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.
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.
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.
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.
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.
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.
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.