times and has all of the equipment.  He wants to arrange a schedule of times for Scott and me to alternate being at the display for book signings.  I sure hope we can work out the details and that it isn’t too late.

The clinic didn’t look all that big so I tried to get some important administrative work done.  Scott had developed a proposal for keeping Francel here at HAH.  He is being courted by MSF where he worked for a while before starting his peds ortho fellowship.  I gave him my input on that important issue.  Arrangements have been made for the orthopedic surgeon from Curacao to come the day before we are scheduled to leave.  It is not nearly enough time for him to become familiar with the multitude of different areas that he will need to learn on his own.  Dr Nau emailed me about a case that I had scheduled for surgery next week.  He wants to come and help.  He apparently knows the patient.

I helped out with the last half of the clinic and meanwhile, Mario went to the OR and started a case.  I really enjoy working with Ian.  Unfortunately, many of the foot and ankle cases we had saved up were operated on by Dr Perez when he was here just 2 weeks ago.  Ian did the BK amputation on the diabetic  today.

Oct 27
The surgery schedule was full.  Dr Bernard Nau, a well known Haitian orthopedic surgeon arranged to have a patient of his evaluated this morning.  Dr Alexander did the evaluation and felt that he was a very good candidate for a fusion of his ankle and subtalar joints.  The patient has very large cysts throughout his talus(ankle bone.)  He injured his ankle playing basketball 2 years ago and has had progressively worsening ankle pain since.  He walks with a noticeable limp now.  This type of problem is an area of expertise for Dr Alexander.  We scheduled him for surgery next Tuesday.  Dr Nau is planning to assist.

Out for some sightseeing with the Alexander team

I did an arthroscopy with Lily assisting.  She is very good with her hands and handled the instruments very well.  She has a very good knowledge of anatomy as well.  Mario did more children’s feet and leg cases and he and Ian took out a SIGN nail and put in antibiotic beads and placed an external fixator on  a tibia.  ZJ and I revised an amputation stump on a young girl that he has been following closely and has gotten to know very well.  We tried giving her tetracycline and using a black light to try to identify dead bone.  I can’t say that it worked convincingly.  We put antibiotic beads in the stump.  I hope it finally clears up her infection.  We have another diabetic with a severe infection in her foot that we will try to take care of tomorrow.  This is our fourth case in 3 days.

The reply from the Academy was that it is NOT too late for a display.  In addition, it is complementary for nonprofits.  Ian and I are excited.  He is planning a ¼ page ad in the ORTHO NOW newspaper to raise awareness before the Academy.  It will be fun to hopefully interact with many of the attendees and share with them what is happening here at HAH and what a wonderful opportunity it is.

I received word via email from Frank and Kaye that they have decided to not take over here for us.  Of course, I am disappointed.  I know he would do a great job.  Perhaps they can be convinced to help this transition for a shorter period of time.  I know this is God’s project and have complete confidence that He will keep this project accomplishing what He wants it to do.

Oct 28
The clinics continue to be large and challenging.  Ian, Mario and I worked steadily through the morning.  We got in another diabetic patient with two dead toes and infection in the forefoot.  Ian took him to the OR and removed the dead tissue and packed the wound open.  Another patient with an Ilizaroff frame needed the foot wires and plate removed under anesthesia.  The big case was Felix and his ankle.  Felix had and open fracture of his ankle more than a year and a half ago.  He also had a femur fracture.  He first came to us several months ago with a nonunion of his femur and an infected failed ORIF of his ankle.  Drs Weinfeld and Den Hartog removed the hardware from his ankle and debrided it thoroughly and placed an Ilizaroff frame.  The infected wound was left open.  It finally completely healed about a week ago.  In the meantime, the ununited femur was treated with first an external fixator to get the bone out to length and then a SIGN nail was placed by Dr Yoon about 3 weeks ago.  Mario tackled his ankle today to do a formal ankle fusion with iliac crest bone graft that Ian helped Lily harvest.  We are all hopeful that this will be the last procedure that Felix will need.

I saw several patients in the clinic today in followup.  One was Stephanie Bryce, the nine year old with severe bilateral Blounts that was treated with TSFs and tib-fib osteotomies.  She and her family are so happy with her result.  She is back running and playing again and is very happy.  Her osteotomies are completely healed.  Her mom brought us another great meal for lunch.  I saw the ACL reconstruction that Anthony Feniston did four months ago.  He is likewise doing very well.  He is anxious to return to playing soccer.  I am going to let him start some light jogging and then gradually increase his activities.  Perhaps in 2 more months he will be able to play again.  The patient with the TSF that I did last week came in.  He has no problems.  I had Franz teach the family how to adjust the struts properly.  He will return next week to check on his progress.

Sabbath at Jardin de Mer

Oct 21
The Friday clinic was somewhat helter skelter.  The CURE clubfoot
program has had a pediatric orthopedic surgeon here this week and she
has been here a couple of days including Tuesday and today.  She had
several TALs to do which she did in the clinic as well as castings.
That kept our cast room totally tied up all morning.  I did clinic in
the hall while Frank used our clinic room.  We also had several cases
today.  One was a dressing change on Franz.  I followed the email
advice of a hand surgeon from Ohio.  He recommended transferring the
lacerated tendons to the index finger to the adjacent extensor tendon
to the long finger.  I couldn’t find the proximal part of the extensor
tendon to the thumb so left it for a hand surgeon to deal with.  I
partially closed the wound and put on a wound vac.  I plan to skin
graft the defect in a few days.

Oct 22
Sabbath again – what a blessed relief.  I love the work here and the
interaction with all of the patients and their families, but it is
pretty intense and I really look forward to a day of rest.  Amy and
Nathan had arranged to take a group including the Whitney/Mulder team
and us to a small resort on the Caribbean.  It was a three hour drive.
We all went in a good sized van.  I had a great time talking with
Frank almost the whole way there.  The Jardin du Mer(Garden by the
Sea) is located on a hill which is on a small peninsula that protudes
a bit into the Caribbean.  The views are spectacular both directions.
We went exploring one of the beaches and came upon “The Sloop John B”.
It is a very small handmade wooden boat(cannot) with a handmade
wooden mast, boom and hand sewn sails.  It was much like the boat that
we went out on a few months ago but only about half the size.  It was
very photogenic.  There was a nice buffet dinner prepared for us in
the early evening.  We all had a good time.

Oct 23
I got up early to take advantage of the morning light to get photos of
the scenery. I hiked up the hill a ways and got some great shots of
one of the handmade sailboats coming in from an early morning outing
presumably for fishing.  Steve had also been up early and had gone
down across the road and climbed a different hill with a bunch of
kids.  The rest of the group was up and talking with Bob Anglade, the
owner of the resort.  He is a most interesting man.  He grew up in
Haiti and studied marine biology.  He spent 10 years working in
Africa, mainly in the Belgian Congo where he met Michelin, his wife.
Twenty five years ago he came back to Haiti and started an oyster
fishery where he now lives.  At the same time he acquired the property
where he has built his little resort.  The entire property was barren.
He has planted shrubs and trees on the entire property.  There is
extensive stonework made into retaining walls and patios and the open
air restaurant/bar.  There are 10 rooms that accommodate 18  visitors.
Unfortunately, the oyster business was a failure.  The locals all
harvested and consumed his product before he could get  to it.  He
throws up his hands in resignation and says,”What can you do?”  They
all believe the sea belongs to everyone.  He continues to fish and
that is how he makes his living.  His resort has a 10% occupancy.  His
brother, a well known Haitian author, died in the earthquake along
with a couple of other family members.  Bob told us of the experience
of the one surviving family member who had moments before left the
house to get something from the trunk of her car.  She felt the severe
movement of the earth and watched as the entire house which she had
just walked out of collapsed in a pile of rubble whith her husband and
brother and sister-in-law underneath.  No effort was made by the local
officials to recover the bodies.  Six weeks later, the Canadian
government brought heavy equipment and removed the bodies.  His
brother wrote this great book about Haitian laughter that Bob showed
us.  I hope I am able to get a copy of it.

After breakfast we followed Steve and the kids on the same hike up the
hill that Steve had done earlier.  The view was equally spectacular to
the ones I had earlier.  We had a great time taking lots of pictures
with the kids and each other.  We didn’t have time to try to get a
boat ride so decided to walk as far around the peninsula on the beach
as we could.  We got a lot of really good pictures.  The dozen kids
all came along.  There was a little dugout boat on the beach which had
a mast step.  I had never heard of a dugout sailboat but there it was.
It had fishing nets in it so is obviously still in use.
We presented the kids with a new soccer ball that I had taken with us.
They were delighted and wanted to use it so we headed back to their
soccer field/cow pasture.  It was a lot of fun watching them play.
Several of them were obviously more talented and skilled than the
others.  Steve and I got out with them for a bit and ran around.
Everyone took a lot more pictures.

After settling up with Bob, we piled in the van and headed back to the
hospital.  I spent the entire three hours talking with Steve about
mainly the origins of the universe.  He believes strongly in a literal
7 day creation week.  We discussed a lot of different viewpoints and
the arguments for and against.  The time really went by very quickly.
I really enjoy spending time with him.  He is a quality person.  We
plan to get together and enjoy our passion for windsurfing.

New Renovations to Take Place at HAH!

Oct 18
Cam and Chris left early this morning.  It is exciting and very
gratifying for me to see them so interested and with such good ideas
for fundraising for this project.  I went for a run after they left
and had my best time ever by 5 seconds.  I continue to detest the
uphill part but the fairly level part in the middle gets easier and
less somewhat less detestable.  Then the downhill is even kind of
“fun.”  Having a nice set route gives me the opportunity to time
myself and makes it a game and new challenge each time I do it.
We had surgery all day.   We started with 8 plates on a 3 year old.
Mimi had never seen one done so I helped her with it.  It went fine.
Then we had a couple of smaller cases and a delayed ORIF of a wrist
fracture that Frank and Mimi did very nicely together.  Our last case
was actually two procedures.  A large teenager had a genu varum and
painful knee that he and his family said began when a wall fell on his
leg in the earthquake.  There were some mechanical symptoms in his
knee as well. He had an expensive looking knee brace and was well
dressed.  His xrays showed the nearly 15 degrees of varus that was all
in the femur.  There was no apparent old healed fracture.  His
epiphyses were closed.  Frank first did an arthroscopy and found some
unstable chondromalacia on his medial femoral condyle.  He did a nice
job and trimmed it.  We then switched to the radiolucent table and
Mimi and I put on an LRS femoral fixator and osteotomized his distal
femur and corrected his femoral deformity.  I really enjoyed the case
as did Mimi.  I continue to be amazed at all of the equipment we have
here for doing this type of surgery.  Virtually all of it is because
of the earthquake and Scott’s unbelievable hard work and vision.  That
this type of work is being done in post earthquake Haiti is pretty
mind boggling.  After the case I talked with Frank for quite a while
about how Jeannie and I made the decision to volunteer here for a
year, how it has been such a tremendous experience for us and how we
would like to stay longer if it weren’t for my contract back in
Wisconsin.  I am hoping that the circumstances with my work will allow
me enough flexibility in the next year to return(if I am needed) from
time to time.  If the practice in New London is able to attract a
younger orthopedist who would like to work full time, then I might be
able to reduce my time there significantly and be able to come here
for longer periods as necessary.

The internet finally came on here at the hospital.  I have a ton of
emails to answer and many others to send.  I have seen about a half
dozen patients that I need to run by Scott.

Jeannie made soup and salad and we ate dinner together with Frank and
Kaye.  We had a good time talking about our experiences with our
orthopedic practices through the years.  He was in solo practice in
Sonora, California until a year ago.  He had a same day surgery center
that he really enjoyed working in.  It was very efficient.  He sold it
to the hospital in town and “retired.”  He has been doing locum tenens
about half time since in the community where Scott grew up and where
his parents still live.  Steve Mulder gives anesthesia for him
regularly.

Oct 19
Very busy day today.  Jeannie and I took Frank and Kaye out and showed
them the duplex that we want to upgrade for living quarters for the
orthopedic director.  The large clinic went well with the three of us
steadily working.  Several more patients with frames came in today for
adjustments and strut changes.  Franz, our xray tech here at HAH had a
motorcycle accident last night and injured the top of his left
hand/wrist badly.  He “sandpapered” off a large area of skin and two
tendons down to bone.  The tendons go to his thumb and index finger.
The wound was highly contaminated and required extensive debridement.
The tendons are missing a segment each and will require specialty care
and probable tendon grafts.  He may also need a pedicle flap to get
skin coverage over the area.

The Mulder/Whitney team provided an excellent meal of “haystacks” for
dinner.  They brought all of the ingredients with them.  It was
terrific.  All of the long and short term volunteers enjoyed it
thoroughly.

Oct 20
We had a good sized surgery schedule today including an 8 y/o boy with
moderate Blounts for a TSF.  Frank helped me and it went nicely.  We
finished in well under 2 hours.  Passing the Gigli saw was
uncomplicated.  I helped Mimi do an ORIF of a proximal femur fracture
with a SIGN nail.  She hadn’t done one before.  The patient has
osteogenesis imperfecta and didn’t know for sure when she had
fractured her femur.  The fracture had begun to unite with the
proximal fragment flexed about 30 degrees or more.  We eventually got
it reduced after shortening it a bit and then the rod down and locked.
I spent time emailing to see if we can get a hand surgeon down to
work on Franz.  I sent out about a dozen emails.  I continue to apply
subtle(and occasionally not so subtle pressure) on both Frank and
Kaye.  They haven’t given us any indication of which way they are
leaning.

Nathan announced today that funding is now available for building a
new kitchen that will apparently be a sit down facility as well as a
commercial laundry.  Both could be revenue centers for the hospital.
Jeannie made a tasty chili and salad dinner tonight for the two
medical students who are leaving in the morning.  It has been great
having Andy and Josh here the last three weeks.  Andy is totally
commited to orthopedic surgery at this point.  Josh really likes ortho
also but is going to wait to make his decision.  One of their
classmates arrives this weekend for a three week rotation.  Andy is
planning to arrange with his school for Jeannie and me to give them a
presentation about the work here and mission work in general.

All in the Family- A visit from Cameron Dietrich

Oct 14
The clinic was the usual size today.  I had a meeting with Nathan and we discussed a number of items. There is a possibility for another orthopedic surgeon that might be able to replace me.  He is from the Philipines and is currently working at the Adventist hospital in Curacao, apparently doing just administrative work.  The funding apparently wouldn’t be an issue.  Even if he doesn’t do much surgery, perhaps he could keep the program organized so that the specialty teams have good cases set up and there is satisfactory followup.  He and Francel could run the clinics and take care of the

Jeannie with son Cameron

everyday cases. It will be interesting to see where that possibility goes.  Of course, Dr Frank Whitney and his wife Kaye are coming on Sunday.  We have hopes that he will be willing to take over for me for at least six months or more.  The surgical cases were mostly foot today, but Dr Bibiloni did the tumor case.  I was busy in the clinic when he did it but he said the tumor was immediately on the vessels in the groin but not invading.  He again did an excellent job on a very difficult case. We have been hoping to get the report back on our teen age girl with the lesion in her hip that Dr Yoon biopsied especially with Dr Bibiloni here to help with the management.  Dr Perez and Dr Guzman have done a really great job on all of the foot and pediatric cases we have had. We arranged to have dinner together
this evening at the Auberge where the team is staying.  We had a really great time talking and telling jokes and getting better acquainted.  Juan told Jeannie and me about his 500 acre farm in central Puerto Rico.  He farms about 100 acres. He has Valencia oranges on most of it.  He also has limes and some plantains.  He has a foreman and 9 employees.  He has 3 children and loves his wife very much.  He  has a big concern about the drugs, crime and violence that seem to be more and more prevalent every  year in Puerto Rico.

Oct 15
Another Sabbath has come to give me the break that is so helpful in keeping balance in my life.  Having a special day each week that is set aside as God's day is one of the best gifts ever given to  mankind. I took an early morning long walk up the hill. We all wanted to go to the prosthetics program that the Puerto Rican team has developed so we took the pickup to Delmas with Emanuel leading us.   It took a while to find the site.  We even arrived before the Puerto Rican team who had to call us for directions.  We got a bunch of pictures especially of Cam and the younger amputees.  We had lunch at a nearby café and talked with Cam and Chris about funding the project.  Chris has many connections with the media especially in England. On our way home, we took pictures of Haiti’s ruined nationalcathedral.  There were a number of beggars at the site.  It is hard for me to walk away from people who have so little but I have resolved to not encourage begging.  We also stopped at the ruined National Palace for more pictures. The internet went off today.  It won't be worked on until Tuesday since Monday is a holiday.

Oct 16
I was able to do my early morning run in 28’ 05” .  It was my best time yet. Whitney/Mulder team  arrived fairly early in the day.  I had an enthusiastic meeting with them sharing how I perceived the unprecedented opportunity here.  Of course, my hope that Frank will takeover for me had no influence on that at all.  Steve Mulder’s return is his first since the “Rocket Man” episode.  He calculates that he has spent 50 days here in Haiti since the earthquake.  Mimi Batin is a trauma subspecialty trained orthopedist who shares the ER work with Frank in his work in San Luis Obispo, California.  She has been here before not long after the earthquake.  She is very enthusiastic.
----------------------------
The students and Cam wanted to go to Petionville to check out the souvenirs and paintings.  Jeannie and I found one that we liked a lot. As we were leaving we had an interaction with a group of youth who were asking for money for "protecting" our vehicle while we were looking at paintings.  It was a somewhat threatening situation and required a hasty departure.

Oct 17
The clinic was much smaller than usual due to the National holiday in remembrance of the assassination of Haiti’s first president/emperor, Dessalines.  We were finished before 2 pm.  That gave us an opportunity to all go to Franz’ orphanage.  The kids put on a great program singing and dancing. We took a lot of gifts and clothes and candy.  Cameron really enjoyed having fun with the kids.  Josh and Andy did also.  The students and Cam and Chris all wanted to go to Leogane, the epicenter of the earthquake so we spent the rest of the day driving there and looking around and then coming back. Still no internet

Haiti Stands Up

Oct 10

Freddy left very early for the airport. ZJ also left for the week to get some medical issues checked and treated in Miami. I went for my morning run and felt really good when I started. I was pretty sure I

Master Surgeon Juan Bibiloni

would have a good time for the run and I was able to do it more than a minute faster than my last run. (28’ 50”) I’m getting close to my best time ever. Ed and I started the big Monday clinic. The Puerto Rican team arrived mid morning. They immediately dove in and started working. Juan Bibiloni and Humberto Guzman are the two orthopedists leading the team. Dr Ramos is their anesthesiologist. They have 2 OR nurses/techs also, Ulisses and Julia. Juan is a subspecialist in both reconstruction and orthopedic oncology and teaches at the University of Puerto Rico orthopedic teaching program. He did his oncology training in Boston with Dr Mankin and also at the Instituto Ritzoli in Bologna, Italy. His joint reconstruction fellowship was also in Boston. Humberto did a fellowship in children’s orthopedics in San Diego, the same program where Scott did his fellowship. Humberto finished fairly recently and has never met Scott. They have both been very involved here in Haiti. They have been instrumental in starting a foundation called “Haiti Se Pone de Pie.”(Haiti stands up) or (Haiti gets back on its Feet). The emphasis is on providing prostheses for the many amputee victims of the earthquake. Humberto and others from Puerto Rico did many amputations starting three days after theearthquake. They brought an entire truck over from Puerto Rico on the Ferry from Mayaguez to the Dominican Republic. They made it as far as Jimani at the border and found a facility with many patients needing care (amputations, external fixators and fasciotomies for compartment syndrome.) Their experience was wrenching but also gratifying. They had an incredible experience in the aftermath of their week of nearlynonstop, heroic efforts to help injured Haitians. Several pictures were posted on Facebook by team members that were totally misinterpreted by some members of the press in not only Puerto Rico but also in the national media in the US. Such a negative light was shown on them all that they were even brought under threat of medical license revocation in Puerto Rico. They paid several thousand dollars to take out a full page ad in the Puerto Rican news media explaining the misinterpretation of the pictures. It clearly shows how the popular media can take information and without proper analysis, use it in an inflammatory manner that can discredit highly trained and qualified specialists who are donating their valuable skills to save peoples lives in a disaster situation. Of course, the motivation is to attract more viewers and readers to “sell” their product and improve the “bottom line.”

Two more orthopedists will be arriving on Wednesday. Juan and
Humberto started evaluating patients as if they were at home. I am
really impressed with them. Ed did a case of tibial 8 plates and I
did a couple of small cases. Dr Bibiloni then started the case of the
large popliteal cyst with the peroneal nerve palsy. He spent between
2 and 3 hours very carefully dissecting out the lesion and identifying
the peroneal nerve and the neurovascular bundle. The peroneal nerve
was located between two large lobes of the cyst and was flattened so
that it looked almost like a ribbon. Clearly it had been under
pressure for quite some time. The neurovascular bundle was displaced
significantly toward the medial side of the knee by the cyst. Juan is
certainly a skilled surgeon. He made what for many orthopedists would
be a sphincter puckering experience look fairly straightforward.
The cases as well as the clinic were all finished by about 5 pm. It
was a rainy day all day long so I chauffered the team to the Auberge
in the “new” tap tap to be. I also took JJ and Roosevelt home so they
wouldn’t have to find a taptap in the rain. The traffic was awful out
on the main street in Carrefour and what should have been a ten minute
event took more than half an hour. The evening was still young so
Jeannie and I took Ed and the two medical students to the Auberge for
pizza. The Puerto Rico team was just sitting down so we joined them
and had a great time talking and getting to know each other.

Oct 11
We had a good list of cases for today. Unfortunately, we had to
cancel a child because of a cold and two other patients didn’t come
including the patient with severe Blounts for a TSF. We were able to
call one of the patients scheduled for tomorrow and he agreed to come
in. It turned out to be a good day after all. Tomorrow the
foot/ankle specialist, Dr Perez, arrives as well as the sports
medicine specialist, Dr Mayol. Today was Ed’s last day. Jeannie made
dinner and we invited him to join us. We had a good time talking for
nearly 3 hours. Ed and I went to college together and he was one of
the more colorful students. He was involved in several pranks that
eventually led to him being asked to leave. The experience didn’t
embitter him and he finished premed at another school and ultimately
did orthopedics at Loma Linda. During residency we did socialize a
bit and have stayed in contact since, mostly through the Neufeld
Society of which he was a founder and our common interest in
supporting the orthopedic program at Loma Linda. Jeannie and I really
appreciate his support of the work here. Many of the orthopedists
that I know well and had hoped would be willing to donate a week of
their time during this year have not been able to come. Ed has come
TWICE and that puts him in a special category for us. He has been
extremely generous also with helping with resupply of implants. He
brought the 7.0 cannulated screws that he tested and then ordered and
payed for from the company in India. We now have a full set as well
as replacements that should last for quite a long time. The Zimmer
7.0 screws are much better than the Synthes 6.5 screws because the
guide wire used with them is much beefier and doesn’t deflect like the
thin one for the 6.5 Synthes one. The screws can be placed more
accurately especially in the hip.

Oct 12
Jeannie and I got up early and bid farewell to Ed. The clinic was big
as usual. Having two more orthopedists to help when they weren’t in
the OR helped us finish before 4 pm. An unexpected case came in for
Dr Perez, the foot specialist who arrived around 10 am along with Dr
Mayol, the shoulder specialist. Another tumor case came in to the
clinic. The lady has had a lesion growing in her groin for several
weeks. It is large and has eroded through the skin. Dr Bibiloni felt
it was something that he could remove. I would have never attempted
something like that. It was so intimately related to the
neurovascular bundle. We arranged for her to get blood ready and to
come back on Friday for surgery. We eventually did seven cases and
finished before 8 pm. Dr Bibiloni runs 2 or 3 times a week as well,
so we arranged to run together early tomorrow morning. Our son,
Cameron, has been having intermittent symptoms of pain in his ankle
that sound somewhat like a loose body. He would like to be evaluated
by Dr Perez to see if an arthroscopy might help him. He is going to
try to make arrangements to come here with a professional
photographer. He lives in Cabarete in the Dominican Republic and
could drive. I encouraged him to fly. The challenge of finding his
way across Port au Prince if he drives would be daunting, especially
never having been in the country before. The digital machine for the
ortho clinic has finally been repaired enough to be usable again. It
definitely makes the clinic go more smoothly.

Oct 13
Cam’s early email said he had decided to fly and would be in this
afternoon. Juan and I ran my route and had a good time. We stopped a
couple of times to enjoy the view from high above the hospital. There
were 12 cases on the surgery schedule today. There were three
arthroscopy cases including the Bankhart repair of the shoulder.
There was no clinic so we could use all three rooms for at least part
of the day. The fifth orthopedic member of the team, Artemio Torres,
arrived this morning from New York. He is also sportsmedicine and
does mostly knees. Five of the cases needed C-arm so we still didn’t
get done until after 7 pm. I did a talectomy case with Humberto and
that was a first for him. Dr Mayol is an extremely skilled surgeon.
He set up the shoulder arthroscopy as if he were operating in his home
hospital. Dr Torres assisted him. He made what for me would be a
challenging case look very simple. He put in three very accurately
placed anchors to repair the Bankhart lesion and the shoulder was very
stable. He has a great sense of humor as well. All of these guys,
except the serious one, Dr Bibiloni, are constantly “putting each
other down.” They make snide little comments about how slow one is
compared to the other. It is all in fun and they have a great time.
They obviously respect each other very much. Cameron arrived with
Chris Black, the professional photographer this afternoon. He had the
sportsmed guys and Dr Perez, the foot and ankle specialist, examine
him and the ultimate conclusion was that surgery wouldn’t be likely to
help him. Of course, the ankle isn’t bothering him right now. Chris
is an extreme water sports photographer. He mainly shoots surfing and
kiteboarding. He is from England. He has a lot of connections in the
movie industry. He and Cameron have planned to come here to get a lot
of photos of the project and then combine them with photos of a kiting
trip on the north of Haiti. They are sure that they can make a
several page spread in the kiting magazines that will help get media
exposure for HAITI: TOGETHER WE MOVE and the project here. I talked
with Chris about the possibility of getting national media exposure in
England for the book. He thinks there is a good possibility. With
the popularity of ‘reality shows’, he is going to work on getting one
done here to help publicize the opportunity and needs.

Outing to Furcy

Oct 7
I saw several more patients in the clinic today in followup of their frames.  I also saw a new patient with severe Blounts for a TSF.  We had several smaller surgical cases that Ed did while I concentrated on seeing clinic patients.  We finished with surgery and clinic by 5 pm. Wilfredo Perez arrived this  morning from Puerto Rico.  He brought manuals and tools and kits to go over our anesthesia  machines.  He started to work right away on the machine in room 3 and after several hours we  concluded that it would be better to test the machine in storage downstairs for leaks. We brought the other machine up from downstairs and he began working on it.  It didn’t take him more than an hour or so of testing it and checking all the hoses and connections to conclude that it is in better shape than the room 3 unit.  It doesn’t have any significant leaks and we decided to concentrate on getting it in good shape rather than waste energy and time and resources on the older machine that may be more  problematic.  Dr Adrian tested both machines and she agreed.   He has really gotten a lot accomplished since he got here this morning.  About then, the Sabbath had begun so Freddy put his tools down.  It is once again a delight to have a day apart from the business of the week.   Jeannie made a great meal of savory beans and rice that everyone really enjoyed.

Haitian Countryside

Oct 8
Our patients are doing fine.  I planned to take Ed, Andy and Josh away from the campus so they could see some of the Haitian countryside. Freddy wanted to come as well.  They all wanted to go up to the cooler high country.  I  had missed seeing Ft Jacques the last time we were up there.  It is a fairly well preserved fort built just after independence in 1804.  Our four main translaters wanted to go as well. Jeannie decided she needed the rest and stayed at the hospital. Emmanuel did a nice job of directing me to Petionville and then on up the narrow, winding road to Fermathe where the Baptist mission and hospital is located.  The group all looked through the mission and then we headed out on a very bumpy, never paved road to the fort. There was some very nice scenery on the way so we stopped a couple of times to take pictures.  One spot was a rock wall along the road with several different types and colors of hibiscus hanging over.  I love flower photography so took a few minutes to compose about a dozen images.

Ed & Terry at the fort

The fort’s small parking lot had several people selling fresh fruit as well as cooked food.  There were French fries, whole vegetables thatlooked like a potato, and some other veggies as well as ‘peekleez.’ I got a plate full of a variety and it was very tasty.  Most everyone except the translators were a bit reluctant at first but once they tasted it, it was “Katy bar the door.”    Two more platefuls were bought and devoured.  Everyone really liked the peekleez. We paid admission to the fort and a young guide started the tour.  His heavily accented English was fun to listen to.  The earthquake had caused a lot of damage and the cannons had been taken off the wall

At the Fort

s and placed on the ground in front of the fort.  We all enjoyed poking into various rooms and areas and taking pictures.  I set up a groupphoto and the guide did a nice job of working everybody's  camera.  The small central “plaza” has a cistern nearly filled with water and lily pads.  The flowers were beautiful.  We got more pictures at the end of the tour on the cannons as well as of the Haitian flag on the flagpole in front of the fort.  I paid the guide very well for the group but he continued to hang around and started asking the others for money also. I don’t have patience for that sort of thing and he quickly got the message.  Back in the parking lot, four more plates of food with peekleez were purchased.  It all disappeared quickly. We continued on our outing through the town of Kenscoff.  It continued to get cooler.  The Lonely Planet guide book describes the little town  of Furcy as “picturesque” so that was our destination.  We continued on the road that became more and more “rustic.”  It seemed as though we travelled quite a bit farther than the guide book had indicated before we finally got there.  I got a couple of relatively uninspiring photos and we put the pickup in 4 wheel drive for the trip back to Kenscoff.  It runs very well in 4x4 and felt very solid.  The whole trip back to Delmas took about 2 hours.

 

Welcome to Furcy

Stephanie Bryce’s family had invited us to their house on Saturday again.  I had told Emanuel that we were going to Kenscoff and beyond and weren’t sure how long it would take and when we would return. Freddy also planned to spend the

In Furcy

evening working on the anesthesia machines.  I told Emanuel that we wouldn’t have much time and for them to not make us a meal.  We got to the Bryce’s around 6 pm and they had a whole meal ready.  We all had a great time with the family.  Stephanie is doing really well.  I had JJ take some pictures of me dancing with Stephanie.  Everybody got a kick out of it.  We didn’t stay late.  Freddy worked late into the evening on the machines.  He is unbelievably knowledgeable.  He plans to get up early in the morning to get as much done as possible.


Oct 9
Pt with femur fixation last week by previous team had some persistent serous drainage so I took him back to the OR.  I only found a hematoma/seroma.  I washed him out thoroughly and closed him so he hopefully can

Freddy working his magic

seal and not drain any more.  I spent a lot of time on the computer also catching up with my journal and sending emails. Freddy worked all day long with only a short lunch break.  He finally wrapped it up after 11 pm.  All of the machines are now functioning and have been serviced.  He services each of his machines every 6 months.  I hope we can arrange with Bella Vista Hospital for him to come every 6 months.  Even better would be for us to have Freddy train a Haitian to be our Biomedical technician and have our own department. Roosevelt spent almost the whole time with Freddy. I will have to get some feedback now from Freddy to see if he thinks Roosevelt has the aptitude to do the job.

Wisconsin September, Haitian October

Oct 2
Arrived back in Haiti.  Ed Miller is back for his second stint helping me.

Wisconsin September

He will be here for 10 days.  There are two students from DO school in Colorado here for three weeks.  Dr Pat Yoon’s team covered the last two weeks while we were gone.  They left earlier today. Francel is also gone.  He will be spending most of the month of October with Dr Karl Rathjen in Dallas.  I accepted a young teenager with fractures of both of his tibias.  Apparently a stack of bags of cement fell over on him this morning.   We won’t have any anesthesia until Maria gets here from the DR Tuesday afternoon.  The fractures are closed so we will just have to wait until Tuesday or perhaps Wednesday.  We checked out the anesthesia machines and then called Freddy again.  He wants me to take pictures of them and email him with more information.

Oct 3
The Monday clinic only had about 40 patients but it took a long time.
I think I saw at least a half dozen patients with TSF and Ilizaroff
frames.  Each one took quite a bit of time to study and sort out
potential issues.  I also saw a 57 y/o man with a huge fluid filled
cyst that fills his entire popliteal fosso(area behind the knee) and
extends out around the lateral side of the knee and welll up the thigh
behind the back of the knee.  He has had the cyst for several months
but in the past few days noted that now he can no longer dorsiflex his
foot and ankle.   The cyst was very tense and filled with what felt
like fluid.  We put in a needle and drained a lot of dark colored
fluid.  I suspect Pigmented Villonodular synovitis.  At most we were
able to only get about 20% of the fluid out by aspirating with a
needle.  I emailed  the clinical data and pictures of his knee to Dr
Bibiloni in Puerto Rico.  He is an orthopedic oncologist who teaches
at the University of Puerto Rico in the orthopedic department.  He is
helping organize the team from Puerto Rico that will be here next
week.  I would prefer to wait for Dr Bibiloni to do the definitive
surgical treatment since that is his specialty.  Perhaps keeping the
cyst partially decompressed will relieve enough of the pressure on the
peroneal nerve that it might have a chance to recover.  We still don’t
have an x-ray machine working in the clinic and there may be an issue
with the Ministry of Health questioning our use of the C-arm for
clinic patients.  We are encouraging patients to go to the xray
department for permanent films.  Many of the patients seem to be able
to pay the fee involved.  Ed did a couple of cases in the OR with
local anesthesia and also helped in clinic.  Clinic lasted until
nearly 6 pm.  Jeannie made a really nice meal for us and we invited Ed
and both of the students to join us.  We had a good time talking for a
couple of hours.  I called Freddy again tonight and he has gotten
permission to come.  I’m really excited!  I hope this will be the
beginning of a good working relationship with Bella Vista Hospital.

Oct 4
There were 7 cases scheduled for today in anticipation of Dr Adrian
and Lucia arriving early this afternoon from the DR.  They didn’t get
in as early as we had hoped and we didn’t get started until after 4
pm.  A patient with a calcaneal fracture came into the ER last night.
His fracture is displaced and should have a surgical reduction and
fixation.  We should have time to do his surgery on Friday.  That will
give the swelling time to go down a bit.  We postponed one case until
tomorrow.  Ed and the students did the hip hemiarthroplasty with JJ
assisting.  ZJ and I did the rest of the cases in the other room
including an arthroscopy on a patient with an AK amputation.  We
finished all of the cases and got everythingcleaned up just before
midnight.  Dr Adrian did her usual terrific job.  It was even more
impressive given the fact that she had hardly had any sleep the night
before because of a neurosurgical emergency that she gave anesthesia
for until 5 am.  ZJ  did very well with the arthroscopy.  He has very
good hands.

Oct 5
Apparently the patient with the calcaneal fracture knows Dr Hans
Larson, the president of the Haitian Orthopedic Society.  He wants Dr
Larson to do his surgery.  He has been admitted as a private patient.
The clinic including the clubfeet patients was large as usual.
Several more patients with frames came in and took quite a bit of
time.  We had three cases including the boy with the bilateral tibia
fractures.  Ed did his usual very careful, well thought out, precise
surgical management of a difficult case.  The entire medial tibal
plateau, half of the entire growth plate of the proximal tibia was
extruded medially.  The ACL was shredded as well.  The students, Josh
and Andy, are getting totally inundated with amazing orthopedic
pathology.  Jean Sondy, the boy who was an inpatient for so long last
year with the infection in his tibia, finally got his Ilizaroff frame
removed today.  He has no infection and the tibia is healed although
it is a bit short yet.  He is really happy and expressed his
appreciation for all we have done.  His father did likewise.  I
continue to be impressed with the Haitian people.  Another case was a
4 y/o orphan boy who is being treated for neglected clubfeet.  Dr
Nelson put Taylor Spatial frames on both feet and legs in August.
Using the TSFs for these deformed feet is considerably more difficult
than a straightforward frame for a long bone deformity.  If I could
have a few more weeks doing these kinds of cases with Dr Nelson,
perhaps I could even do them myself.  The reality is that they can
easily wait for a few weeks until an expert can do them and then I can
follow them.  This boy’s followup has been a little more complicated
than usual and I had to spend some time on the phone with Scott last
night and again today to get everything right.  These cases need two
separate treatment programs.  The first is to correct the forefoot and
midfoot so that the navicular bone is reduced on the talus.  Then the
wire that is stabilizing the talus is changed from its attachment to
the proximal ring and attached to the distal ring.  The new program
then corrects the remaining equinus deformity(foot pointing down
toward the floor).  Of course, it requires a completely new
prescription.  The data is again entered into the computer including
the amount of deformity(equinus).  The patient and the caregivers then
adjust the 6 struts over a period of several weeks to get the foot
straight.  It is fairly common for patients to have infections around
pins or wires during the several months that they have the frames.
The simpler infections respond almost always to oral antibiotics.  I
have had a couple of patients with infections that were significant
enough to take to the OR for debridement and IV antibiotic treatment.
So far, I haven’t had to take any frames off before finishing with the
full treatment because of infection.
The clinic and surgical cases were all done by 7:30.  I admit that the
12 hour days are preferable to the16 hour days.

Oct 6
Seven cases were on the board for today including a 17 y/o girl with
severe Blounts for TSF and osteotomies of the tibia and fibula.  About
10:00 I was told that Dr Hans Larson was coming at noon to do the
surgery on the patient with the calcaneal fracture and was going to
start at noon.  That left us in a bit of limbo since we were planning
to use the C-arm for two cases that could each take up to 3 hours.  We
certainly want the Haitian orthopedists to want to come here and do
surgery without having to wait for a room or equipment.  We waited
until nearly 2 pm and didn’t have any word from him so we went ahead
with our shorter case.  Then we followed with the TSF.  Ed helped me
with it and it went very well.  He had never seen one done before.  We
had a really good time doing it together.   Of course, we had to clean
up all of the instruments and trays and restock  all of the trays with
the bone screws, rings, struts, connectors and bolts.  We finished
everything by about 8:30.  Dr Larson did the calcaneal fracture in the
other room while we were busy in Room 2.  I guess he didn’t need the
C-arm.

Go, PACK, GO!

Sept 12
We had another quite large clinic today.  In addition, we had a couple of cases including a hip hemiarthroplasty that I did with ZJ.  It turned out to be another fairly long day.  Nathan and Amy came back today.  He still has the symptoms of dizziness when he stands.  I asked about the xray machine getting fixed.  The Fuji rep apparently needs to come here to deal with the problem.  He is going to try to get that arranged in a timely fashion.

Sept 13
7 cases were scheduled today.  We canceled one and did 5.  One patient didn’t show

There were some smaller cases.  One was the bilateral clubfoot patient that Bill and I did last week.  The feet look really good.  We recasted them in neutral.  The next cast change should let us get to 10 degrees of dorsiflexion or more.  The biggest case was the obese lady with the pathological fracture of the femur and many metastatic lesions throughout her femur and pathological humerus fracture.   We fixed her femur with a SIGN nail and methylmethacrylate.  She bled significantly and since we only had one unit of blood decided to not fix the humerus.  The case took quite a long time.   I also did another arthroscopy with Francel. The patient is morbidly obese and Francel had difficulty getting visualization.  I took over and the case was not easy for me either.  It may not have been the best learning experience for Francel.  Our last case was an elderly gentleman with an intertrochanteric hip fracture.  We set up the fracture table and the case went well.  We finished at nearly 2 am.  Irma was a real trooper all day long and until we finished.  I offered to watch the patient in recovery but she insisted that it was her responsibility.

I talked with Francel earlier in the day and he told me he will be here til end of year and would like to stay on afterward.  That is great news for us and the program here.  I am sure there will be some financial issues and probably a need for us to be involved in subsidizing his practice in some way.  I’ll talk with Scott and others about that.

I had an interesting encounter with an expatriate today also.  Anthony Kilbride  is a friend of Brooke Beck.  He is from England and works here on water project.  He has had an ongoing problem with a knee for about a year.  He suspected it was a meniscal injury.  He had a prior meniscal lesion in the other knee several years previously and had an arthroscopy.  I assessed  him and his findings are consistent with a torn meniscus.  He was very surprised that we do arthroscopy here at HAH.  He thought he would have to go home to England to have it taken care of.   I talked about HAH, the work being done here and the need for fund raising for this program to have long term stability and success.  He must be a fairly important person in his program because he told me he meets with Bill Clinton on October 8.   He said he would like to talk to Clinton about our work here.  I plan to scope his knee before that.  I gave him a book to give to Clinton.

Ernie Schwab from the LLU School of Allied Health was here for a few days.  I talked to him about the possibility of getting some type of certificate for JJ as an Orthopedic Technician.  He believes it shouldn’t  be very hard to do.

Sept 14
Clinic went well.  I left for the airport at 2 pm for Santo Domingo.  Jeannie and Cameron picked me up and we drove to Cabarete.  It is so nice to be back here again.   It’s great to be with Jeannie after nearly a week.

Sept 15 -17
Just two days in one of my favorite places is hardly enough.  A couple of good windsurfing sessions and a nice round of golf made the short trip worth it.  Tim and Summer were there also.  Tim got out on the windsurfer and did really well.  He is making steady progress.

Sept 18 – 29
Pat Yoon from Minnesota is bringing a team to cover for me in Haiti while I am gone.  He has been very involved in the project and his commitment  to the work there is remarkable.  This is his third or fourth trip there.  I cannot thank him enough for what he and his teams have done to keep the work going.  He is fellowship trained in foot and ankle and does a lot of trauma in the Twin Cities.

This was our last return trip to Appleton to work during our Year in Haiti.  I was again on call for 9 of the 11 days.  I once again enjoyed being “home” with Jeannie even though we are staying in our neighbor’s downstairs apartment.  This trip back was fairly similar to the others with office hours and several elective cases including total joints and one Oxford.  I got several cases in while on call also.  We ate out several times and made it to the tennis center several times.  I had several meetings in New London to work on getting things ready for my work beginning there in November.  Jeannie and I also attended a Foundation banquet  in New London and had a good time meeting and talking to several of the people that I will be working with.  We took some time to look at houses with a real estate agent and found one that was a really good price that we like a lot.  It has been on the market for two years so perhaps we will have time to sell our house and buy it.  It has a main floor and basement – NO upstairs which I like.  The kitchen is perfectly functional but some changes will need to be made.  There is no fireplace in the master bedroom either.  There is a three car attached garage and a two car detached one.  That will be perfect for a tractor to deal with the acre lot.  The landscaping in the front is bad and will need to be redone.  It is less than 5 minutes from the hospital and office.  I would favor moving to New London mainly because of the winter road conditions.

Something very special occurred also.  We were able to meet with Joan Malchowski, the director of publicity for the Packers.  Jeannie and I had about an hour with her.  I explained the work being done and the amazing opportunity it presented.  I gave her a signed copy of the book as well as two others to give to whoever in the Packers organization she wanted.  She is very interested and supportive and will try to spread the word to Packers fans.

Sept 29
I got an email from Haiti that we have only one functioning anesthesia machine.  The large team coming from Puerto Rico is wondering if they should even come.  I am sure we can solve this issue with a good biomedical technician.  I have offered several times to bring the head of the biomedical technology department at our sister Adventist hospital in Puerto Rico to help us develop this area at HAH.  Now will be a good time to bring him over to solve this “crisis.”  It might be the start to developing our own program with their assistance.  The young man, Wilfredo Perez, who heads their department is a good friend of ours.  When we first moved to Puerto Rico more than 40 years ago, his family lived two houses down from us.  His mother did medical transcription for me.  He was about 3 years old.  A few years later, I taught him to windsurf.  He still practices it avidly today.  When he decided to study biomedical technology, he came to Walla Walla, Washington where we were living to study.   He spent many weekends at our home during the years he was studying there.

Sept 30
Last day of work in Appleton.  We leave tomorrow morning to return to Port au Prince.  I called Freddy Perez today and told him about our needs.  He is very interested in knowing more about the types of anesthesia machines that we have at HAH.  He will have to check with administration to see if they will give him the time off to come and check things out.

Oct 1
Left Appleton.  No problems with the trip to Miami.