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.

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