Sunday, May 29, 2011

Patients & Needs Continue to Abound

May 11
Wed clinic went until after 7 pm.  I saw 12 new peds patients with operative conditions and put them on Herzenberg's schedule.  I sent John 2 emails with pictures of patients and xrays.  His response to the first email was "yikes."  To the second email was "double yikes."  The attached hand xray is of a 12 y/o boy with an "earthquake" injury.  The most impressive cases were an entire family with severe genu valgum.  The mother has combined 75 degrees valgus.  The 14 y/o daughter has combined 115 Degrees and the 13y/o daughter has combined 125 degrees.  They walk with marked hip flexion presumably to take some of the stress off the ankles looking rather like crabs.  Pat did the patient with the tibial plateau malunion.  It wound up looking really good on the C-arm.  That will be a real win for the patient.  He is a mason and really wants to return to work.

May 12

We had twelve cases scheduled.  Several were smaller cases of post op cast changes and manipulations and debridements.   We started the first two at 7 am and finished the last one at 9 pm.   Pat did an arthrodesis of Subtalar and talonavicular joints and was very pleased how it went.   Together we did a case of chronic osteomyelitis in a femur fracture.  It is a case that the Yoon team had cared for when they were here in November last year.  We found at least two sequestrums and did an exchanged antibiotic SIGN nail rodding.  We have been able to get quite a few cases done that have been pending.  The Yoon team is really great to work with.

May 13

The Yoon team went to an orphanage today.  It is the same one they went to the last time they were here. Jeannie said they all had a great time interacting with the kids. 

Today I did the clinic by myself and saw two more good patients for the JH team.  One is a 6 y/o with bilateral tibial hemimelia (the shin bone, or tibia, doesn't form properly and in some cases can be mostly missing).  She scoots around in the sitting position.  I offered her surgery to allow her to stand and walk and be as tall as her friends and she is eager.  Bilateral AKAs (above knee amputations) and prostheses will make her a happy girl.  A five y/o with untreated clubfoot also came in.  A displaced femoral neck fracture, nasty diabetic foot and 3 day old unstable pelvic fracture all came in within 2 hrs yesterday.  The coming week with no one to help me and only spotty local anesthesia help will present some challenges.

Maxi is a man who was transferred here from 8 hours away with a fractured hip and femur on one side and an open fractured tibia on the other side.  The transfer occurred two months after his injury.  This fractured tibia was still exposed with open dead looking bone.  I stabilized everything and fixed his hip and femur shortly after he arrived a couple of weeks ago. The tibia has been the big challenge.  I had asked Pat specifically to help me with this patient.  Pat does soft tissue flaps to cover exposed bone.  We decided to shorten his tibia to eliminate the dead bone then Pat did a nice fascial-cutaneous flap from anterolateral.  We put STSG (split thickness skin graft) on the donor site.  I learned something good from Pat on that case that might be of help here in the future with these open fractures.  I certainly hope and pray that this will allow him to heal.  A nice bone transport could eventually restore his length.  I did the BK (below knee amputation) on the diabetic who came in yesterday and finished about 11 pm.  Two 12 hour days, two 14 hours days and one 16 hour day made for a tiring week.  I plan to put in a femoral traction pin to bring down the hemipelvis on the guy with the S-I (sacro-iliac-- where the spine meets the pelvis in the lower back) dislocation.  He also has a wide symphisis fracture- separation.  The superior ramus is quite comminuted so I won't be able to do an ORIF.  My game plan is to put perc cannulated scres across the S-I joint if I can reduce it closed supine then pelvic exfix for the symphysis.  If not, then open red and cannulated screws of S-I prone.  Then second stage exfix supine for the symphysis.  It will depend on the availability of blood too.  I sure wish I had some more help these next two weeks to help with the work load and especially the challenging cases.

We have a big problem with our large cannulated screw set.  Our current set is a mixture of screws that require three different cannulated screwdrivers.  We are looking into the possibility of using screws and other orthopedic implants from a company in India. If the quality of the product from the company in India is good, we could get a full set with 20 or 30 backup replacement screws of every size.  That would give us inventory for a couple of years before needing to restock.  At ten cents on the dollar compared to Synthes, the price is certainly right if the quality is there.  They also have a proximal femoral nail system that bears looking into.  We could flesh out our implant options and at the same time solve our resupply issues for our entire implant inventory.  That would be an invaluable contribution to this program.

Now the energy saga!  Randy and Sammy changed out the radiator last Sunday and were unable to restart the generator.  That left us with one smaller unit with its own overheating problems.  Haiti Power gave us more than usual during the week which helped, but the remaining unit pooped out on Thursday-THREE dead generators!  Randy found a small generator to continue charging the batteries for the invertor so we could continue to work.  I did several arthroscopies with no AC and a SIGN nail exchange with lead apron and no AC.  You should have seen the sweat I wrung out of my scrubs after the case.  My little pocket notebook is still drying out.  Administration quickly made arrangements for a rental deisel generator that came Thursday late afternoon.  It took Randy and Sammy all day yesterday to get it hooked up.  It runs 24/7 and purrs like a kitten.  It makes hardly any exhaust.  It is a Caterpillar.  Randy told me they can be bought brand new for 34k.  How I wish I had a couple of hundred k just sitting around looking for a good use.  The plan is to put a strong effort into getting our generators repaired and working.  The rental costs $200 daily.

May 14

The Yoon team left today.  It has been great to work with them.  They are hardworking and very good at what they do.  I appreciate so much their dedication to this project and the people of Haiti.   Pat told me they are planning to come down again in September.  Tom Slater has a knee that bothers him a lot.  He has advanced medial compartment DJD.  He had an ACL reconstruction nearly 20 years ago.  I talked to him about my experience with Oxford unicompartmental replacements in patients without a normal ACL.  He is very interested.  I didn't give him encouragement, only told him of the options.  I think it is a reasonable procedure in a person his age with a normal lateral compartment.  I emphasized that there are no long term studies to give us statistics on the likelihood of long term good results ij knees like his.  I also encouraged him to make an appointment with Dr Keith Behrend in Ohio and discuss it with him. 

I made rounds and everyone seems to be doing reasonably well.  I had hoped to put in the femoral traction pin on the patient with the pelvic fracture but there were no translators here today.  I'll do it tomorrow.  I got a lot of rest today and am thankful for that.  I am so thankful for the Sabbath.

Thursday, May 26, 2011

A Daytrip to Jacmel

May 8

I was up early and bid Ed farewell at 5:30.  It has been a pleasure working with him again after so many years.  He and I think alike about so many things.  His interest in the work here seems genuine.  I look forward to more time together.  His brother, Gordon, is an ophthalmologist who has had a major project in Mexico for many years.  He has already contacted HAH and is interested in helping develop a high quality eye surgery program here. 

Dr Yoon has an excellent team.  The first time he came last summer, he didn't have any anesthesia providers and was unable to do very much surgery.  He now has 3 providers and is loaded for bear.  He is subspecialty trained in foot and ankle.  He works in Minneapolis and does a lot of trauma.  He has an OR nurse, a 4th year med student and two ortho scrub techs. 

We had three small cases today.  We had an outing to Jacmel planned so we started before 7 am in the OR.  We were finished by 9:30 and took off in two pickups for the Blue Pools near Jacmel.  It took 3 hours of largely curving mountainous roads.  We discovered that the river was too high to cross to get to the pools.  We changed to plan B and went to a beach.  The water was warm and most enjoyed swimming and playing in the surf.  Several beachfront bars had music playing.  A live "rara" band came on their bus and cranked it up.  I was glad for the opportunity to see and hear it.  They have the "konets" which each play one different note, drums and cymbals. Manuel went with us and we enjoyed a walk together to a quieter part of the beach where we ate our lunch and enjoyed several little kids who shyly accepted our tootsie roll pops.  One of our group brought a watermelon and we all enjoyed several pieces.   It was very sweet.  We stopped and bought fresh fruit at a community fruit stand on the way home.  It was fun to see another part of Haiti.  It was very cool in the mountainous section.  We drove through clouds some of the way and some got a little chilly.

May 9

Pat and I dove into the clinic after rounds.  We worked steadily and were able to finish reasonably early.  We had some smaller surgical cases and got them all done by early evening.  There are a lot of cases scheduled for tomorrow.  We plan to start as early as possible.

 The proofs that Tim sent for Brian to bring from Orlando came this afternoon.  They are absolutely spectacular!  As good as they looked on the computer, they are 'over-the-top' impressive in full size and brilliant color.  The quality of the printing is remarkable.  Once again, i take my hat off to all who have put so much energy and time into this project.  Tim and Dave have, in a few short months, produced an exceptional piece of work.  Tim's father, Steve Gerke, has been instrumental in getting the best possible prices from the printer.  I can hardly wait to hold the finished book in my hands.  I pray that God will continue to bless this project.  The national media exposure that could make it possible to raise funds in amounts much greater than we had originally proposed is the next element.  There are so many areas that, if properly funded, could help insure the ongoing capability to provide high quality orthopedic care to the indigents in this country.  Helping the hospital laboratory develop a blood bank and microbiology capability would improve our patient care tremendously.  An orthopedic formulary for our pharmacy would be hugely beneficial.  Satisfactory housing for patients who live long distances away could be funded.  The volunteers could at last have satisfactory accommodations.  We could help procure clinic and hospital supplies.  Our large cannulated screw set could be standardized and reserve screws of all sizes kept in storage.  The list goes on and to some might even seem endless.  This is God's work and I have a strong belief that it will work out in His time frame.

May 10

Our surgery day didn't quite go as planned.  We were about to get a second case started when I was notified that a bleeding patient in the ER needed emergency surgery.  That hasn't happened too often here but there is not much to do when it does happen besides suck it up and wait it out.  We had some good cases.  Pat helped me with a postero-medial clubfoot release that went well.  The child for TAL/post release cancelled d/t an upper respiratory infection.   The patient for ORIF malunion medial tibial plateu had to be postponed until tomorrow d/t HBP.  We wound up operating until about 8 pm.  A C-section also came in that slowed us down some.  Pat did an ankle fusion and had problems with our mismatched 6.5 cannulated screws and screwdrivers.  I am hopeful we will be able to get a replacement set from the company in India.  I have been told that an American Orthopod has used their implants a lot and finds them to be of high quality.  Ed Miller has started the process to test the screws.  We might be able to get more sets of implants such as a proximal femoral nail set if their quality is good.  The cost will be about 10% of the full Synthes price.  It also might solve our implant resupply issues.  We finished the day with an ORIF of a distal radius fracture.  It turned out to be more comminuted and intraarticular than anticipated.  I struggled and was unable to get a satisfactory reduction.  Fortunately, Pat still had some energy and he scrubbed in and made it look pretty easy.  It wound up looking very good with good fixation.  I wish I could have Pat or someone with his skills here much more often.

Tuesday, May 24, 2011

A Chance Encounter to Spread Word about HAH!

May 5

The surgery schedule was overbooked today and not by choice.  Dr Spendey gave us the go ahead to do the amputation on the man with the completely avascular, foul smelling foot.  The elective cases included hardware removal, clubfoot surgery, wound vac changes/debridements, removal of a wrist mass and extensive quadricepsplasty.    Ed and I with the whole team working aggressively were able to get all of the cases done by late in the evening.  Unfortunately, at 5 pm the powerhouse people notified us that they would be turning off the power immediately.  No amount of reason prevailed.  In spite of Madame Clotaire being notified of the situation, the power went off.  The cases that had already been prepared for me proceeded.  By the time I finished, my scrubs were totally soaked with sweat.  I hope and pray that the wound will not get infected.  The power returned after the case was over.  Fortunately, it stayed on for the quadricepsplasty which took over two hours.  Another 15 hour work day left all of us  ready to get some well deserved rest.

May 6

It turned into a light day today.  Ed started in the OR with a couple of smaller cases while I did the clinic.  Our big cases cancelled.  It was a real disappointment for both Ed and me.  It was the bilateral Blounts for  TSFs.   We were both looking forward to that case as the highlight of the week because of Ed's special interest in external fixators.  The patient decided to wait until next month so she wouldn't have to miss any school.  I hope Ed can come back and do the case with me then.

Ed has really caught the vision of what is happening here at HAH and what the future can hold especially if we can effectively establish strong networks and partnerships.  He told me of an exciting idea.  He is good friends with Dr David Moorhead who is  involved in a high leadership position at Florida Hospital.  They have a children's hospital together with Disney and are intent on attracting patients from around the world.  The advanced orthopedics that is done here especially with children is an area that could be very beneficial for their program.  He is planning to approach Dr Moorhead with the idea of a relationship that could be mutually beneficial.  Having a sister institution with the Disney name attached could be very helpful for HAH.  He is planning to invite Dr Moorhead to join him here at HAH for a site visit.  What is being done here on an everyday basis has to be seen to be believed. 

I also had a chance encounter with Dr Archer in the hall yesterday.  He asked about the coffee table book and if he could still make a contribution.  I told him I was sorry but that the book had just gone to the printer and it was too late by a couple of days.  Since he is quite politically connected, it occurred to me to ask if he had any relationship with the president elect.  He said that he does and would be meeting with Mr Martelly that very evening.  I asked if there was any chance that he might be able to inform Mr Martelly of the remarkable things that are being done here at HAH.  His awareness of the excellent work being done here could help especially if he could give our fundraising efforts more exposure especially in the national media in the US.  Dr Archer said he would talk to the president about that.  It would be wonderful if the book could get exposure on a program like Oprah.  I can only dream.  I asked Tim to send me some proofs as well as the electronic version of the book so that we can use them to show anyone interested the high quality of the product.

May 7

The e-version of the coffee table book came early this morning.  I downloaded all four large files and looked at the first few.  It is outstanding.  I am sure it will be a big hit.  The layout and the images are really professional.

Ed and I needed to take the patient with the open tibial fracture back to the OR for a vac change.  We decided to skin graft the fairly large granulated area.  There is still bone exposed and left us with a challenge of how to get it covered.  Dr Pat Yoon will be able to help us deal with that problem.  He arrived today with his team from Minnesota.  He is a trauma orthopedist and has been here twice before.  We will take the patient back to the OR on Monday and reassess his status.

I spent a couple of hours after lunch today with a new acquaintance.  His name is Scott Thurmon.  He is an Adventist businessman who has recently had some major life threatening medical problems.  He has reassessed his priorities and now is putting his energies into a nonprofit that is directed to help Haitians.  His plan is to start an agricultural program as well as culinary institute in the Les Cayes area.  He also wants to have a medical facility of some type.  He apparently has a lot of resources backing his ideas.  I showed him the electronic version of the coffee table book and he really liked it.

For more information on the book, please visit the webpage.

Wednesday, May 18, 2011

The Reality of Haiti

April 29

Thanks to Dave giving anesthesia, we were able to do several cases today. I spent most of my time in clinic and we were able to finish with both clinic and surgery by mid afternoon.
Long time friends Ed Miller and Terry Dietrich
Michel's blood pressure is still high so we will wait for the antihypertensives to take effect. Hopefully we will be able to do him the first of next week. It has been really great having Phil and his team here as well as Shane. The unexpected anesthesia help was wonderful.

April 30

Shane and I made early rounds then Jeannie and I went to church. It was a very restful Sabbath. I finished reading the book THE HOLE IN OUR GOSPEL. It has really challenged me to rethink my entire decision making process and reassess my value system and priorities. It has also given me some good ideas about how to approach potential donors for our indigent patient program. Ed Miller arrived today. He is an orthopedist who lives in Northern California. He has been a good friend of mine since college days. We were orthopedic residents at the same time at LLU back in the 70's. Ed sent me the "hillbilly" traction that we can attach to our C-arm fluoro table. His wife, Nancy, was going to come down with him but had to go take care of her elderly mother who was recently hospitalized. Ed is a mechanical genius. He has a lot of interests including flying aerobatics. I'm looking forward to this week with him.

I learned something very interesting about the 12 y/o girl who was transferred here with the femur fracture a few days ago. Apparently she was in the employment of a Haitian man as a sex slave at the time she was injured. I had heard that this sort of thing goes on here in Haiti. If her family was responsible for her being in this situation, she won't be able to go back to them. It is hard for me to imagine that this can actually happen. The grave reality of Haiti for so many children is sobering.

May 1

Jake Ricks, anesthetist extraordinaire with his sister
Shane left early this morning. He has been a really big help this week. We have had a good time working together. He plans to come back in a few months. I hope he can bring a team. John Herzenberg just emailed me a good suggestion. He advertised in the national anesthesia website and got a bunch of responses and could only accept two. Jake Ricks, our expatriate anesthesia provider for this week came this afternoon. He is a young anesthetist from Maine. He is FLUENT in Creole! He was a missionary for his church for two years here in Haiti about 8 or 9 years ago. He brought his sister who is a recent college graduate. We had a case to do so we put him right to work. Michel's BP came down enough so Ed and I did his surgery this evening. It went well. We first positioned him prone to harvest the ICBG then turned him over to do the antero-lateral approach for the tibio-fibular synostosis. This was the first time Ed and I have been in the OR together in more than 35 years. We both really enjoyed doing the cases together. Jake is a very good anesthetist. He likes to do blocks and is smooth as can be. Obviously, his language skills add hugely. Another volunteer is Dr Matt Jenkins. He is a third year general surgery resident from Temple. He came at the recommendation of Dr Tony Coletta. It will be fun to have him here to work with and teach and share the work load.

May 2

Dr Miller fixed this with a hybrid ex-fix
A patient came in early this morning with an open fracture of his tibia (see photo to the left). Ed took him to the OR and I helped him get the case started before going to see patients in our very large monday clinic. The fracture was extremely comminuted but stopped short of the ankle joint. Ed set up the traction and put in a calcaneal traction pin. This was a very high energy injury. Many of the fracture fragments had no soft tissue attachments and were removed. Ed put on a hybrid external fixator after fixing the fibula and then put a wound vac on the open wound. The patient now has a significant bone defect. It may either require tibial shortening or bone transport. We finished with the big clinic by late afternoon and saw all of our patients. Roosevelt and I threw the football back and forth a bit after clinic. I admitted two patients for surgery tomorrow to add to our full schedule of elective cases. One is a diabetic with a foot ulcer that needs to be debrided. The second is a man with a dead foot. He must have lost his circulation a week or so ago. He will have to have at least a BK. I just had laid down and put my legs up when I was notified that there was a patient in the ER with a femur fracture. The patient had been injured playing soccer. He had a quite distal oblique fracture of the distal femur. He hadn't eaten so we took him to surgery and put in a SIGN nail. We didn't want to interfere with our big surgery schedule for tomorrow. I finally got to lay down again just before midnight and promptly fell asleep.

May 3

All of our elective patients came in this morning. I told them that we might not be able to do them all because of the urgent cases that had come in. Ed and I worked on the cases together and got them all done except for one. We will do that one tomorrow. Our long case was a bilateral clubfoot for posteromedial releases. I did one side with Ed helping me and then I helped him do the other side. It was fun working with him. He is a very good careful surgeon. We have also been having to deal with a problem related to our generators. The two generators are being alternated to avoid overheating. Our third generator blew up a few weeks ago from overheating and now precautions are being taken to avoid that happening to the other two. Unfortunately, the decision is being made to randomly rest the generators which means that the power goes off in the ORs unexpectedly. We have the inverter in two of the ORs which will run everything except the air-conditioning. If we are doing a big case, it becomes insufferably hot especially if the C-arm is being used and we are wearing lead aprons. Randy our electrician finally helped convince the people making the decisions that the generators could be used continuously by alternating them during the working day and letting them rest if necessary at night while we are sleeping. The powerhouse people were ordered by administration to not turn off the power while we were still working in the OR. They are to come and ask when we will be done so that they can plan how to rest the generators as necessary. I hope the administrative order is followed so that we can provide proper care to our patients.

We got more information about the 12 y/o girl with the femur fracture. Apparently the family has more children than the parents are able to care for. She was "given" to the other family to be cared for. No money apparently exchanged hands. Whether the family knew what was going on or not is not clear. A cousin of the girl's mother has been by her bedside almost continuously. She is willing to take the girl and care for her.

May 4

This may have been our biggest clinic ever. I worked steadily through the day with ZJ and Matt helping. Ed was busy with cases much of the day but was able to come to the clinic and help for a few cases in the mid afternoon. I had hoped to finish before 5 pm but finally finished taking care of the last patient well after 6 o'clock. It seemed like there were an inordinate number of patients who
Matt Jenkins a Temple general surgery resident with the Ricks, Ed Miller, and the Dietrichs
were earthquake casualties. We are still seeing malunions, nonunions, painful joints, stiff joints and infections.

A team led by Ernie Schwab is here from the School of Allied Health of Loma Linda University. They are exploring the possibility of settling up a formal degree program for areas of therapy. This presents a great opportunity to perhaps formalize our Ortho Tech training program. Ernie and I arranged to take his group and our orthopedic team to the Auberge for pizza. Several of our translators came with us. I fired up the 'tap-tap to be' pickup and the whole crowd of 13 jumped in or on and we bumped our way to the hotel. The fried plantains and pizza and peekleez were outstanding as usual. Ernie and I got acquainted and had a good talk about the teaching program and how it might be accredited. It was a delightful evening.

Saturday, May 14, 2011

Hillbilly Traction

April 24

I'm certainly glad to see Shane Williams.  He is a young orthopedic surgeon from southern California.  Unfortunately, the anesthesia provider that was going to come with him had to cancel at the last moment. 
Phil Hurley and his team, Shane Williams, Jeannie & Terry
Nathan has arranged for a local Haitian anesthesiologist to provide service for us on Tuesday and Thursday.  It is great to have an orthopedist to help with the work after the last two weeks by myself.  I have several elective cases scheduled.  One is a teenager with severe Blounts disease on one side.  We'll do a TSF with osteotomies.  Today was totally quiet and I got in some reading.  I finished a book named "BORN TO RUN".  It is a must read for anyone interested in exercise and nutrition.  Every orthopedist should read it to be able to give sound advice to runners.  It is highly entertaining.  It is not flattering to Nike and Phil Knight.

I was finally able to to some exercising in the room today.  I can't do nearly as many repetitions of sit-ups and pushups as I could 6 weeks ago but it is a start.  I'm definitely on the road back.

April 25

Shane and I had a big Monday clinic.  It is great to have someone to help see all of those patients.  Several more new patients came in.  One nine year old has a 70 degree scoliosis.  I am reluctant to schedule much elective surgery with the anesthesia situation as it is.  I was told late tonight that the Haitian anesthesiologist that was contracted to give anesthesia tomorrow and Thursday will not be arriving tomorrow until 11 am.  There are 5 cases scheduled. 

April 26

We somewhat impatiently waited until 11 o'clock but still no anesthesiologist nor any word either.  I decided to try to lessen my negative feelings about the whole situation and went to our room and read several chapters of the book, "THE HOLE IN OUR GOSPEL."  I don't know if it was the book or something else, but when the anesthesiologist came a bit after one o'clock, I was able to be surprisingly pleasant.  That is not my usual state of interaction when anesthesia is so tardy.  I had already cancelled one baby and wound up canceling a second case.  Some of my positive feelings where related to the fact that I got a call from an expat orthopedist at a  hospital about 2 hours away.  He wanted to transfer two patients with fractures for surgery.  I asked if he wanted to come along with the patients and help with the work here.  He had told me that the ORs were not functioning at his hospital and he couldn't do any surgery and was getting itchy.  His team included an anesthesiologist who also was frustrated at not being able to do what he came here to Haiti to do.  The whole team came including 2 OR nurses and an ortho tech.  Nathan cleared all of their credentials and they came this evening anxious to go to work.  Phil Hurley, the orthopedist, is from Kentucky.  This is his fourth trip to Haiti since the earthquake.  He and his team are planning to stay through Friday.  What an answer to prayer!

The big case today was our patient with the hip and femur fracture on one side and the tibia fracture on the other.  Shane and I fixed the hip first with multiple cannulated screws and then put in a SIGN nail to fix the femur.  Shane did a nice job for his first SIGN nail.  We put it in retrograde and had a bit of trouble getting in the proximal locking screws and wound up using the Carm.  I also manipulated his stiff knee again.

April 27

Today was a full throttle situation.  The monster clinic seemed to never end.  Shane and Zj  and I just kept seeing one after the next after the next.  For some odd reason, Frantz came early and took 4 X-rays then disappeared for several hours.  A huge clot of patients formed around the X-ray room door waiting some not so patiently.  Meanwhile, Phil Hurley and team got the first patient into the OR.  She is a 12 y/o with a comminuted midshaft femur fracture so we set up the "hillbilly" traction.
The Hillbilly traction set-up
It worked very nicely.  Phil did a nice job of putting on an Orthofix external fixator.  Her hemoglobin was only a bit over 6.  I split my time between the clinic and the OR.  I wanted to make sure that Phil and team didn't have any questions or problems.  Phil's second case was a patient with a segmental tibia fracture.  He did a nice job on the SIGN nail.  He got both distal and proximal locking screws in with ease.  He is a very good surgeon and a fun guy to be around.  I had hoped to do an elective case also but the generator needed a rest so we didn't have AC in the OR.  We postponed her until tomorrow.  We got in another transfer from Phil's hospital with a  femur fracture.  We'll try to do him tomorrow.  I hope our anesthesiologist comes earlier tomorrow so we can get all of our cases done.

The whole group went to the Auberge for pizza.  A downpour struck on our way over and the pickup couldn't make it up the steep hill.  We parked at the bottom of the hill and walked up through the rain.  We had a great time stuffing ourselves and getting better acquainted.  The rain had stopped by the time we were finished.  It was a good end to a day full of a lot of work.

We have a lot of cases tomorrow.  It should go well if we can run two rooms.

April 28

We got a fairly early start in one room.  Unfortunately,  the local anesthesiologist didn't arrive until noon.  We were able to do one case with her.  Shane and Phil did the SIGN nail on the femur fracture that came in yesterday.  It went really well.  Shane did the case with Phil assisting.  Shane is an outstanding surgeon.  He had a bit of difficulty getting in the locking screws but it was mainly because of the very dull drill bits.  Shane helped me with the girl with Bounts.  The TSF went very well as did the tibial and fibular osteotomies.  We cancelled our last case because the patient had such high blood pressure.  Hopefully we can get a medicine consult and get his pressure controlled so we can do him in the next day or two.  I've been enjoying reading the book that Andrew Haglund gave me, "THE HOLE IN OUR GOSPEL."  It certainly very clearly lays out the Christian's responsibility in a world with so many poverty stricken people.