Tuesday, February 15, 2011


Feb 5 - 6
Another very restful Sabbath blessed my existence today.  I said ‘goodbye’ to the love of my life early this morning.  She will be spending a few days with her mother before joining me in Wisconsin on Thursday.  A few hours later I said ‘goodbye’ to the Vitale team.  This is now about as quiet as it can get.  I don’t have an anesthesia provider to do any cases.  Even if I did, Jeannie isn’t here to run the OR so I’m pretty much totally ‘hosed’.  I made quiet rounds and everyone is doing fine.  Is there anything better than to spend Sabbath afternoon reading?  Scott left me the new book by Richard Schaeffer on the history of CME and the efforts and faith displayed by the founders.  It is humbling to read about the things they went through with the odds so stacked against them.  Journaling took up the evening until about midnight.

Sunday was productive.  Rounds and dressing changes were followed by a ton of emails.  I had an issue with the last TSF that I did that required triangulated electronic messaging from the Atlantic to the Pacific and the Caribbean.  After several communications with both Michael and Scott the mystery was solved.  I had entered data incorrectly in the TSF website.  When Michael pointed it out, it was clear.  It is gratifying to know that the surgery was not done incorrectly.  Incorrect data entry however is nearly as bad as improperly done surgery since the internet will give instructions for strut adjustments that could lead to a poor outcome for the patient.  Fortunately, correcting an error in data entry is vastly simpler that correcting improperly placed wires, pins or entire frames.

The first TSF that I watched Scott do seemed moderately complicated as far as surgical procedures go but certainly within the capability of a reasonably intelligent and coordinated orthopedic surgeon.  Him just describing the additional steps to complete the procedure and begin correction  made my head spin.  Getting the x-ray done in proper orientation and then measuring the frame mounting parameters, the deformity to be corrected and the structure at risk and then actually entering the data correctly on the spatial frame website was clearly way beyond me.  I concluded that the whole process was out of my league as a general orthopedist.  A few more cases with Scott whetted my interest more.  The decision to spend a year in Haiti meant that I would be following quite a few of these patients.  I would clearly need to at least understand it well enough to take care of the patients and not have to call or email Scott with every question.  The challenge of learning how to do the whole thing bit me and now I am hopelessly engaged.  I hope to one day have the privilege of meeting Charley Taylor, orthopedic genius extraordinaire.  In the somewhat limited time left for me to practice medicine, I will undoubtedly not be able to accumulate a very large case load of TSFs.  What I have learned is immensely interesting and continues to add to the unbelievable experience that I have had in more than 39 years of learning and practicing orthopedic surgery.

The time I had after the computer session allowed me to explore some options for getting a vehicle that might work for a tap-tap.  My desire to own and drive one of these unique vehicles would probably be considered a fixation by most non-adolescents.  The latest option that looks very promising is a pickup that has been abandoned under a tree behind the hospital.  It has not moved since I first saw it last April, nearly 10 months ago.  I asked Nathan about it and he believes that it could be repaired to function again.  No one is sure of the exact nature of the pathology affecting the vehicle.  I am giving Samuel a bonus to find a mechanic to examine and diagnose and then give a prognosis for the infirm beast.  Of course, I will need an estimate of the costs of any  implants and the projected fee of the practitioner giving the treatment.  If the overall projected expenditure to bring it back to health isn’t excessive, then we’ll proceed with surgery.  It’s current color is white which is somewhat similar to some of my patients after a surgery involving major blood loss.  A colorful tap-tap paint job, top, bumper, side tassels and flashing lights are all that are needed to bring the patient to total health.  It’s exciting!

Feb 7
I had a good day.  I talked to the translators and CBM guys about the book project and asked them to contribute text to help tie together some of the pictures.  I told Emmanuelle that I wanted to get pictures of Haitians living and enjoying things.  After clinic we went down to the corner and then for a long walk up the street in Carrefour.  Joseph and Dorgil and Roosevelt joined us and both JJ, his girlfriend and Junior joined in as we went up the street. I got photos of shoeshiners and kids and barbecues and tap-taps and dominoes and buying popcorn.  The popcorn was very tasty.   One street corner had some good music playing so I demonstrated some Rumba.  JJ's girlfriend wouldn't dance with me (she belongs to a very conservative church that considers dancing a sin) so I demonstrated with JJ.  Everybody had a good laugh watching us, including a number of bystanders.  Along the street there was a bourette (large pull cart) loaded with tires so I had Emmanuel pretend he was pulling it with the other guys pushing.  I got some pictures of the joke and we all had a good laugh.  These guys are a hoot!  We went to Roosevelt's house where he has lived for 20 years.   He has a little business that sells beverages so I bought everyone a soda.   We rode a tap-tap back to the hospital after dark.  Emmanuel said I was the first American to do anything like that with him.  I will have even more time tomorrow afternoon so we are going to go to Leogane (30-45 minutes by taptap.)  I hope to get some good pictures of cane fields and farms and such.

The clinic went well today.  I scheduled three cases Friday for the orthopedist who will arrive on Thursday.  The last patient was a young lady who had dislocated her elbow in an auto accident this morning.  I reduced it with conscious sedation (Titrated Fentanyl and Versed).  The post reduction x-ray showed a displaced lateral epicondyle fracture so I scheduled her with Ken for Friday since I don't have anesthesia.   I talked to JJ about what he needs to do to help make things go well for the surgeon (Ken Graf) as well as to be sure to restock the implants used and prepare all of the instrument trays properly.

It’s pretty lonely here without Jeannie.

Feb 8
Our clinic was big.  Nathan called me while I was seeing patients to tell me there was someone in the hospital who wanted to talk to me.  The gentleman was from Puerto Rico and works for ADRA.  He had come with a phalanx of Puerto Rican journalists to assess the current social needs in Haiti.  I started to answer his questions in Spanish and within moments found myself surrounded by reporters with camcorders large and small and recording devices.  A key question that seemed important to answer was “Is it true that much of the generous equipment and materials donated for earthquake relief has been stolen?”  I reassured them that there was an incredible amount of orthopedic equipment, supplies and implants that had come to HAH and was being used nearly every day and would continue to provide the needed materials for high quality orthopedic care into the future.  The interaction lasted for more than half an hour.  The chief reporter stayed with me for another 15 or 20 minutes to ask me questions about my background and why I had come to Haiti for an extended period of volunteerism.  I recounted  my relationship with Dr Nelson and how I had been impressed with the heroic work that he had done mainly at Haiti Adventist Hospital in the months after the 12th of January and the incredibly rare opportunity that it presented to Jeannie and me.  I told her of how impressed that my wife and I had been with the character and patience of the patients, largely indigent, that would wait for hours to be seen, evaluated and cared for in the clinics. The fact that patients were presenting to the clinics day after day with orthopedic conditions that have affected them for years was a huge part of it.  We wanted to be part of a process that could now offer hope and then actualize those hopes into reality, correcting deformed legs and arms and spine for patients who have never had this available before.   She asked about what had motivated me to do work in developing countries.  I told her of my experience as a teenager reading a book about a medical missionary who had moved with his wife to Nepal to serve as a missionary.  He served for years with his family.  He built a hospital.  That story had an impact that made me decide to also be an overseas medical missionary. The reporter had tears in her eyes as I was speaking.  We didn’t get done with clinic in time to go to Leogane.  That was a major disappointment for me.  I really want to get pictures of the Haitian countryside, especially the cane fields and banana plantations.  I also want to get photos of Haitians working and laughing and having a good time.  Emmanuel thinks we will have time tomorrow but I have my doubts. The Wednesday clinic is usually big and we have clubfoot clinic besides.  I have to leave for the airport at 1:30.

I used the time this evening to make a small desk for our room. Virtually everything we have here is on the floor or in suitcases on the floor.  I sawed an old door in half and used some scrap wood laying at the end of our hall to make legs.  I built a frame and attached it to the undersurface and securely attached the legs.  It took several hours of sawing, drilling, screwing and gluing before I was able to haul the finished product into our room.  It’s a bit crude but it doesn’t wobble and is quite sturdy.  It needs a paint job.  It will work for journaling.  I think Jeannie will be pleasantly surprised.

Feb 9
What an event-filled day this has been.  Emmanuel arranged for us to go to Leogane this morning.  The father of our patient Stephanie Brice (bilateral TSFs) is very appreciative for the surgery that we did on his daughter.  He offered to take us in his vehicle.  Jean Joel came along.  His family on his father’s side all are from Leogane. The traffic was extremely heavy getting through Carrefour but once on the highway, we moved right along.  We had to slow down to nearly a stop in several places due to irregularities in the paved road.  The epicenter of the earthquake was in Leogane and the road suffered badly in spots.   There was at least one more than 12 inch dropoff in one place.  When we got to Leogane, it looked a lot like many other Haitian towns with one story buildings.  Not much quake damage was apparent.  I found out later that all of the big buildings had pretty much been turned to piles of rubble by the force of the quake.

JJ directed us down some side streets and then we stopped along side the road by a long open sided building with a tin roof.  Large piles of sugarcane surrounded the building.  Machinery under the roof was making  a loud noise.  About a dozen men and boys were at work processing sugar cane.  The end product was pure alcohol.  The pictures I was able to get with Emmanuel’s and JJ’s help are incredible.  Most of the younger workers didn’t want their pictures taken.  Some would just turn their bodies and continue with their work.  Others would laugh and pull their shirts over their heads.  One older gentleman paid strict attention to his job of feeding the cane into the processing machine.  He appeared oblivious to the dozens of photos I took of him.  He was wearing a straw hat and has a face filled with character.  If his face appears in the book we are making, I will make another trip to Leogane and personally present him with a copy of the book.  The machinery was very basic with lots of fast moving belts and wheels.  It looked like a fairly dangerous place to work.  I am sure that OSHA would have a field day meeting out fines there.  The far end of the building contained the furnace for distilling the alcohol. The whole scene was totally captivating for me. 
200 proof alcohol after the cane had been used to make molasses
One of JJ’s cousins came over and I was able to meet her.  I got a great picture of them hugging with huge smiles. I can hardly believe my good fortune.  There were large fields of sugar cane in the background and lots of banana plants as well.  Shortly after getting back in the car for the urgent return to the hospital, my phone rang.  MSF Holland had a patient with  fresh injury of his leg and arm and wanted to transfer him to HAH.  I told them to go ahead.  They thought he had a fractured femur.  Ken Graf loves femur fractures.

On our way back to the hospital, we passed close by the sea.  We stopped and once again I was able to get some great photos of Haitians enjoying life.  There were large black cooking pots filled with small conchs over open fires.  There were piles of thousands of small orange conch shells piled on the shore.  Vendors came to offer small plastic cups filled with cooked “lambi.”  I treated Emmanuel, JJ and our driver to the delicacy.  Each cupful comes with a generous splashing of hot sauce.  The three seemed to thoroughly enjoy their mouthwatering treats.  For the price of $3 a cup, I was able to obtain priceless photos of the three Haitians laughing and smiling and savoring a favorite local treat.  Both JJ and Emmanuel purchased a plate of “bananfrit.”  This is a combo of mashed bananas made into 2” disks and fried along with “piclise”, a spicy mixture of shredded cabbage, carrots, onions, cooked potatoes and beets.  The bananfrit is then topped with some type of protein usually of animal origin.  It could be chicken, beef, pork or fish.  This appetizing local preparation again provided the material for some good photos.  Being basically vegan, I wonder how it would go down with tofu.

There was a hall full of patients waiting(a few not so patiently) when I dashed back into the hospital.  The patients with the TSFs that we did last week were there to be checked and to start on their corrective programs.  I printed the prescriptions off the web and we gave them their instructions.  Two will need strut changes while I am gone so that information was given to Jacque to pass on to his son, Kinzey.  He is a remarkable young man who is very quick to catch on to some very complex concepts.  I was able to see all of the patients and write the corresponding clinic notes as well as evaluate the patient sent form MSF Holland with a comminuted distal femur fracture and ipsilateral wrist fracture (same side of the body- left leg and left wrist or right leg and right wrist).

The trip to the airport was uneventful and to my surprise, there was no line.  There wasn’t a single person in front of me as I went through security, checked in and got my boarding passes and went through customs and passport control.  That gave me more than 2 hours to sort through some of the amazing pictures I had gotten at the sugar cane mill and at the beach.  I am really excited that these pictures will really help portray a true picture of Haitian life, work, food and fun.

The flights to Chicago through Fort Lauderdale were also without incident.  The zero degree F temperature in Chicago certainly got my attention.  An 85 degree differential in a few hours can stress the systems of even a relatively hardy person.   The rest of the trip the next day to Appleton went smoothly.  Jeannie got in a few hours later.  It’s really good to be back together with her.  She had several good days with her mother and I’m glad.  I wish I could have had the time to be with her.  Tomorrow I go back to work with ThedaCare for 11 days.  This will be my first of 5 trips back to cover call for my partners.  Each trip involves 11 days of work.  I have a strategy meeting tomorrow with leadership.  I imagine we will be discussing the schedule I’ll have during my time here as well as get started on brainstorming on the plans for my return on November 14.  I am sure they will be looking for reassurance that I will not be having second thoughts about staying longer in Haiti.  I also have ER call this weekend.

Wednesday, February 9, 2011

The Vitale team, a Vital team!

Feb 3

Today started with a fair amount of uncertainty.  The government had said that the announcement regarding the results of the election would be made yesterday.  That didn’t happen but there was unrest in the streets anyway.  Apparently a couple of policemen were killed and others injured.  The CBM therapists didn’t come in and that usually means that there is too much potential for disorder in the streets.  There was a 26 week old newborn in the nursery that the anesthesia crew were trying to intubate so our surgery lineup was a bit delayed.  Charlie was hot to do a shoulder scope so he proceeded with that.  It went well and he got great visualization with Mark’s help.  It may have been the first ever to be done here.  Aldo sacrificed himself to do the clinic while I did the other leg of the big girl with the bilateral (bilateral meanign both sides/legs) Blounts.  Mike did the worst side 3 days ago.  Jean Joel (JJ--Haitian man training as an Orthopedic assistant) scrubbed and passed instruments.  It helped him a lot to get better acquainted with the procedure. 
Connie reorganizing the nonorthopedic OR supplies
It was the first TSF that I have done by myself without having Scott in the country.  Putting on the frame and doing the tib-fib osteotomies was pretty straightforward.  I got the post-op x-rays while JJ filled the TSF trays and cleaned up the instruments.  I made the measurements and entered all of the data on the TSF website.  Now we will have to wait a few weeks to see the results.  If her deformity is twice as bad when she finishes the treatment, we will know that I got it all backwards.  Seriously, I’ll send the info to Mike for him to verify everything.  I am pretty confident that it is ok.  It is a pretty intimidating process for someone without formal training.  I consider myself to be pretty lucky to be in this place and be able to learn all of this cool stuff from these outstanding orthopedic specialists.

Aldo finally got to do his case this afternoon with Mark.  It was another earthquake case.  The guy had an ununited fracture of the base of the femoral neck.  He had initially been treated with pinning with several “old school” Knowles pins.  Two of the pins had already been removed.  Mark and Aldo found the fracture quite displaced.  After cleaning out the scar tissue and reducing the fracture, they fixed it
The 3 Vitales Michael, Mark, & Aldo
with an Omega 3 hip compression screw.  It looks very good on the post op films.  We are again reminded of the generosity of Stryker in sending this very useful equipment and implants here with the Vitale team.  Our DHS implant inventory is greatly depleted with only very short and very long compression screws remaining.  The Omega 3 was perfect for the occasion.  I hope we can establish a good system with Stryker to resupply the used sizes.  My thanks again to Stryker for this generous and very helpful donation.

Charlie and I finished up the day in the OR with bilateral clubfoot corrections in a severe arthrogrypotic.  Charlie assisted me on the first foot then I assisted him on the other side.  He did a very nice job.  He is a confident skilled surgeon. The surgery is a bit controversial because it is largely cosmetic.  These kids have virtually only fibrous scar tissue in their legs and are commonly unable to stand or walk.  Their feet are very rigidly deformed and the mothers are unable to get shoes on the kids feet.  Should we be spending valuable time and resources doing procedures on kids that won’t help them to walk or even stand?  Scott and I agree that doing the correction gives the mother of the child a much better image of her child and that makes it worth it.

During the day we got the word that the government had announced that the top two vote getters in the first round were the two who everyone thought had honestly won.  These were the same two that the OAS had determined to be the winners.  The current president’s hand-picked candidate is out.  There seemed to be virtually no street unrest that followed the announcement.  Now there will be the final election sometime in the next few weeks.  No one seems to think that there will be any violence from now on.

Feb 4
This was our last work day with the Vitale team.  Mark and I did an exchange SIGN nailing of a femoral nonunion.  The case went well.  Extracting the rod took a while.  The distal end was covered with a fair amount of scar tissue and bone.  Once the rod was out, the reaming and reinsertion of a larger diameter nail proceeded uneventfully.  It has been great for both of these orthopedic residents to be able to do these cases and become acquainted with the SIGN nail.  It is being used so extensively throughout the world that all orthopedists should have a working knowledge of it.  Lew Zirkle has made a tremendous contribution to orthopedics and mankind with this device.  There is a worldwide epidemic of femoral fractures especially in developing countries. 
Preparing the SIGN nail for implant
The tremendous increase in the use of small motorbikes as the principal means of transportation for the poor has fueled this huge increase in lower extremity long bone trauma. Prior to Lew, the 3rd world was left behind in the treatment of these fractures because of the cost of the high tech fixation devices and the need for very expensive xray technology as part of the procedure.  His elegant yet simple solution now has made a high quality locking intramedullary rod affordable.  It has eliminated the need for the costly C-arm fluoroscope also.  If this device were to be used in hospitals in the US instead of those that are currently in use, millions of dollars would be saved.

Aldo again took care of the clinic while Charlie
Kame, Connie, and Nitin- anesthesia providers
took out some hardware in the other room.  Having two anesthesia providers makes such a huge difference when we have more than two orthopedists here.  We can be so much more productive.  Ben is a great anesthesiologist and is fluent in French as well.  What a combination!  I had thought it couldn’t get any better when we had Kwame and Nitin and Connie giving anesthesia last week.  This week we have one less anesthesia provider but the language skills of both Ben and Jan have really helped a lot.  Jan is Haitian-American.  She wanted to come after the earthquake but was pregnant and about to deliver.  She left her ten month old to come and be with the Vitale team.  She came on Tuesday and saw her father for the first time in 6 years.  Of course, she is fluent in Creole.  The composition of this team these two weeks couldn’t have been planned any better.

Brittany, Lab Technician giving hope of a strong lab soon
Having Tom Lyon the first week really set the tone.  His evaluations of these complex trauma cases, many of them earthquake victims with history of infections, was always done carefully and thoughtfully.  His well planned operations always went well even when unexpected situations were encountered.  My comfort level with these cases has been upgraded significantly.  I was able to do the second case today with Charlie with much more confidence, not to say that I didn’t still have some second thoughts.  This patient was also a victim of January 12.  She was taken to Santo Domingo and received her surgical care for her fractured femur there.  Unfortunately, she developed a post operative infection and has had nine subsequent operations.
 Tom doing a very tough case on an earthquake patient.
How I wished Tom could have been here (my confidence level had slipped a bit as the time came to make the incision.)   By following Tom’s example, the case went well.  We were able to debride the dead bone and extensive scar tissue mobilize and ream the bone fragments, harvest bone graft and prepare the antibiotic coated SIGN nail and a chain of antibiotic beads.  Inserting and fixing the nail was the easiest part.  The more than 4 hours passed quickly.  Thankfully, the blood loss wasn’t overt and transfusion wasn’t necessary.  I felt a bit of fatigue when it was over but Charlie continued to play the part of the energizer bunny.  I think I have finally found my match for energy level.

While we were occupied, Aldo and Mark did a couple of cases including a diagnostic knee arthroscopy/MRI.  This has been an incredible two weeks for all of us.  The new friendships forged, new things learned and new opportunities explored have helped all of us become better human beings.  Sharing this time together in service to people who have so much less than us has given us a much deeper appreciation for how privileged we really are.  I want to hold this Vitale team up as the prototype for future teams.   Mark was the driving force that put things together.

Mark, Terry, Charlie, Micheal, & Aldo
Aldo’s desire to make it happen and relationships with Tom, the anesthesia providers and orthopedic assistants, gave the team the necessary expertise and horsepower.  Fritze, Sammy and Allen are hardworking Haitian Americans who have a deep love for the people of Haiti.  Their work in the operating rooms and clinics was a big part of the success during these two weeks.  It helped Jeannie hugely.  They also contributed in another very important way.  They spent a lot of time with both Jean Joel and Jeanty training them to set up rooms and pass instruments and anticipate the needs of the surgical team.  That teaching will be invaluable for them and all of us in the future.  I cannot say enough about Mike and the 3 days he contributed to this work here. My understanding of how to manage the children’s orthopedic needs here has been
Bidding Aldo goodbye
significantly upgraded. Those who have an interest in making a difference in peoples lives can follow their example.  I am sorry that they will all be leaving tomorrow.  They all have families and/or responsibilities that call.  It will undoubtedly be impossible to put that exact same team together again.
Tom camping out at HAH in the volunteer quarters

Saturday, February 5, 2011

Quake Injuries and Orthopedic Needs Abound a Year Later Part I

Jan 29
Today was an unusual Sabbath.  It tuned out to be very restful.  Denise is a volunteer psychologist here at HAH.  She had arranged for a bus to take those who wanted to a beach resort for the day.  Jeannie and I had not been away from the hospital together since we arrived in November except for the once a week jaunt to the mini-market just down the street.  We decided to go and leave the Vitale team to cover the hospital.  We were told it was a 1 ½ hour trip to the north of Port au Prince.  The bus was old and creaky and lacked shock absorbers.  The potholed filled roads meant that we crept down through and then out of town at a snails pace.  We went through a couple of small towns on the way that looked like they might be interesting to explore.  As we got closer, the road improved and we could go a bit faster.  It took us more than 2 ½ hours to get there.  It is called Wahoo Bay Beach Resort.  They charge $10 per day for day visitors.  The beach is white sand.  It is quite narrow and extends perhaps 200 yards in length.  The have a fairly large fresh water pool and a restaurant.  After worship we relaxed in the shade and cooled off in the water and read and slept.  It was very peaceful except for the two watercraft that would occasionally buzz by in search of customers to take for rides.  A fisherman in a very colorful boat came by and we got some pictures.  There were some interesting looking old fashioned sailboats off in the distance that never got close enough to inspect or photograph.  The trip back home took even longer because of having to divert around an area that was having some demonstrations.  Jeannie and I enjoyed the day away from the hospital and got to see a new part of Haiti.  I hope some of the pictures I took will be useful for the coffee table book.  Nothing of consequence happened at the hospital in my absence serving to point out that we are commonly much less important than we think we are.  Tomorrow Scott will be coming on the private jet from California along with the owner and some other people that are interested in what is happening here at HAH.  Dick Hart is also coming as well as Jerry Daly.  There will be a hospital board meeting and there are high hopes that decisions will be made that can put in action some important pending projects.

Jan 30
Tom Lyon leaves today.  He has been a huge part of a very effective Vitale team.  His
The ortho team resuscitating a premie.
expertise in
managing these complex earthquake related trauma cases is exactly what I have needed to learn how to better manage these difficult reconstructions.  I just wish he could stay a couple of months so we could really make a dent in the number of patients that still remain with infections and deformities still more than a year later.  He did promise me he would come back this year.  I look forward to that.  He also is planning to do as much as he can to help get a trauma rotation set up here for teaching.  It might even involve a trauma fellow some of the time.  All three of the Vitale team’s anesthesia providers leave this weekend.  They have all been great.  They are careful in their patient evaluations and commonly will pick up on aspects of our patients that we might have overlooked.  Connie isn’t as talkative, but I have enjoyed getting to know both Nitin and Kwame during times of lesser intensity in the OR.  Nitin’s experience getting called to give anesthesia for the birth of the premie made a significant impact on him.

After rounds, I spent quite a bit of time journaling and emailing waiting for Scott and the group as well as Michael Vitale.  He is Aldo’s son and is a very well known pediatric orthopedist.  He is a professor of orthopedics at Columbia Presbyterian where Mark and Charlie are doing their residencies.  They all made it in just fine.  Scott says the Gulfstream 550 is definitely the way to travel.  Besides the two pilots, it carries 15 passengers in comfort.  It has a range of about 8000 miles.

Scott brought several bags of our things that we had left in Loma Linda at Christmastime.  Summer and Tim had urgently sent Scott a box with homemade jam and canned fruit to bring to us.  They are so thoughtful.  Scott also presented me with a very generous donation to help with the purchase of a tap-tap so Jeannie and I will have some local transportation.  There are so many things to be thankful for.  Our excursion to the beach in that falling apart bus was an adventure that I don’t want to repeat.  Having our own wheels will make it possible to get around more quickly and reliably.

I had arranged a pediatric clinic with Scott and Tom so we went right to work.  Scott wanted to try to have an orthopedic surgical case to demonstrate the orthopedic capabilities of HAH.  We had a straightforward case of a fractured patella that worked well for the purpose.  Charlie and Mark did a very nice job as the visitors observed.  It also gave us an opportunity to talk with them a bit about the more complex cases that we do fairly routinely here including the Taylor Spatial Frame.

Scott started right in on the calibration of the C-arm.  He had finally succeeded in acquiring the service disk.  It took several hours and there were some tense times.  After trying to do a simple calibration following the steps given by the service disk, no progress was made.  We tried tightening the mounting screws on the collimator and to our dismay, the C-arm would not work at all.  Scott decided to call the GE rep in Salt Lake City for help.  It took 42 minutes of a very helpful GE specialist giving us the instructions of how to check the resistance across the potentiometer and set it properly before it began working again.  He then helped to calibrate it and it now works like new.  There is no need to keep it set on Mag 1 to keep it from giving us error messages.  Strong kudos are due General Electric for having a specialist willing to spend Sunday afternoon/evening trying to help people thousands of miles away solve a difficult problem.  We finished by 10 pm and then went to the Auberge du Quebec (hotel) to meet with the group that was eating dinner.  Most everyone was gone to their rooms but there was lots of excellent pizza left that Scott and I wolfed down.  The hospital board chairman,  Elie Honore waited up to talk with us so Scott and I stayed and talked with him until midnight.  There are a lot of concerns among hospital leadership about the orthopedic work at HAH.  There is a strong desire to have the hospital continue to be well known for orthopedics and be able to attract patients from throughout the country.  Elie definitely wants all patients to be charged at least a minimum amount so that they can participate somewhat in their care.  My concern is that the truly indigent that are the most needy will not even come for evaluations if they know the hospital will be charging them.  Another issue is leadership’s desire to have Haitian orthopedic surgeons involved here.  Medishare’s situation after going that direction has not been very good.   We discussed that at length as well.  Finding a replacement for me in November is their biggest concern.  They are fearful of starting any programs that will not be sustainable if no one can be found for this position.  God’s hand has certainly been leading this effort to this point and I am confident that He will continue to provide answers to these challenging situations.  We just have to be willing to be used by Him as we continue to use our judgment from day to day.

Jan 31
Unfortunately, Scott had to leave very early this morning.  The airport was going to be closed starting at 11 am d/t Hilary Clinton’s scheduled departure later in the day.  It was disappointing to not be able to do the planned case with Scott.  We reorganized the schedule and started the cases planned with Mike Vitale.  He certainly is a confident, skilled surgeon.  Our OR capability is not nearly as great now that we only have one anesthesia provider.  The first three left over the weekend and Ben is by himself until tomorrow afternoon when Jan is supposed to arrive.  Mike started off with a foot case and I stayed in the clinic.  The second case was a large girl with severe Blounts disease.  It involved an elevation of the medial tibial plateau and bone graft as well as tibial epiphysiodesis, placement of TSF and tib/fib osteotomy.  The case went very well.  Mike is very good at getting everyone involved with the case.  The C-arm worked very well.

Feb 1
We again concentrated on our pediatric cases since this is the last full day we have Mike.  We had another case of severe Blount’s disease.  Mike had done two of these requiring elevation of the medial tibial plateau in the last 10 years and now has done two of them in two days. He is amazed at the pathology that we see here.  Our C4 quadriplegic patient died very suddenly today.  He had been recovering very well from the sacral pressure sore drainage.  The CBM therapists were working with him when he suddenly became very short of breath and died.  It was probably a pulmonary embolism.  Mike also did a posteromedial clubfoot release and a third case of lateral transfer of Anterior tibial tendon and calcaneal osteotomy (heal bone realignment).  We didn’t finish until 9 pm.  Charlie wanted to take Mike and the team to the Auberge for dinner since it was Mike’s last day.  We begged off due to the lateness of the hour.  We are hoping to get in another case or two with Mike tomorrow before he has to leave.

I tested the new suction set up that Randy had set up.  Scott brought down a big ShopVac which we hope will work for the OR.  The idea is to install it in the shop under the OR and run tubing into the OR which we can connect a standard suction canister to.  The noise of the suction will not be a problem(at least not for us) and it might give us good suction without costing an arm and a leg.  Randy set up the test in the hall outside our room with two sections of 2” tubing each f which was 40 feet long.  The suction from both long 2” tubes was very good even when they were sucking at the same time.  Now he and Samuel need to drill some holes and install them in ORs #1 and 2.  The whole idea was Scotts’s.

I had a very pointed discussion with Nathan and Madame Clotaire today about micromanaging the size of the volunteer orthopedic surgical teams.  I get the sense that hospital administration is becoming less and less willing to have so many free orthopedic cases done.  I have a hard time accepting the gradual progressive limitation of care to the indigent, especially when so many generous surgeons, anesthesia providers and their support staff are willing to pay their own way here and work for no pay in order for these indigent people to get their orthopedic care for the first time in their lives.  I am very much in favor of the hospital having a sound financial picture.  I would like for that to happen at the same time as we continue to provide care for those who cannot pay.

Feb 2
We had a third case of severe Blounts today to do with Mike.  It’s pretty incredible for a pediatric orthopedic surgeon like Mike with world class experience to come here and have 3 cases of medial tibial plateau elevation and tib-fib osteotomy with Taylor Spatial frames in under 72 hours, given that he had only had 2 in the last 10 years.  It again highlights the amount of orthopedic pathology that has been neglected or at least markedly undertreated here for decades.  We finished the case at noon.  Even though he was under the gun to get to the airport to catch a flight back to New York, Mike took the time to carefully go through the next step with all of the three patients that we had done to measure their TSF mounting parameters and deformities and then enter all of the data on the Spatial frame website.  That time that he took was invaluable for me.  I want to be as helpful as possible with these types of cases that are outside of my skill set so that these subspecialists who so generously donate their skills and time will feel that their efforts are not wasted.  I want these patients to have the same probability of an excellent result as if their surgery had been done at Columbia Presbyterian or any other center of excellence in the US.

These two Vitale children would probably only have come here and done this type of work as a result of great parenting. Aldo is to be commended for being the type of caring role model and setting the example of unselfish willingness to reach out to people in need.  It has been a wonderful opportunity for me to be able to work with Aldo and Mark and to assist Michael and learn from him.  It has been
The Vitale team with Terry and Jeannie
equally a joy for Jeannie and me to develop a friendship with Aldo and his family. Our lives are already richer for having them as our friends.  Aldo and I have already made tentative plans to spend the first week of September next year in Sicily.  Jeannie and I love to travel especially in Italy.  This will be a dream come true for us to be able to enjoy time with such quality friends and get even more acquainted with a part of Italy that we haven’t been to before.  I also asked Aldo what was the name of his favorite restaurant in New York City.   Without hesitation he answered, “my daughter’s kitchen.”  I told him the next time Jeannie and I are in NYC we are going to make a reservation.

I was called at about 11 pm to see a patient in the ER with a shoulder injury.  He had a terrible quality xray but I could tell it was dislocated.  I got some morphine, Fentanyl and Valium and went to work.  I was too impatient to wait for the ER nurse to start the IV so I tried it.  I had just hit the vein with the needle when there was a loud clap of thunder, heavy rain started and the lights went out.  Needless to say, the vein was blown when the lights came back on about 10 minutes later.  The nurse then walked in and boldly nailed the vein on the first try.  Talk about insult added to injury.  I titrated the cocktail and when he was snoring reduced the dislocation easily.