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.

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