Sunday, January 30, 2011

Supplies from Stryker!

Jan 22
What a wonderful break today has been.  I was able to make quite leisurely rounds and change the necessary dressings.  That was the end of clinical duties for the day except to field one phone call from a physician at MSF Holland (Doctors Without Boarders).  He was seeing a lady with a mildly displaced wrist fracture that had occurred 19 days previously.  When I told him that I would be happy to see the lady in the clinic on Monday, he asked if I was closed for work on weekends.  Of course, he had no idea that I had just finished a very busy, challenging week with three days that each had 14 hours of work.

Jeannie and I were able to walk up the hill to the Adventist University for church service.  I recognized a few Creole words and the music was inspiring.  Personal devotional study added to this very restful day.  To not have this special day apart to be refreshed physically, emotionally and spiritually would mean a life of progressively mounting stress.  What do people  do with that mounting stress when they don’t have a day away from continuous work and activity?  I imagine it would probably drive me close to the edge of sanity, if not actually over the edge.  How many are living lives that are at that point right now?  The Sabbath offers all who accept it the opportunity to restore balance and calm to lives that are close to the edge.

Jan 23
Jay left today and the big team from New York arrived. This team is as good as they get.  It consists of 4 orthopedic providers, 3 anesthesia providers, a Haitian American nurse and a Haitian PA who grew up in PAP and actually attended the SDA school that is up the street a few steps.  Fritze, the HA nurse has been here quite a few times before.  The "Godfather " of the team is Aldo Vitale who is a very experienced general orthopedist.  Tom Lyon is a trauma specialist and there are 2 ortho residents, Mark Vitale (Aldo's son) and Charley another ortho resident.  Aldo is a gregarious, even jolly, man of vast orthopedic experience.  He has a large comfort zone with many and varied types of cases.  Tom does about 50% trauma in his practice.  He also has a sizable comfort zone and has an interest in learning to do clubfoot surgery.  He has made a number of trips for international service in the past.  Aldo’s son, Mark, is a senior resident.  He put in a lot of effort to organize this whole team.  He has a huge level of enthusiasm.  He is remarkably calm and collected.  Charley Jobin is also a senior resident in the same program as Mark.  His enthusiasm is contagious.  No situation seems to phase him.  He clearly loves orthopedic surgery.  All of these team members expressed a desire to throw themselves completely into the task at hand to accomplish as much as possible.  None seem to even have a hint of any pretensions.  All of the anesthesia providers are equally willing to pitch in.  It is wonderful to have this type of support.  It is a real privilege to have them all here.  The tendency since we have so much manpower will be to overwhelm the hospitals capability with more cases than the nurses and other support services can manage.  That will be my biggest challenge during these two weeks.

They brought with them many needed materials, supplies and implants.  Eric Tamweber, Ryan Jukovic and Dave Federowicz are all with Stryker and played a part in this very generous corporate support.  They donated a large number of replacement 6.5 cannulated screws as well as an entire set of modular implants with instrumentation for hip fractures. Included are the Stryker Omega 3 set of instruments and implants for fixing intertrochanteric hip fractures.  Dozens of all sizes of Stryker 6.5 Asnis cannulated screws, Austin Moore prostheses of many sizes and large and small fragment sets for fracture fixation were donated as well.  I consider this to be the essence of corporate generosity.  I am unable to thank Stryker enough for this remarkable donation.  I wish it would be possible for me to personally meet each of these people and express my appreciation for what they have done and what these implants will continue to do in the months and even years to come to provide hope  for recovery for the Haitians who do not have the resources to pay for their orthopedic care.

The Stryker rep in my home town of Appleton, Wisconsin is Eric Torkelson.  He has been very supportive of the Dominican project that I am  involved with for many years.  He also donated Stryker power equipment to this project.  That equipment complements nicely the Stryker instruments and implants that we just received.

Jan 24

I was fairly sure the clinic would be big today and it was – probably the mother of all clinics here to this point.  I had only scheduled two OR cases for today so that the new team wouldn’t be overwhelmed trying to learn where things are and how to make things happen in this unfamiliar environment.  Aldo and his son took the ankle fusion and needed no help from me at all to make everything work.  I was able to stay in the clinic the entire day.  Tom and Charlie dove right in and started seeing patients.  Even with all three of us working steadily, we didn’t finish with the last patients until 5:30.  Charlie’s horsepower to manage a big machete wound to the forearm as well as manage the evaluation and admissions of two urgent infected cases was a lifesaver for both Tom and me and later Aldo in the clinic.  One infection was a teenager with three swollen joints and the other was a diabetic with three pussed out toes. His management of both of those cases also helped Lynne a lot with her otherwise overwhelming work load.  We added the last 2 clinic patients on to the schedule for tomorrow, a displaced bimalleor fracture (ankle) three months out with at least 4 mm of lateral displacement of the talus and a patellar (kneecap) dislocation that happened 2 weeks ago.  To my delight, this team requires very little “babysitting”, really none at all.  They are totally take charge in the best sense of the words.  They understand and have quickly adapted to the environment.  It makes a great difference that they have OR personnel with Creole language skills and extensive OR experience.  I briefly mentioned their ortho PA, Sammy, who grew up here in PAP.  His presence takes a huge load from Jeannie’s shoulders.  The anesthesia providers couldn’t be a better fit.  They are very friendly and totally professional.  They also seem very at home in this unfamiliar environment.  The 11 cases we have on the board for surgery tomorrow will certainly test the entire orthopedic/anesthesia team’s efficiency as well as the hospital’s capabilities.  I have emphasized the importance of being aware of the limited staffing and bed situation to everyone.  The patients are also aware that some cases might need to be delayed 24 – 48 hours or perhaps even more.  At least we have plenty of work for a very eager and talented team.

Hans Larsen called me in clinic yesterday and asked if I could give him some Austin Moore prostheses for 3 cases.  I went ahead.  I don't want him to think we are selfish with all of these donated items.  I don't want to be HIS resupply chain for his paying patients though.

Jan 25
We didn’t succeed in getting all of the cases on the board done today but we gave it the old college try.  We were largely done in by emergencies.  An open bimalleolar ankle fracture and then a deep wrist laceration involving tendons were  responsible.  I kept the clinic as small as possible so we could concentrate on getting the cases done as efficiently as possible.   Charlie and I put the Taylor Spatial frame on the tibial nonunion.  It went very well.  It is a real treat to be able to work with Orthopedic residents.  Both Charlie and Mark are very knowledgeable.  Charlie has excellent hands and a winning personality.  His eagerness to do cases of all kinds is a delight.  I haven’t done any cases yet with Mark.  He has been largely with his father and Tom doing cases.  He always offers to help with anything to make things go smoothly including cleaning and washing instruments.  Tom and Mark did a very difficult quadricepsplasty (surgery on the quadriceps/thigh muscles).  The patient is very large.  She had been treated months ago for an open femur fracture.  The skin scarring was a good indicator of the magnitude of the injury she sustained.  The muscle and tissue had become extremely scarred to the bone in the area of the fracture.  She only had the smallest bit of knee motion.  With extensive release of contracted muscles and resection of scar tissue, they succeeded in gaining flexion (bending) to 90 degrees.  The challenge now will be to maintain that motion.  A lot of physical therapy will be in her future.  Two kids with cerebral palsy deformities of the legs and feet kept me busy during the middle of the day while Aldo did several cases in the third room.  It is wonderful to have 3 anesthesia providers.  We had to postpone a knee arthroscopy and a tibial nonunion because of the two emergency cases that took precedence.  Tom and Charlie put the open ankle fracture back together beautifully.  The C-arm continues to work well.  We have to be careful to keep it set on Mag 1 rather than normal to prevent the error messages from appearing on the screen which could presage a shutdown.  Aldo managed the last emergency.  It was a challenging wrist injury with lacerated and avulsed tendons.   Both Sammy and Shirley have been a very important part of the success we have had to be able to do so many cases in one day and still be done by 8 pm.  Jeannie seems a bit less fatigued as well although she didn’t get to eat lunch until nearly 5 pm.  We have another large clinic day tomorrow so only have the surgical cases that were postponed from today as well as any emergency cases that may come in.

Jan 26
The Vitale team continues to churn out the work.  The two cases that we postponed last night were the first ones for today.  Tom did a great job on the difficult tibial nonunion.  It was his first SIGN nail.  We weren’t planning on dealing with an infection, but that is what it turned out to be.  That turned a fairly straightforward case into one involving coating the SIGN nail with antibiotic impregnated bone cement after reaming out the canal to get rid of as much of the infected bone as possible.  It also increases the challenge of locking the rod with the proximal and distal screws.  He is a meticulous, methodical surgeon and he managed using an unfamiliar system very well.  It is a privilege to work with him and learn as much as possible.  We have another SIGN nail tomorrow in an infected femur.  Both Aldo and Tom estimate that nearly 50% of the cases we are seeing are residuals from the earthquake.  The clubfoot clinic went well.  Several older kids with untreated clubfeet came in.  I saved them for Mike Vitale who will be coming this weekend for several days.  His specialty is pediatric orthopedics.  I wish I had a good peds spine case or two for him to do.  Scott will also be here this Sunday and we plan a peds ortho clinic for both Mike and him.

Both Charlie and Mark dove into helping Lynne with inpatient work.  I wanted to give Lynne the afternoon off.  We have been clearly overworking her with all of these cases.  Charlie did a great job on two arthroscopies and Mark did a nice little hand case as well as a couple of wrist fractures with his dad.  Mark and Charlie had the case of the day.  The spinal cord injury patient had a sacral pressure sore that was draining.  They debrided it (cleaned it out) and got a large amount of pus and necrotic material then put on a wound vac.  The pathology here amazes all of us.

Jan 27
We had another good day thanks to the Vitale team.  Tom with Charlie assisting did a really excellent job on another challenging case.  The patient had a nonunion of a depressed medial tibial plateau fracture (knee fracture that wasn't healing).  They osteotomized (cut) the bone which had healed at a bad angle, then got some good fresh bone graft from his pelvis and packed it in the space created by lifting the fragment into its correct position. They then fixed it all in place with a metal plate and screws.  It looks essentially perfect.  The patient will now have a stable knee with a straight leg.  The personal satisfaction that we as surgeons get from cases like this is really great.  While they were working in room 2, Aldo and Mark were working in OR 1putting in a prosthesis in a lady who had sustained a hip fracture about 6 months ago and had been hardly able to walk since.  By default, I had the good fortune to do the clinic.  These challenging pediatric cases keep coming in.  Their seem to be a lot of untreated club feet in the 6 to 15 y/o age group. It would be interesting to get a group  of them and treat them with TSFs (Taylor spatial frames).  I also saw the little doll that I did the BK amputation revision on 2 weeks ago.

Jan 28
A week filled with many interesting and unusual cases closed today.  A pilon fracture (a type of ankle fracture) came in last night so Tom fixed it today with a hybrid external fixator (ex-fix).  It came out perfect.  While he was doing that case, I did a lady with a nonunion (non-healing) of a femur fracture that had been treated with a plate and screws and hadn’t healed.  She had a history of infection after the initial operation so I wasn’t surprised to find fluid and granulation tissue around the plate.  It meant changing my game plan from fixing with two plates and multiple screws with bone graft to cleaning everything up, fixing the fracture with an ex – fix and placing antibiotic cement beads.  All of that will just be the first stage.  We will follow with ex-fix removal canal reaming and antibiotic coated SIGN placement.  Her hemoglobin (blood count) wasn’t very high to begin with and she lost a fair amount of blood during the case.  We’ll need to get more lined up before doing the second stage.  Aldo stuck to the clinic so the rest of us could do what we love in the operating room.  Several of our TSFs came in.  One needed strut changes so I showed the residents how that is done.  The other patient needed his removed so now we have a few more spare struts.  One of our diabetic patients continued to have ascending infection in the leg after a foot debridement so we did an open BK.  Dr Montaz, an internist here at HAH, asked me to see a stroke patient of hers with pressure sores on her buttocks.  She is draining a lot of purulent material from one of them.  I’ll take her to the OR tomorrow and clean it up and put a wound vac on.  Connie has taken on a huge, intimidating for most, project.  The three walls of the storage room that don’t have ortho replacement supplies have shelves stuffed with OR and anesthesia supplies.  There are different types of tubing, dressings, drain materials, wound vacs and many other things.  In between giving anesthesia for our cases, she has spent hours going through all of that material and putting it neatly in order.   Many evenings she will be there on that project even after we have finished with cases.  All three of these anesthesiologists are of extremely high quality.  The size of our orthopedic team and the volumes of cases we have done this week have really required three anesthesia providers.  It serves to point out how thin we are stretched for both orthopedics and anesthesia when we have only one other orthopedist and a single anesthesia provider.  Heaven forbid that I am left by myself with NO anesthesia provider.

Dinner this evening at the Auberge d' Quebec hotel compliments of Aldo was icing on the cake for the week.  We all had a good time getting to know each other better.  Amy and Nathan had arranged earlier for us to order our meals ahead of time so we didn’t have much wait.  Tom entertained us after dinner with some magic tricks.  We all had a good time talking.  Once again, Shirley dominated the evening with constant chatter.  It is virtually impossible to get a word in edgewise when she is in the room. LOL!  It was a delightful time.  We got to the hotel in time to even take a quick dip in the pool.

Tuesday, January 25, 2011

A Special Thank You to SYNTHES!

Jan 15 - 16
Today was a very restful Sabbath. I really needed it. I was able to make leisurely rounds on the inpatients and all are doing very well. I have no help other than Jeannie on Sabbath. I guess everyone else thinks that the patients don’t need to be seen. I had made tentative arrangements to go to a Project HOPE storage area yesterday to evaluate a large donation of orthopedic implants. The cases lasted too long so I decided to go this afternoon and spend a bit of time there. There is a lot of stuff but most looks unusable, especially the implants. I couldn’t find any instrument trays that are necessary to actually implant them. They might be there, but weren’t apparent on the inventory sheets nor was there physical evidence. I didn’t make an effort to go through the mountain of boxes to find what I was pretty sure wasn’t there. I did meet Dr Charles Prospere. He directs Project HOPE in Haiti. He sounded very enthusiastic about the fundraising project of our coffee table book and agreed to help with an introduction as well as editing the text. He also wants to help me get good pictures of Haiti and Haitians. He has a connection to Haitian American organizations as well.

Jay Neil came in today. He is a med school classmate of mine who has practiced orthopedics in Vermont for many years. He fully retired last month after being half time for the last four years.

We made rounds with Jeannie and changed all the dressings. The patients continue to do well. Jay had arranged for a friend, Henry Perry CRNA, to come for the week to give anesthesia. He arrived today. We look forward to a productive week. I spend at least 6 hours on the internet today on the fund raising project and general communications. Jeannie and I also took Jay and Henry on a big outing to the delimart just around the corner.

Jan 17
I hadn’t scheduled any surgery today so that Jay and I could concentrate on the clinic. It was a good thing, too. We didn’t finish with the last patients until after 5 pm. One of the last patients was the lady that Scott and I had done the pelvic fixation on the night before we were evacuated last month. She is doing very well. I had spoken earlier to Madame Clotier about the hospital billing the patient for the surgeons services as well as for anesthesia and for the hospitalization. The patient is not actually married to the man who lives in West Palm Beach Florida. They are engaged to be married. She lost her home and her place of work(large pharmacy downtown) on Jan 12. She hasn’t worked since. Her fiancé was with her today. He has moved to PAP in the last few days and plans to look for work here. He had been selling multimillion dollar homes in Florida. The recent housing market is so bad in Florida that he decided to move here to save money. I doubt that either the patient or her fiancé will pay much if anything. I told Madame Clotier that she should give them a bill for at least $2000 for the surgeons’ work.

I saw a patient with a pelvic fracture today who checked herself out of a hospital in Cap Haitien and rode in a public car 9 hours to get here. It is just amazing what comes here for orthopedic care.

Jan 18
Even though Tuesday is supposed to be our big surgery day, there was a good sized clinic. Jay stayed in the OR and did cases while I took care of the clinic. I slipped in an arthroscopy after clinic. We finished off the day doing a hip hemiarthroplasty together. It went well. We finished work after 9 pm and Jeannie and I were both pretty bushed. I opened up a can of tomato basil soup and microwaved it. It was pretty tasty and it saved Jeannie from more work. The local “French” bread is very tasty and we had some balsamic vinegar with olive oil for a bit of dipping sauce. A pretty simple meal but it hit the spot.

We got some terrific news today. There is a team here to completely rehabilitate the lab. They plan to add bacteriology and upgrade virtually everything else. There is even a good chance that we will be able to have a blood bank. Hallelujah!

Jan 19
The clinic looked like it was bursting at the seams today. Of course, the clubfoot patients are there all morning. A couple of them needed Achilles tendon lengthenings so that added to the work load. Jay did an AK (above knee) amputation and some smaller cases and I came over for the Achilles tendons and then did another arthroscopy. I had another interesting experience today. Bryan Denhartog came to HAH to meet with me and check out the hospital. He represents the American Orthopedic Foot and Ankle Society. They are considering starting a program here. It would involve periodic teams of surgeons coming to perform surgery and be involved in teaching. I would certainly welcome any arrangement that would improve our academic credibility. It might even improve our chances of having a regular orthopedic resident rotation here. Brian is from Rapid City, South Dakota and knows my classmate, Dale Anderson well. He seemed favorably impressed with the facility and with our equipment and implants and with the work we are doing. I had an arthroscopy while he was here so he came in to the OR and observed. Our setup is pretty basic but it gives a nice view in the knee. The patient had a classic tear of the lateral meniscus and the case went well. I think he was favorably impressed. Today was only a 10 ½ hr work day but, of course, that doesn’t include the two hours or more of emailing and journaling this evening.

I discovered today that 2 of the Haitian ortho techs that work for CBM also play tennis. There are apparently several courts that aren’t too far away. I might be able to get in some court time this weekend.

Jan 20
Jay and I operated on a very muscular young man who had a humeral nonunion for 5 years. He had a very large amount of callus at the fracture site. The deformity presented a challenge to identify and protect the radial nerve. It took some time and we were able to find and protect it. It was still very difficult to remove enough of the callus to adequately reduce the fragments without over stressing the nerve. We were able to get an 8 hole plate on with 8 screws. The post op xray shows residual angulation but I believe it is satisfactory.

I spent most of the rest of the day in the clinic and Jay handled the OR. I saw an amazing 8 year old patient in the clinic with congenital deformities of both legs. He has never been to a doctor before. He has normal hips but deformed femurs. His knees, tibias and feet are nonfunctional. He scoots around everywhere basically sitting. He has a mischievious smile and seems totally happy. I asked both him and his mother if he would like to have legs that were normal in length so he would be normal height. They both answered “yes,” without hesitation. The only real option, given the severity of the deformities would be bilateral amputations and good prostheses. They want to go ahead.

   We had a comminuted midshaft femur fx (a fracture of the mid portion of the femur-thigh- bone into multiple pieces) that had been fixed in Santo Domingo with a small diameter Kuntscher nail(old school – can’t be locked) The patient had fallen a few days ago and the rod was fairly prominent above the greater trochanter (up by the hip area) and the rod looked a little bent. The fracture occurred just two months ago so we thought we could get it out even though we don’t have a Kuntscher rod extractor. It wasn’t easy but Jay got it out after a bit of a struggle. He then put in a nice sized SIGN nail and locked it. This job would be virtually impossible by myself. I wouldn’t be able to see many patients in the clinic at all if I were tied up continually in the OR. Of course, I wouldn’t schedule many elective cases without sufficient help. Jay is really a great help. He has so many years of experience that he isn’t stymied by a problem. He just keeps at it. He is getting acquainted with all of the instrument/implant sets and the power equipment. I would love to have him here more. He is going to cover for me when I am gone in February. Henry is an excellent anesthetist. He is calm, cool and collected. He is fun to work with, too. He has a good sense of humor. His best quality is his work ethic. He never complains and seems to be happy getting in another case in the evening even after working all day long. I wish he could take two or three months off and spend them here with us. I hadn’t realized that Henry was going to leave tomorrow until later this afternoon after I had scheduled several elective cases. I decided to pay the fee for getting his ticket changed so we would be able to do cases tomorrow. I’m not sure why that scheduling glitch didn’t get passed on to me. We really need to have the volunteers staying at least through Friday and even through Saturday if possible. We never know what urgent cases may present.

Jan 21
The work just keeps flowing in. A patient was transferred from MSF (Médicins Sans Frontières-- Doctors without Borders) yesterday with a comminuted patellar (kneecap) fracture associated with a displaced lateral femoral condyle fracture (the outside of the knee). He also has a displaced clavicle (collarbone) fracture and a mandibular/maxillary (jaw) fracture. Jay and I did the knee fracture together then I went to the clinic and spent much of the day there. The first half of the clinic was pretty uninteresting with several patients with back pain. A little 6 month old was sent from one of the other hospitals with fever and a swollen knee. I got her ready for the OR and aspirated her knee and femoral metaphysis. I didn’t find any pus fortunately. I hope the pediatricians watch her closely, she is so tiny.

I had just finished clinic and was doing some emailingwhen I was told that the ambulance had just arrived with an 8 year old with a femur fracture. The boy had been hit by a motorcycle. We decided to do him tonight since Henry is leaving early tomorrow. That meant postponing an arthroscopy and a femoral nonunion that were waiting. Things can get somewhat hectic in a hurry here. The case went well with me serving as a component of the fracture table. We used a sheet between his legs and tied it to the top of the radiolucent table (table that you can shoot x-rays through). Then I had on sterile gloves and gave traction to help reduce the fracture. Jay did a very nice job of sliding the flexible nails up the canal after we got the fracture reduced. It was a fun case. Again, Henry was his usual chipper self even though we didn’t finish until after nine o’clock. It’s really a good thing that we changed his flight to tomorrow.

This case again highlights the generous donation the Synthes company made to Haiti in the aftermath of the earthquake. The flexible rod tray is a Synthes product. It worked beautifully last night to fix that child’s fracture. The tray is complete with all of the instruments necessary to complete the job in state of the art fashion. Much of the equipment and implants that we use day in and day out to manage both straightforward cases as well as very difficult and challenging cases here is equipment and implants supplied by Synthes. Our sterile supply room is stocked with two Large Fragment and two Small Fragment sets as well as an external fixation set and two full sets of Synthes battery powered drills, reamers and saws. We also have pelvic fixation plates and screws. In addition in our non- sterile resupply room, we have a Synthes Hybrid External Fixation set and a 4.5 Cannulated Screw set and two very full bins of carbon connecting rods and Synthes external fixation connectors. I am sure we are better equipped with Synthes implants here at Haiti Adventist Hospital than many larger hospitals in the US. It is almost mind boggling to find this remarkable array of sophisticated devices and tools in a small hospital in post-earthquake Haiti. I cannot thank the Synthes company enough for their generosity. The patients, I am sure, have no idea of the magnitude of what this really allows us to do here. We do face the challenge of resupply of the implants that are used. I am hopeful that a workable solution will be found.

Saturday, January 15, 2011

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We are rolling out a new Facebook page for Orthopedic Ministries of the Caribbean. This will include links to all our blog posts, updates from other volunteers at HAH, and other news worthy items on Haiti recovery. Please "Like" us!

Another Leg and Life Changed at HAH!

 Jan 9

A very quiet day.  Lucia, Jerry and Dave all left this morning.  The patients are doing well.  I spent much of the day on the internet networking with orthopedists that have been here or will be coming.  The work on the Coffee table book to be was also time consuming.  I did follow the Packers some as they won their wild card game with Philadelphia.  I finished carving my little Haitian Santa during the game

Jan 10

A HUGE day.  Monster clinic worked around an ORIF (open reduction and internal fixation-- plates and screws) of BB of the forearm (both bone forearm fracture).  Dr Hans Larsen came during the clinic and we talked a bit.  He is the president of the Haitian Orthopedic Society.  Then towards the end of the afternoon there was the screech of tires and the sounds of a collision with breaking glass from out in front of the hospital.  A few minutes later the ER was very active with two patients with multiple long bone fractures.  The open tibia fracture was very actively bleeding.  One patient had no recollection of what had happened or how he got to the hospital.  He also had neck pain so the C spine needed clearing (making sure there were no fractures of the neck).  I finished washing him out and fixing him with an ex-fix after 9 pm.  I also put in a cannulated 6.5 screw for an undisplaced vertical split to the joint line that I found with the C-arm.  We had to clean up all the instruments and restock the implant trays so finally got to eat a little supper at 10pm.  We’ll do the other patient’s femur fracture and both bone forearm fracture tomorrow.  I scheduled about a dozen cases from the clinic today and saw several others that I put on the list for upper extremity and peds teams.

Jan 11 

I kept the clinic as small as possible today.  I had 4 cases scheduled since Craig Tingey and his anesthesiologist would be arriving in the late morning.  I hoped to be through with clinic by then so I could orient him to everything and do the cases.  There were hundreds of flight delays going through Miami because of the big snowstorm (where is “global warming” when we need it) on the East Coast.  They didn’t make it here until quite late in the afternoon.  Fortunately, one of the Haitian anesthesiologists offered to do 2 “short cases.”   I did them both after having to wait a bit because they weren’t quite ready. The wait created some anxiety on my part and, shame on me, I got upset at Jeannie.  Can you believe it?  She works at least as hard as I do if not harder and is trying to do her best to learn to do many things she has never done before, and I have the gall to take out my frustrations on her.  I am not sure exactly what type of punishment I should have for that but I am sure if there are any Tonton Macoutes (‘Uncle Gunnysack’ – see Wikipedia) still on the area, they would delight in taking care of it.  Fortunately, she is a wonderful forgiving person and I am pretty sure she won’t leave me over it.  I am such a lucky guy to have her in my life.  She is an unbelievable collection of beautiful things.  She is lovely to behold.  She is thoughtful and kind and hard working and intelligent.  She has a heart bigger than you can imagine.

We did the last 2 cases with local and sedation.  There has been an unbelievable flurry of activity all around us with painters painting and carpenters carpentering and cleaners cleaning and scrubbers scrubbing.  All this in preparation for the big day tomorrow – the one year anniversary of the EARTHQUAKE.  A large area in the parking lot has been covered with a  huge tarp and a platform set up and many chairs set out.  There will be dignitaries here to participate in giving homage to those who died and pay tribute to those, like Scott Nelson, who responded and heroically gave of themselves under unbelievable circumstances.  There is a planned emphasis on all of the good things that have happened since that event filled day.  Leading that list, in my opinion is the fact that HAH is now providing a world class orthopedic service to the indigent Haitians who have lived with their disfiguring and/or disabling limb or spine for years and even decades.  I am privileged to now be a part of that service.

Jan 12 – 13 – 14

This has been a good week with Craig  from Las Vegas with his physician assistant (PA) and an excellent anesthesiologist, Jenny Geracci.  I have known Craig for several years since he first came to the DR on our mission work there as a resident from LLU (Loma Linda Univ).    He has come to the DR several times since.  They were only here for wed and thurs but the timing was great.  I got in a big lady with a BB forearm and midshaft femur at the same time as a second  pt with a pilon fx (fracture of the tibia just above the ankle).  I had several big elective cases scheduled as well.  Craig did the BB forearm and followed with the retrograde SIGN nail on the femur while I did a below knee amputation in the next room.  Craig had never seen a SIGN done before.  Before starting the cases, I went through the surgical technique with him and Neil, his PA.  I thought I would be finished with the BK in plenty of time to help him do the distal interlock screw.  When I walked in the room, they were putting the dressings on.  Jeannie said it was the slickest one she had seen done.  Eat your heart out Scott.  It certainly doesn't say much either for how my surgical skills have impressed my own wife.  The pilon got a TSF (Taylor Spatial Frame).  It was a treat for me to show Craig something so sophisticated.  Only at HAH!

My meeting on Wednesday with Elie Honoré went fairly well.  He is the chairman of the board of HAH.  We talked for more than an hour.  I emphasized the importance of satisfactory comfortable sleeping quarters with at least a bit of privacy for the volunteers.   He instructed Madame Clotaire and Nathan to make it happen without delay.  Now we will see if it really will happen.  When I told him about the indigent patient fund and the coffee table book fund raiser, he immediately said that I should put it in writing as a request.  I told him that I had no intention of doing that.  The fund raising started 8 months ago.  I envision an independent, board controlled endowment that will provide necessary subsidies through a contract with the hospital.  I was very clear that the funds would be specifically to subsidize orthopedic care for indigent Haitians and that those funds could be used in any hospital.  My strong preference is HAH.  I believe an independent program is the only way that the endowment can function for its specific intended purpose.  There would be just too much opportunity for diversion of the funds for other needy areas.  During the meeting Dr Honoré used such descriptive terms as “maverick’ and ‘loose cannon.’  I reminded him of the situation 20 years ago when we were involved with a high level decision while I was a full time missionary in Puerto Rico and he was on the board of Hospital Bella Vista.  I had envisioned a program for reimbursing specialists so that we might have hopes of stemming the tide of returning missionaries who were difficult to replace.  That idea had been agreed upon by all of the leaders involved for the approval process.  Unexpectedly, an authority at a higher church level intervened and prohibited the approval of the program.  When reminded of this incident, Dr Honoré looked a bit taken aback and somewhat sheepishly nodded his head and said, ”I remember.”  I am unwilling to allow church leadership to have “control” over this endowment fund.  If being a ‘maverick’ or ‘loose cannon’ applies to me and is too much to be tolerated, perhaps I will be asked to leave.  I certainly hope not.

We did elective cases all day yesterday and then got in a 4 year old cutie with a displaced supracondylar fracture of the humerus about 9pm (elbow fracture).  Jenny got him to sleep quickly, we fired up the C-arm and got an anatomic reduction and 2 K-wires in by 10 o'clock.  I would wager to say that there are precious few hospitals in the US that could even come close to that time frame.  I wish they could have stayed longer but left this morning.  Jenny is a fearless anesthesiologist.  She dove right in doing cases here as if this was her home turf.  She was not bothered by lack of her usual medications and monitoring devices including end tidal CO2.  She fit in perfectly and I would love for here to come back as often as possible.  It was a quick hitter as teams go but helped me enormously.  Craig had a great suggestion for organizing anesthesia coverage.  Get state anesthesia societies to each take responsibility for a month here at HAH.  He and Jennie are going to work on Nevada.

Her leg can be straightened at HAH!
I saw another incredibly precious little girl in the clinic.  She has a major deformity of her leg.The tibia is very bowed in a fairly sharp angle above the ankle   She bopped in with her wrap around shades up on her forehead like she owned the place.  I held her in my lap and she was totally mine.  It gives me unbelievable pleasure to know that this little girl can be given a nice straight leg and I can be a part of that process.  I am very proud to say that it can be done at Haiti Adventist Hospital.   If not for the disaster of one year ago, she very well may have lived her live limping on a deformed short leg.  I want to see that little girl to grow to become a young lady with perfect posture, a ladylike gait and loads of self esteem. 
(note the normal left leg compared with the right. On X-Rays, left and right are reversed as though you are looking at the person).

I had an interesting interaction toward the end of my day Friday.  As I was doing an arthroscopy on a PAYING patient, Dr Hans Larsen walked into my OR.  He is the president of the Haitian Orthopedic Society.  We talked about several things including arthroscopy.  He has done some arthroscopy in the past at HAH.  He currently does an occasional case at a different hospital.  I told him of my interest in teaching local orthopedists and he suggested that the residents from the university program should rotate with me.  I asked him if he did ACL reconstructions and he said "no."  I told him I would be happy to help him with his cases either here at HAH or at his hospital.  He said he would bring them here.

Tuesday, January 11, 2011

Over the Next Few Days

Over the next few days, you will be bombarded with images from the earthquake and destruction that changed the lives of millions of Haitians forever.  Over the next few days, your eyes will see things that will make you want to look away.  Over the next few days, you'll hear more news of destruction, of tent cities with people whose homes are not yet rebuilt. 

Over the next few days, it will be easy to turn away from the TV and videos, to turn the page in the newspaper, to change the radio station, but over the next few days, I hope you'll let that tear roll down your cheek for the pain and suffering in Haiti. It rolled down mine today, 364 days after that treacherous day in January 2010.

It often feels hopeless, what can one person do? What can one dollar do? What can one prayer do?  A lot. When I was in Haiti in April of 2010 just three short months after the quake, one dollar bought food for a family, one person comforted a crying child or brought a smile to his face, one prayer saved a life. Twenty dollars paid a week's salary for a man to provide for his family.  Twenty people saved limbs, cleaned wounds, taught people to walk again, gave new limbs to amputees, served food to hundreds of people daily. Twenty prayers, we pray, saved souls.

I have no doubt that you are bombarded with organizations constantly asking for money, and in these financial times, every dollar counts for many, many people, in our own communities, in our own country. But please don't forget the people of Haiti, who are a grateful people, loving and caring, and looking for hope for tomorrow.  When you think of Haiti, don't think of all the things that haven't been done yet to rebuild. Think of the things that are being done, and that bring that oasis of hope to the people there, an oasis of hope and healing to the tired and weary.

Here is just one of many stories of the good work being done at Hopital Adventiste d'Haiti.  Yes, we need help funding care for indigent patients, and for building improvements, and we still need volunteers.  As you watch, consider what one dollar, one person, one prayer can do in the life of one person. If you feel led, please Join Us.

Out of the Rubble from Loma Linda University on Vimeo.

Sunday, January 9, 2011

Spine Surgery Success!

Updates from Terry Dietrich, MD
Jan 6 

Another very large clinic even though a ‘nonclinic’ day.

The Bilateral clubfoot posteromedial release in a 5 year old patient with arthrogryposis took most of the morning  for Jerry and me.  That made the clinic last much longer into the late afternoon than usual.  I also did a knee manipulation in a patient that Scott and I had done a femoral osteotomy on.

Jan 7

The volume of cases continues to increase.  We had 3 cases planned including bilateral 8-plate femoral epiphysiodesis in a 3 year old, adjustment of a TSH and the spine fracture.  A patient with a healed femur fracture and very stiff knee came as well for a quadricepsplasty.  I was quite sure he wouldn’t show up since I had ordered blood typed and crossmatched.  He had come in 2 days previously and told me he had B+ blood and there was none available.  He had a unit ready.  Since the blood was still not in the hospital for our spine patient(it was coming from a hospital a couple of hours away), we decided to do the quadricepsplasty.  It was an interesting and quite challenging case.  The vastus intermedius was completely fibrotic and limited knee motion,  There was marked intraarticular fibrosis that also required extensive debridement.  After eliminating those obstacles to knee range of motion, Jerry and I were able to get 130 degrees of flexion prior to repairing the vastus medialis and lateralis to the rectus femoris.  After the complete repair and closure, we held him at 80 degrees of flexion and immobilized the leg in a splint.  I will consider it a success if the patient gets 90 degrees of flexion and at least some power to fully extend the knee.  I would love to have a CPM(continuous passive motion) machine to help him get the desired motion.  I will try to jury rig up something to keep him from becoming totally stiff.  I am sure that at least one manipulation under anesthesia will be necessary during his recovery.  By the time we finished all three of these cases, the blood had arrived for the spine case.  It was after 5 pm and we decided rather than risk a late night recovery from a major surgery for the spine patient that we would do it next morning.

Jan 8
The Spine Team. Note the c-arm - an integral member of the team.

The spine case went well yesterday.  We had to put his case off until Sabbath because of the delay in getting blood prepared.  I wanted everything totally in order before starting.  I didn't think that I would actually need blood during surgery(and I didn't) but I wanted it just in case.   I was fairly well rested even though it has been difficult to get good sleep for the last week or more d/t a challenging family situation.  I prayed for God to give me courage and keep my mind clear.   I have done no spine surgery in the last 10 years except for the one case I helped Scott with last month.  I have NEVER done a case of pedicle screws without a spine surgeon helping who was much more experienced than I.  The last one of those that I did was in 1992 and I only did 2 cases.  I did a lot of spine surgery in Puerto Rico more than 2 decades ago including many instrumentations, but pedicle screws are another step up in complexity and risk.  Jerry King did a very nice job of assisting on the case, but he has never done any pedicle screws himself(nor seen one put in) and has done virtually no spine cases in his practice in the last 20 years. I had planned to instrument L1 and L3 with a total of 4 pedicle screws connected by rods and then fuse the two levels.  We encountered more pathology than expected.  The interspinous ligament between T12 and L1 was disrupted and there was an obvious fracture of the lamina of L1.  I decided to include T12 in the pedicle screw instrumentation and fuse that level as well.  A quick phone call to Scott in Loma Linda confirmed that decision.  A preop CT scan would have given us the information ahead of time and proper planning could have been done.  That capability will be some time in the future for surgeons here at HAH.   At that point, I was very thankful that I had made sure that blood was available since the magnitude of the operation had just been increased by 50%.  Everything proceeded smoothly and the blood loss was not great.  The pedicle screws went in nicely thanks to the C-arm functioning perfectly.  Jeannie put on her x-ray tech hat, lead apron and did a great job of positioning it all during the case.  After putting in the first 5 screws, I offered Jerry the initiator and he proceeded to place the 6th screw perfectly.  Placing the rods and finishing the fusion was the easiest part of the whole procedure.  Dr Brannon gave excellent anesthesia.  He was able to lower and then maintain the patients pressure to a safe level that decreased significantly the blood loss.  Lucia was a tremendous help.  She is totally familiar with the instruments and implants.  It was an answer to prayer that she was able to come on short notice and help the case go so smoothly.  She is a wonderful Christian lady.  Her elegant preop prayers are a thing of beauty.  We are incredibly fortunate to have her skills, experience and enthusiasm as a resource.  Scott is again to be commended for the part he has played in developing this relationship. 

Having both Dr King and Dr Brannon here this week has been a great help.  They provided the support that was essential for the cases that presented.  If more acute trauma had come in, a larger team would have been necessary to deal with the volume.  I believe the two week hiatus at the end of December was responsible for the smaller number of cases that needed surgery.  Hopefully, the field hospitals will realize that we are once again available for orthopedic treatment and will resume sending patients.  Some may have found alternative solutions to their pressing operative orthopedic cases and perhaps will no longer refer patients here.

Dr King takes the perfect approach for evaluating and managing the wide variety of, at times, complicated cases we see in the clinics.  He is thoughtful and considers the options carefully.  He broad experience as a general orthopedist gives him the background to assess patents and develop an appropriate plan of treatment.  His efforts to stay in the big somewhat intimidating clinics while I did cases was admirable.  In addition, he would finish cases, place casts and take care of orders and paper work while I would go back and finish a clinic or have an administrative meeting or spend time on the internet studying some aspect of patient management.  I wish he were in a position to be able to come and work with me for longer periods of time.  I am optimistic that he will come back at least one more time during the remainder of my year here.

Dr Brannon is one of the best anesthesiologists I have been privileged to work with.  He thoroughly evaluates each patient prior to initiating treatment.  I have worked with faster anesthesiologists but certainly none have been better than David.  His careful preparations match the  smooth inductions.  Even the “Brutane ” induction of the little 3 year old girl for 8 plates in both distal femurs went quickly.  None of our cases had any anesthetic issues.  His patience in dealing with our lack of PACU was admirable.  Again, if our volume of work had been greater, it would have been very helpful to have a nurse with the team to manage the recovery in the OR and then Dave would have been free sooner to initiate another case in the second room.  I would love to be able to work on a regular basis with David.  I am optimistic that he will return again this year.  We talked a fair amount about different scenarios for solving the fractured Anesthesiology service here at HAH.  It is a fracture that a simple cast will not adequately treat.   A full ORIF is necessary.  Perhaps a solution as complex as a Taylor Spatial Frame is necessary.  One idea is to find 12 anesthesiologists who would each take responsibility for one month of the year at HAH.  Each of those twelve could then network with however many anesthesiologists/anesthetists they would like to cover the 4 weeks.  If volunteers provide the anesthetic care for the indigents, it removes another cost so that the subsidies necessary for the indigent care provided are minimized.  I believe that developing a formula for charging every patient, especially indigents, for their care so that we can then pay Haitian anesthesiologists to give them anesthesia would be in essence “robbing from the poor to pay the rich.”  This is not to say that the Haitian anesthesiologists are rich or shouldn’t get some compensation for their work.  I believe that if the hospital provides the necessary environment to attract paying patients, then there will automatically be plenty of work that the independent anesthesiologists can bill for.  That means that emphasis should be placed on finishing the new patient wing and remodeling the OR.  An alternative would be to contract with the anesthesiologists so that any money collected by the hospital specifically for anesthesia services could then be shared equitably with the providers.

I asked both Dr King and Dr Brannon for suggestions from their perspectives of how things could be improved so that we could be more effective in our mission.  They both specifically suggested that some improvements in the basic accommodations might be helpful in attracting needed specialists.  They found it difficult to get sufficient rest on an uncomfortable army cot night after night.  Though this might be satisfactory for the occasional masochist, the majority of people need a good night of rest whenever possible.  Simple bunk beds with a firm mattress would be a major improvement.  The current area for short term volunteers could easily be temporarily enclosed and even air conditioned to provide a bit more privacy and comfort.

Saturday, January 8, 2011

New Year News from Orthopedic Ministries of the Caribbean

Here are the updates from Terry's journal, starting from post-evacuation to their return this week at HAH.

Dec 18 -19 -20

It is quiet!  No diesel generator cranking away in the background or honking of cars can disturb our current environment.  What  a great way to start the Sabbath.  Our long walk down the beach in Cabarete Bay gives Jeannie and me a taste of what God has in store for us when all of the hunger, unhappiness, heartache, disease, suffering, disasters, violence and death are things of the past.  None of these sad afflictions of humanity have seen fit to bypass the people of Haiti.  To the contrary, they seem to all be more prevalent, even intense in this country that was once the most prosperous of all French possessions.  Albeit, that prosperity was no doubt in large part founded on slave labor.  Is there a possibility that the permeating societal belief in voodoo could somehow be related?  My Christian beliefs make me aware of the satanic powers that Christ faced in his life and ministry.  Could the fallen archangel have an all pervasive influence on the entire country and somehow make misery Haiti’s currency of life?

We received some interesting news via internet today.  The OAS has approached the Haitian government with an offer to help resolve the current political/social standoff.  They are willing to bring a panel of international experts to Haiti to review the election results.  Perhaps, if the offer is accepted, a way may be found to avoid more violence and danger.  It may also just put off the inevitable unrest that would be felt by supporters of whoever loses the election.  Now we have to wait and see what decision the Haitian government makes.  It could take considerable time for the panel to be assembled and complete the necessary work.  That leaves us with more uncertainty.

Dec 21-22

We are back home – well sort of.  We are in the US.  Our flight to NYC from Santiago was uneventful as was the continuation to San Diego.  We arrived at our final destination at 4 am our biological time.  It made for a very long day made even more interesting by a highly unusual checkin and then a totally chaotic situation at JFK.  I had to hand carry an oversized bag to a different terminal so it could continue to San Diego.  Then we made several trips back and forth to a third terminal to go through security and get to the boarding gate.  It was freezing outside.   It was all worth it to be able to spend Christmas with our children.  It has been almost a year since we have all been together.  We are so blessed to have children who are well adjusted and productive and who enjoy spending time with us.  Our son, Cameron, has been dating a girl for several months and thinks she is the ONE.  We get to meet her family this weekend.

Dec 23-24

We didn’t expect to be able to do any Christmas shopping this year but these extra unexpected few days gave us that opportunity.  It is great fun to just be able to hang out with the kids.  We enjoy doing so many active things together.  The San Diego area has such good weather usually.  There has been heavy rain the past several days throughout Southern California including severe flooding in Laguna Beach.  The mountains have received more than 10 feet of snow in some places in the past few days.  It is the snowiest December ever apparently.  These last 2 days have been mainly sunny and delightful.  Our dinner meeting Courtney’s parents was a lot of fun.  We had a great meal and enjoyed the time together getting acquainted.  Courtney and her brother grew up in this area.  Her parents both keep very busy with their work.  Her dad is a gynecologist and her mother works part time as a nurse.  We will celebrate Christmas in their home tomorrow.

Dec 25

How fortunate we are – Christmas with the family.

Dec 30- 31

Golf with Bob and Cam and Courtney.  Jeannie’s shoulder is slowly improving.  We hit balls and she made some good shots.  She is generally sleeping better as well.  She still uses quite a bit of Ibuprofen.

Emailing for fundraising.  Played games and ate pizza to ring in the new year.

Jan 1 – 2   2011

Spent time at the beach with Courtney and her folks then went to the airport for our all night flight to Miami/Port au Prince.  Nathan was on our flights.  Everything was quiet at the airport and the drive through town to the hospital.  It is nice to be back “home”.  We are the first expatriates to return and we received a very warm welcome from the Haitians who met us.  There are only a handful of patients in the hospital and none of them are orthopedic.  I anticipate a monster clinic tomorrow since we have been gone for nearly two weeks.  Jerry King came in on an afternoon flight.  Jerry is a friend of mine from LLU.  He practices orthopedics in North Carolina.  He came to HAH about two weeks after the earthquake.  He is accompanied by David Brannon from Georgia.  David is an anesthesiologist.  We hope to get a lot accomplished in the next week.

Jan 3

The clinic today was much smaller than anticipated.  It still took us most of the day.  We didn’t have an xray tech until after 10 am.  I wound up having a fairly long meeting with Nathan, Madame Clotaire, and Dr Simeone.  A patient came in to the ER with an extensor tendon laceration.  Jerry did a nice job of repairing it while I stayed in the clinic.  A patient came in to the clinic with what appeared to be an infected distal femur fracture s/p ORIF with plate and screws.  We took her to the OR and removed the plate and screws and debrided it.  We made antibiotic beads as well.

Tim sent me 2 long emails with the initial outline for the coffee table book so I responded to them.  Andrew also sent me a very nice response and expressed an interest in helping with the project.

Jerry told me that Dr Brock Cummings had come down also in the aftermath of the earthquake and would probably consider returning.  He grew up in Ukiah and my dad had him in his classroom in the fifth grade.  He practices orthopedics in northern California.  I called him and he is very interested in helping me for a week or two later this year.

Jan 4

Today wound up to be a shorter work day even though we had 4 cases scheduled.  Three cases including a bilateral knee arthroscopy were cancelled for various reasons.  Jerry and I did the ankle fusion and it went well in spite of having a quite limited selection of large cannulated screws.  Having a reliable source of replacement screws and plates, especially the nonstandard types, would be a really big help.  The C arm worked very nicely which delights me.  The clinic was bigger today than yesterday even though it is supposed to be a “nonclinic” day.  The clinics will undoubtedly continue to grow larger as the word gets out that we are back.  At this point it is somewhat difficult to know how to plan and give recommendations to the larger teams that are scheduled to come down.  I am reluctant to tell them to bring specialists, especially extra anesthesiologists, not knowing what the volumes will be in the next 3 to 6 weeks.  We haven’t gotten any fresh femur or tibia fractures yet but I’m sure they will eventually come.  I just hope I don’t get hammered when I’m by myself.  I have heard from several new teams that have been here before and want to return.  That gives me more reason for optimism that I will be able to survive this year in a reasonably intact state.

Jan 5

The clinic today was larger than yesterday not even counting the quite large clubfoot clinic that Bob Cady was here for.  I had only met him briefly in November.  He is a retired pediatric orthopedist who has a special interest in clubfoot treatment.  He has been involved in teaching the Ponsetti method for many years and has made many trips to Haiti in the past.  He does clinics in different places in the country.  It has been a delight to get better acquainted with him.  He is an avid golfer and loves to fish.  He and his wife live in New York state but spend a good share of the year in Naples Florida.  We have played some of the same courses in the Naples area.  He is reading the latest Tracy Kidder(“Mountains Beyond Mountains”) book and plans to leave it with me when he leaves this weekend.  Our surgical cases went well.  One patient had a healed femur fracture that was infected and draining since ORIF with IM rod 3 years ago.  The surgery was performed at Hospital Dario Contreras in Santo Domingo.  The patient was living in the DR at the time he had the fracture.  He speaks excellent Spanish. Jerry did the case.  He debrided the sinus tract and windowed the bone and removed the rod.  It was pus filled.  He made a methacrylate/antibiotic coated rod, over-reamed the canal and put in the rod.  We didn’t have blood cross matched but the patient had a hematocrit of >40 so we thought it would be safe.  I got the great news that Lucia will be able to come tomorrow and assist with the spine case on Friday.

7 year old Alexander with his brother.
I saw another very interesting case in the clinic today that typifies the years of neglect of orthopedic work in this country among the indigent.  Alexander is 7 years old .  He had a normal right leg until he was two when he sustained a severe burn around his knee.  The burn created a contracture that caused the knee to flex to greater than a right angle.  The peroneal nerve was also apparently damaged severely.  He hops on one leg everywhere.  To add to the tragedy, his mother died of some disease nearly a year ago.  He was brought to the clinic by his aunt and 13 year old brother, Stanley.  His father lives elsewhere and is not supportive or helpful.  A team approach with plastic surgery may be able to successfully give him a good functional leg.  I got a video of him hopping.  It will be great to have a comparison video with  him walking with a straight leg.  He might even be a rival for Staille on Youtube.
Severe contracture caused by burns.