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

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