On the ground report from Dr. Dietrich
Appleton and North Carolina Teams Arrive
Aug 7
I had no travel glitches and arrived around noon. Scott was just finishing a case. Jerry King’s team was delayed out of Miami today and won’t be getting in until tomorrow. It’s great to see Scott again. He has done a large number of cases in the week he has been here. More than 80 patients came to the clinic last Monday. Both Dr Adrian(anesthesiologist) and Lucia are here from the Dominican Republic. Scott always arranges for them to be here when he comes down. They were part of his team that went to Cap Haitien four times a year for several years. They also came with him 2 days after the earthquake and stayed for an extended period of time. They have been operating until after midnight nearly every night during the week. Jerry King and the anesthesiologist, Dave Brannon, were supposed to arrive this afternoon. There was a problem in Miami and their flight was canceled so they will be arriving tomorrow. They have several other team members including OR nurse, scrub tech and recovery nurse. Jerry and Dave came here in January and were a big help.
Aug 8
Scott and I went for a 30 minute jog/run early this morning. We had a big clinic today but unfortunately, the generator gave out on us and we had no power to take xrays. We had to send many of the patients away and tell them to return either Wednesday or Friday. Welcome back to Haiti, Dietrich. It took about 5 hours to get the power back on. What a relief that was to get air conditioning again in the OR. We had a lot of cases and were just about to curtail the schedule for fear of running out of power from the inverter. We were able to continue doing cases. The King/Brannon team made it in well rested after their unexpected night of rest in Miami and started to work right away. The Appleton team finally made it in by late afternoon. Their travel started in the wee hours of the morning with a three hour drive to Chicago and then flights to Ft Lauderdale then on to Port au Prince, They were all pretty exhausted after traveling since very early in the morning.
An older man came in to clinic with a terribly foul smelling leg. He was initially injured in the earthquake and apparently has had an open wound ever since. It got a lot worse in the past several weeks. His hgb is less than 8 so we need to get blood ready and then do an amputation. Welcome back to Haiti, Dietrich.
I finished my last case at 11:30 pm and then went in to watch Scott do his last case – a complex TSF that involved the foot. It went well and I learned some more. I still don’t feel comfortable doing those cases though. I am happy to follow them and deal with any issues that come up in their post op care. Scott finished it about 2 am.
Aug 9
The Appleton team was up and raring to go. I had an early morning administrative meeting while Scott got two ORs running. Jeannie arrived fairly early this morning. It is so good to have her back with me again. I really miss her when she goes without me. Scott did some more TSFs today including another fibular hemimelia. It was even more complicated than the one he did late last night. By the time he finished at 6:30 this evening he was ready to throw in the towel even though there was one more patient that needed a TSF. Adam had also pretty much reached his limit and was zoned out. We had the 75 y/o man with the terribly smelly infected leg that needed an amputation. We were able to get one unit of blood for him which was really important since he had a hgb of less than 8. He certainly was higher priority than the remaining elective case. The patient for the TSF was very understanding and agreed to come back tomorrow. He is a straightforward TSF that I can do. Errol helped me do a guillotine BK amputation that we finished before 10 pm.
The team from Wisconsin consists of Errol Springer and his partner Jay Minorik. They brought Eric Bowen, orthopedic RN who has been to Haiti before. Steve Dungar is their anesthesiologist. Steve’s son, Ben, came here with the Wisconsin team last August. Ben is a pre-med student. Dr Springer brought his son, Evan, who is also a premed student.
On the ground report from Dr. Dietrich
Foot and Ankle Society team arrives:
Many of the members of the Foot and Ankle Society team arrived today. They are staying at the Auberge and most went directly there. Brian DenHartog is the leader of the team. He practices in Rapid City, South Dakota. He has several partners who are all subspecialists. He brought an ortho PA, Dan, a nurse anesthetist, Dean Gibson and Karrie a scrub tech and Sue, a nurse to help recover patients. Steve Weinfeld does exclusively foot and ankle surgery in an academic practice in New York City. He has a lot of experience putting on Ilizaroff frames. He brought an OR nurse, Shirley, and Toni, an anesthesiologist from Syracuse, New York. A third foot and ankle surgeon, Dean Jameson from Arkansas is part of the team as well. Bryan and Steve know each other quite well from being on teaching panels for the Foot and Ankle Society.
July 4
We got off to a very good start with the foot and ankle team. Most of the patients we had on the list came in for their evaluations and we scheduled them for the next several days. The clinic was very large. Francel began today as well and he is a big help. I saw a 7 y/o with symptoms and physical findings of discoid lateral meniscus. I scheduled him for Wednesday to do with Francel. I am hoping that teaching Francel arthroscopy will be part of an arrangement that will keep him at HAH for the long term. Adeel, our ortho resident and Jonathon the med student from LLU and ZJ and Lynn complete the entireortho team. We had already scheduled some cases for today and they all went well. One case was an ankle fracture that the team took care of nicely. I did a PMrelease in a child and Bryan, Steve and Dean did a case of chronic infection in the fibula. Scott and I have major hopes that Francel will decide to stay here at HAH after he finishes this peds ortho fellowship. He could help keep all of the equipment organized and implants restocked and be the bridge between visiting teams of orthopedists. He could be involved with teaching residents at the university as well as eventually being the core of the orthopedic practice at HAH.
July 5
We had a total of 8 cases today and they went well. The man with the banana plantation for correction/stabilization of foot and ankle was the biggest case. The team did an elegant job of correcting the deformity and stabilizing the foot and ankle. I chiefed Adeel on a wrist fracture and it went well. We have enough manpower to see all of the clinic patients in a timely fashion as well as do a lot of cases. All of the nurses and techs are very hard working. It takes a lot of work off Jeannie’s shoulders to have a team that is so well planned out. Brian has really done a great job of putting this entire team together. Steve is an accomplished very assured surgeon. He is really great to work with. Dean is the quietest of the group. He did a sportsmedicine fellowship but then got into foot and ankle and does that almost exclusively for his large group.
July 6
I did the child’s knee arthroscopy and found a discoid lateral meniscus just as I had expected. The case went well with Francel helping me. I recontoured the meniscus to make it as normal as possible. All of the clicking with flexion/extension was gone. I had Francel hold the scope and look and probe the structures, then had him take everything out and start over several times. He has watched some arthroscopies but hasn’t had the chance to actually do much. It will take a number of cases for him to start feeling comfortable just getting good visualization. The Wednesday clinic was big but went very well with all of the clinicians seeing patients. Steve did a revision of Stevenson Dorsainvilles Ilizaroff frame while I was doing the arthroscopy. It turned into a pretty big job. I am going to review it again with Scott to make certain it is going to do what he wants.
July 7
One of the most interesting patients I have seen here is a young lady who sustained a femur fracture in the earthquake. She had an open reduction and internal fixation with a SIGN nail that was locked on both ends. The fracture healed and she had no pain. She came into the clinic a few days ago with a complaint that her foot turns out to the side when she walks. Examination showed a 60 degree malunion with external rotation of the healed femur. I did her surgery today with Francel helping. I first removed the single distal locking screw. Then I did an osteotomy of the femur about 3 centimeters proximal with the Gigli saw. The Gigli saw is like a piece of wire with sharp teeth. Once the bone was cut through, I rotated the bone internally so that the foot would point straight forward. Then I put two locking screws back in holding the bone in the correct rotation and alignment. We put some bone graft around the osteotomy site as well. Cases like that are very gratifying. The team did another case of Tibial osteomyelitis with debridement and antibiotic beads. Adeel did a ganglion cyst and assisted on other cases including Maxi. He is the patient from Cap Haitien with the tibia fracture that we shortened with Pat Yoon. Steve did a very nice job of putting on an Ilizaroff. I certainly hope he will be able to heal this fracture and get his life back again. Bryan, Steve and Dean also did a difficult tibio/talar/calcaneal fusion. It went well as have all of their cases.
July 8
We had more tough cases today. The patient from Jeremie was one. He has a midshaft femur fracture which is very shortened as well as an infected ankle/distal tibia post attempted ORIF. Adeel and I put on an Orthofix distracter on the femur and then the foot-ankle team cleaned up the ankle and put on an Ilizaroff. The entire week has gone by very fast. We have gotten a lot of cases done. Toni is an outstanding anesthesiologist and likes to do lots of blocks. She is very thorough. Dean does a great job of getting patients in and ready for surgery. The team has until Wednesday of next week. We have a lot scheduled already. The weekend off will be welcome for everyone.
The Future is Now!
Dr Francel Alexis graduated in 2004 from the Medical School of Haiti State University. He subsequently completed a year of general internship then rendered his one year of mandatory year of social service to his country. He subsequently completed 4 years of an Orthopaedic Surgery residency at the same university where he went to medical school.
Francel is currently engaged in a 14-month Pediatric Orthopaedic Surgery Fellowship comprised of spending 8 months at the CURE Hospital in the Dominican Republic and 6 months here at Hopital Adventiste under the tutelage of Dr Terry Dietrich.
Here at Hopital Adventiste, Dr Alexis divides his time between very busy clinics and the operating room where he has proven to be an eager student. Francel would like to eventually private practice as the only Haitian fellowship-trained pediatric orthopaedic surgeon in his country.
Pictured below is Dr Zeno Charles Marcel who recently graduated from the Universitad de Montemorelos in Mexico. ZJ is currently fulfilling his year of social service by working with Dr Dietrich here at Hopital Adventiste. ZJ’s goal is to complete an orthopaedic surgical residency in the United States and eventually return to serve in an underserved nation such as Haiti.
Jonathan Mills, pictured on the left in the image below, is a 2nd year medical student at Loma Linda University. During his summer break between first and second years, Jonathan has spent several weeks volunteering on the orthopaedic service here at Hopital Adventiste.
All three of the aforementioned gentlemen have been performing in an exemplary fashion and have increased our productivity immensely. Their enthusiasm, energy, and willingness to serve have been greatly appreciated. It appears that the spirit of volunterism in our speciality is alive and well and the future is indeed bright.
On the ground report from Dr. Dietrich
June Winds Down
June 26
It is Nathan’s birthday today so Jeannie made waffles for everybody. Summer and Tim brought us a waffle iron and strawberries so we feasted. It was really good. I had planned to get some work done on the taptap today so focused on that for several hours. Dr. Wilkerson is staying with his team at the Auberge. He invited us over to use the pool so we accepted. It felt really good to cool off. I talked with Rick in the pool about all of his overseas involvement in Iraq and Afghanistan. He was surprised to hear that Loma Linda has a significant involvement there. He is a mountain climber and has climbed many of the Fourteeners in Colorado as well as Mckinley in Alaska and also in the Himalayas. His wife has climbed some with him also.
June 27
We had another big clinic and 5 surgical cases today. Another anesthetist, Carol Crawford, from Pennsylvania arrived today. She should be able to help with the case load. Rick has such a positive attitude. He jumps right in to everything. He is a joy to work with. The AC went out in OR 1 again today. I hope it can get fixed promptly. The clinic went surprisingly fast. I did an 18 month old child with severe arthrogryposis of all four extremities. I did posteromedial releases and talectomies on both feet. Rick did a hemiarthroplasty on a patient with an nonunion of a femoral neck fracture. Adeel worked with him. Both Jonathan and Erick are getting lots of opportunities to scrub in and assist.
June 28
Today was disappointing. More than half of our scheduled cases didn’t show up. We were still able to do 4 cases. A patient with a fractured femur and head injury was brought to the ER. He fell out of a tree. He has an open depressed frontal skull fracture that extends into the orbit. He is unconscious but responds to painful stimuli. I had Adeel clean up the head wound and put in a tibial traction pin. Lynn called Medishare and they agreed to accept him. Erick went in the ambulance with him. The rented hospital generator stopped working this afternoon. It took nearly 5 hours to get it started. That meant no water for showers or even for purifying and of course no fans to help cool us off a bit. There was a bit of a breeze on the roof and we were planning to sleep there but the generator started working again about 9 pm. The water came back on so we all took showers. The cool water really felt good. With the fans blowing on us we were able to get a good night of sleep.
June 29, 2011
Today made up for yesterday. We had good power all day and the AC started working again in room 1. I was very surprised. Dr Wilkerson and his team had to leave today to work on his orphanage project. I wish they could have stayed longer. Anthony Fenison came before noon and we saw patients together in the clinic. Anthony practices orthopedics in Southern California. He is here in Haiti with a church group doing a building project. His wife and two teen aged children are working on the project. We finished the clinic by early afternoon. One of the surgical patients from yesterday came today and a couple of others that had been cancelled previously also came. Anthony did the morbidly obese patient with the femoral nonunion. He got the rod out and the SIGN nail in but locking was virtually impossible. The aiming arm wouldn’t fit over her huge leg. He got one locking screw in above the knee but couldn’t get C-arm visualization for anything proximally. She presented a hemodynamic challenge as well. Pulmonary issues could also complicate things. We’ll have to watch her overnight in the PACU. I did an arthroscopy with Jonathan the medical student. He was totally stoked getting to hold the arthroscope and probe the knee and then suture the portals. We have a lot of cases tomorrow and just one anesthetist. It will be an interesting day. Maxi, our patient from Cap Haitien with the infected open tibia fracture that Pat Yoon helped me with so much came in to clinic today. The proximal pins in his ex fix are loose. The fasciocutaneous flap has all healed nicely. We admitted him to revise his ex fix tomorrow. We continue to have power issues. The rental generators all seem to start off working well then act as if they are starved for fuel. Randy thinks it is water in the diesel and the filters are being overwhelmed. The big diesel tank needs a thorough cleaning apparently.
June 30
Our cases went nicely. Anthony is a very good surgeon. He relates well to everyone and is really fun to be around. Carol with Tim’s help got the cases going with good efficiency. The last case was an ACL reconstruction in a soccer player. Anthony and Adeel did the case. Our set up and instruments are different than Anthony is used to but he dealt well with it and got a nice stable knee.
On the ground report from Dr. Dietrich
A day trip to Kenscoff
Cummings team in Kenscoff
June 22
The hall outside the clinic was more crowded today than I have ever seen it. There were a huge number of clubfoot cases. Dr Bob Cady was here to supervise. Things were very crowded so we split up and started with OR cases as well as the clinic. Brock began with the patient with the very comminuted intertrochanteric hip fracture. The fracture table was a big help. He did a really good job on a tough case. I am very impressed with him as an orthopedist. He takes his time and does thorough evaluations of patients in the clinic and is skilled and confident in the OR. I really enjoy working with him.
June 23
We scheduled 10 cases today and were able to do them all. Adeel had a great time working with me on the patient with the malunion of a tibia fracture that occurred in the earthquake. We put on a Taylor Spatial Frame and osteotomized the tibia and fibula. We’ll get her x-rays and measure the mounting parameters and deformity. Then we’ll get her prescription for adjusting her struts. I really enjoy doing those cases. The patient with the infected tibia was also a very good case. We removed his SIGN nail and made an antibiotic coated one that we put back in after reaming the tibia several more millimeters. Both Jonathan and Erick helped us either running the C-arm or helping with anesthesia observation.
June 24
The Friday clinic was bigger than usual but was handled very efficiently by Rick Wilkerson. He came yesterday with an anesthetist and an OR nurse. He is working on setting up an orphanage here in Haiti. He is going to help me this coming week also. He is in the process of adopting Junior. Junior is now with them in Iowa even though the process is not completed.
We also had 5 more cases scheduled that Brock and Adeel and I were able to get finished by midafternoon. Our daughter, Summer, and her husband, Tim, arrived in the afternoon. It’s great to have them here. This has been a very good week. We have been able to do 32 cases and see a lot of patients in the clinics. I suggested we go on an outing up to the high country around Kenscoff tomorrow and everyone is interested. The heat and humidity here in Port au Prince has been very much on everyone’s mind this week. Emanuel is going to find a driver who will take us tomorrow. I asked him to try his best to get us a decent vehicle that will be reasonably comfortable. We have an early morning dressing change under anesthesia then we will head for the high country.
June 25, 2011
We got the case done early, made rounds and piled into the vehicle that Emanuel had arranged for. Our only ER case of the week came in just then. Fortunately it was just a clavicle fracture so it didn’t slow us down much. JJ wasn’t able to come but three of the other translators came. There were 12 of us besides the driver. The traffic was pretty heavy through downtown and Petiionville but then thinned out. Parts of the road to Kenscoff are heavily rutted and it is quite steep. A 4 wheel drive vehicle would be a must to do that road even infrequently. It was a bit cooler already as we passed through Petionville and steadily got better as we got higher.
Nearing Kenscoff, we found a spot with great views back toward Port au Prince and took advantage of it to get photos of the whole group. We hiked up the road and on some trails from that point. We explored off the main road some and found a spot where we enjoyed some spectacular lightning on some higher mountains in the distance. Then it started raining fairly hard. The vehicle which was otherwise very nice and looked fairly new, was equipped with fairly smooth tires. It was unable to get the heavy load up a steep section that was slick with rain. We all got out to lighten the load and the driver tried a bunch of times. He was a bit timid to get up enough speed until finally he got talked into a longer start up run with more speed. He finally succeeded and we ran up after him and got back in. It was a very fun outing. Just getting out of the heat and humidity of the city for the day was great. We all had watermelon in the evening and talked about the really good experience that we all had this week. Brock and Brad would really like to come back again sometime early next year. I hope to arrange things so that I can come at the same time and then go to Cabarete in the DR for a few days. They would have their families meet us there. The Cummings – Tym team leave early tomorrow. They have been one of the best teams to come. Brad is totally efficient and the cases just seemed to get done so efficiently. Brock really understands how things work here and needed very little help with the clinic process or surgery.
A Hybiscus flower in Kenscoff
On the ground report from Dr. Dietrich
May 27
Our 88 y/o lady with the intertrochanteric hip fracture was finally cleared by the internist for surgery. At last the hillbilly traction was used for its main intended purpose. I set the traction and the C-arm and the patient up just like ED had showed me. It worked perfectly. I took pictures to document the event. I am sure that Ed will be very proud. I helped Erin with most of the case. I don’t think she had
ever seen a hip compression screw before. Most IT fractures these days are treated with an intramedullary device. I didn’t get to the clinic until nearly 11 am and the natives were a bit restless. Several patients had time consuming problems and it seemed like I had hardly made a dent in the waiting crowd and I was already starved. The post op patients all seem to be doing well. The last young girl that I did a TSF on for Blounts came in. Her mom is following the prescription well. A young man came in with an open phalangeal (finger) fracture of one of the fingers of his dominant hand. The fracture had occurred Monday, five days ago. He went to a MSF hospital and they had “washed out” the laceration and ordered an X-ray. The X-ray was done yesterday and confirmed that indeed the deformed finger had a phalanx that was broken in several pieces. Erin gave him a digital block and took him to the OR and debrided and explored the lacerations. We will keep him on antibiotics and try to treat him definitively next week. I saw several more patients that I scheduled for the team next week. I hope they aren’t overwhelmed by all of the patients that are coming to see them. It has been great having Erin here this week. I wish she could stay longer. She is a careful surgeon and isn’t afraid to ask when she isn’t sure. Having Dennis here has made a big difference. We couldn’t have done even 10% of the work we did this week without him here. I have enjoyed getting to know him and discussing mutual interests. I would love to have him come here on a regular basis. The air conditioning in room 1 was finally fixed today. It has been nearly 2 1/2 months since it last worked.
A dinner was planned for all of the volunteers this evening. Most everyone contributed to a “haystack” meal. It was very tasty besides being nutritious. We had a large watermelon that helped finish off the meal. We also sang some songs to help usher in the Sabbath. It was a very nice way to end the work week. I am again looking forward to the rest of another Sabbath.
May 28
I got up early to bid Erin and Dennis goodbye. It has been great having them here this week. Dennis is a careful anesthesiologist. He has been going on mission trips for several years. His wife is an internist and has been coming on medical trips to Haiti for nearly 3 years. Dennis came to Milot shortly after the earthquake and gave anesthesia. He said it was chaotic. I have hopes that he will return and that his wife will come with him. Erin will be finishing her orthopedic residency training in a month and then will be doing a fellowship in sports medicine. She is hardworking and already skilled. I would love for her to come back on a regular basis and help with the work here. The rest of the Sabbath was very quiet. I was able to rest, read and do some emailing. Tomorrow things will crank up several notches with the big Herzenberg team. The power went off for several hours this afternoon. Apparently the diesel tank was empty. After the delivery truck made
a delivery, the rented generator came on but would slow down and nearly stop and the lights would dim. This continued for almost an hour. Eventually one of our surge protectors started to smoke and then the alarm came on from the surge protector as well. Apparently, the diesel filter need replacing. It took several hours but eventually it started to run smoothly.
May 29
Our hip fracture came in, presumably cleared for surgery. The patient with the draining sinus from his tibia also is in. His hypertension and diabetes appear in satisfactory control. I worked on the facing for the arthroscopy tower that I hope will stabilize it and prevent tipping. The big team arrived early this afternoon. Orientation took a bit of time and then we had an afternoon clinic. We scheduled several cases. Medishare called to ask if they could transfer a “stable” patient with a pelvic fracture. Lynn accepted him. Shortly after arrival his blood pressure was 60 systolic with a pulse of 130. A quick check of his Hgb showed it was 7.5. I put him in trendelenburg (head down below heart/foot level) and immediately had the nurse start a second IV and we gave him two units of Hepspan. His pressure promptly rose to 110 and pulse went down to the 80s. Medishare Hospital was just last week visited by President Martelly to inaugurate their new CT scanner. They also have intensive care capabilities.
I suggested to Lynn that she should call the medical director of Medishare and ask that they send one of their intensivists to watch the patient tonight. I checked on him about 2 hours later and found him in X-ray getting worked up for an acute abdomen by the ER physician who is also a general surgeon. His abdomen had started to distend. The ER physician thought he should have his abdomen explored. The only general surgeon on staff at HAH couldn’t take care of the patient. He had RLQ and LLQ tenderness and no bowel sounds. Earlier he did have bowel sounds and only tenderness on the left lower abdominal area which I thought was related to his pelvic fracture. Hgb had dropped to 5.2 but BP was still 110. He certainly needed blood and the family had not been able to get any from the Red Cross. We transferred him back to Medishare. I got some intermittent sleep but not a lot. Right after I was first notified that he was in shock, I got one of the anesthesiologists, Dr John Sauter, to help evaluate and resuscitate the patient. Just having another specialist takes a lot of the stress out of dealing with a situation that is out of my practice profile. Dr Sauter was here last year in April and we worked together for a week. I really respect him for his professional expertise and commitment to this work.
The Herzenberg team is the largest team to come since Jeannie and I came here over 6 months ago. John brought a team here about a year ago and did a large number of cases. He scheduled another trip with a team for December last year but had to cancel because of the street violence associated with the fraudulent election process. We have had many electronic communications in the last several months. He agrees with Scott that Haiti “messes with your mind.” It is virtually impossible to come here from a wealthy country and do relief work and interact with Haitians without developing a connection that draws you back. His wife Merrill is an important part of his team. She is very involved in many parts of the work including organizing and bringing supplies and medication and nutritional supplements. They are very high energy level people. At last they are here to complete their mission. Dr Herzenberg has mentored Scott Nelson significantly. Scott learned much of what he knows about deformity correction from John at Sinai Hospital in Baltimore where John has his center for limb deformity correction. He gives specialty courses for surgeons and has fellows training with him on a regular basis. Scott learned the Taylor Spatial Frame in Baltimore. John has been extremely generous. He has donated most of the TSF and Ilizaroff parts for this project. He arranged to bring down more materials that are regularly used for the frames that need replacement. We were getting low on the special wires that connect the rings to the bone for the TSF and Ilizaroff frames. We also needed more of the special connectors. We now have plenty to last for many months thanks to him.
His team has three anesthesiologists which will allow for significant improvement in efficiency and productivity. Dr Arup De is a member of the teaching faculty at Albany Medical Center in New York in the anesthesia department. This trip is also a site visit for him. He would like to arrange for regular resident rotations here if the situation is deemed acceptable to him and the rest of the leaders in his department. I certainly hope that it works out. One of John’s partners, Dr Ron Delanois, is also on the team. He is Haitian American and speaks Creole. He is a very experienced orthopedic surgeon. His current practice is largely joint replacement and arthroscopy. I have scheduled at least one arthroscopy every day for him. I hope that he will too have a desire to continue to be involved in this project. Two of Dr Herzenberg’s pediatric orthopedic fellows are also team members. Two family practitioners are also on the team. Their principal work will be assessing all of the prep patients and clearing them for surgery. They will also be able to help with the management of hypertension, diabetes and other medical conditions. There is one medical student and several nurses and ortho techs.
An unofficial member of the team, but very important, is Dr Alexis Francel. He is a young Haitian orthopedic surgeon who grew up in Les Cayes on the south coast more than 4 hours away. His plan has been to return to Les Cayes where he has family to practice orthopedics. He is doing a one year pediatric orthopedic fellowship sponsored by CURE. CURE is the organization for which Scott worked while in Santo Domingo. It has pediatric orthopedic hospitals in Africa as well as Santo Domingo. CURE has arranged for Francell to spend at least the 3 months starting in July at HAH. He may be able to spend the entire 6 months until the end of his fellowship with us. He was invited to come here to work and learn with Dr Herzenberg. He will stay and help take care of the orthopedics here while I am in Wisconsin for the next 2 1/2 weeks. Both Scott and I are hopeful that he will decide to stay on permanently at HAH. We could help him develop a private practice and have him continue helping with the indigent patient program as well.
May 30
The clinic today was close to ‘over the top.’ There were so many peds patients with major deformities that came in to the clinic in the last few weeks. I told many of them to come in today so I could evaluate them with John. Even John is a bit amazed at the volume of unbelievable pathology that comes in here. I am sure we are just scratching the surface. We also scheduled several cases for today. The result was a relatively chaotic day. We started with all of us in clinic seeing patients. More of the peds cases with significant deformities came in and we are already overbooked with cases for the entire week.
Dr Delanois seemed very at home in both the clinic and OR. He wasted no time jumping in and evaluating patients and scheduling them for surgery and in doing arthroscopy and other surgical cases. We are getting a bit low on bags for arthroscopy irrigation. I have ordered more and paid for them. Lucia is able to get them in the DR and then sends them here by bus. They are supposed to arrive tomorrow. I want to make sure Ron has enough to do all of the cases for the week. I am hopeful that he will be interested enough and willing to help us set up a good arthroscopy center here. He might also be very helpful in developing a private practice here at HAH for Francell or some other young Haitian orthopedist. I talked to him a bit about that and he is interested. He is also interested in the fundraising project. His mother lives in Miami and is very involved in the Haitian American community. She might be able to help us a great deal to make Haitian Americans aware of the need and opportunity at HAH.
We started the surgical cases before noon and everything went reasonably well. John had clubfoot cases. His incision is different than the one I use. I am impressed with how well it works and am going to try it. I didn’t scrub in with him. He has both of the fellows as well as Francell to assist. I needed to split my time with the clinic until it was finished. It is really great having John’s team here. I have been saving cases for him ever since Dror Paley and Scott were here in March. I am sure we have more than twice as many cases as he will be able to do this week. I wish I could be here the whole week to learn from him.
On the ground report from Dr. Dietrich
May 18
The clinic was definitely smaller. I still saw several new patients including two new untreated clubfeet age 5 and 10. The 10 y/o had bilateral very rigid clubfeet. The left has already had a talectomy (removal of the talus bone of the foot) but the right side has never been treated. I tried a stretching cast. We’ll see what Dr Herzenberg says about it. The younger child’s foot is much more flexible. I also saw a teenager with Blounts. John and I can put a TSF on her if there is time. We still have four more clinics before the Herzenberg team gets here. I continue to be amazed at the pathology that continues to present here. Since we weren’t pressed with a huge throng of waiting patients, I spent a fair amount of time teaching ZJ. I really enjoy that a lot. Unfortunately, Franz, our clinic X-ray tech didn’t come in today. ZJ took a few X-rays. I finished by midafternoon. I spent the rest of the afternoon with Emmanuel, Roosevelt and Joseph. We took the pickup down town and went to several different places to price out bumpers and tiptop materials. We found a guy who will make the doors and windows close properly. It was fun tooling around with the guys. I bought and ate a roasted corn on the cob on the street. It wasn’t like Wisconsin sweet corn but I ate it and it wasn’t bad.
May 19
The anesthesiologist didn’t come until one pm so I had the morning to email and recruit anesthesia and orthopedics. Dr Howard Place is a spine surgeon in St Louis. He has gone to the Dominican several times and done several spine cases in a week. He is planning to come here this fall. I sent him the pertinent information on four patients that are potential candidates. One is a teenage girl with idiopathic scoliosis of 70 degrees. The second is a young man with a bullet in his spinal canal at L4. The third is a lady with Grade III spondylolisthesis that is very symptomatic and the fourth is a quake victim with a severe compression fracture of D12 that is very symptomatic still. I also had time this morning to teach ZJ more orthopedics. He is really soaking it all in.
We had four cases this afternoon including a hip hemiarthroplasty. They all went well. JJ scrubbed and ZJ assisted and we had a good time.
May 20
For a Friday,the clinic was big. It made up some for the small one on Wednesday. More patients came in today for the Herzenberg team including a lady with a large rotator cuff tear. Several interesting peds cases came in as well. The best case was one I am going to do myself this coming week. She is a lady who was injured in the earthquake when her house collapsed on her and broke her leg. She lost a 7 y/o daughter. Her tibia is malunited with 30 degrees of varus. I scheduled her for a Taylor Spatial Frame and tibial/fibular osteotomy next week when we have anesthesia.
We finished the clinic in time to throw the football a bit and try our first scrimmage. A couple of younger kids and Emmanuel and Roosevelt and I had a lot of fun playing. We then took the pickup and spent about an hour looking for some more material to turn it into a taptap. We found just what I was looking for, some abandoned parts for the back of a taptap. It isn’t rusted much, just basically needs some paint. it isn’t quite the right size for the short bed but nothing that a hacksaw and a welder can’t cure.
I am so glad that this week with no orthopedist to help me is done. I will have an anesthesiologist and a 5th year ortho resident next week. Now it is the Sabbath. What a delight! I do have a wound vac change on one patient tomorrow but otherwise no medical work unless something urgent comes in.
May 21
Today was a very quiet Sabbath, just like I like them. We went to both Sabbath School and church up the street at the university. The sermon was given by a fairly young Haitian preacher. He speaks very good English. His topic was “Time.” He chose ten Bible verses that had the word time in them. of course his topic was related to the well publicized prediction that Christ would return to earth today. I am sure there were a lot of disappointed people who fervently believed that the difficulties associated with living here on earth in this day and age were all going to end May 21. I too believe that Christ will fulfill the promise that He made to His disciples that He would come again. It is very clear in the scriptures that no one knows exactly when that will happen. We are told that once the gospel commission has been fulfilled to take the gospel to the ends of the earth, then He will come. The Bible also indicates that there are signs that will occur that indicate the “time of the end” is near. Those signs include wars, pestilences, marked increase in knowledge and natural disasters of increasing frequency and severity. It certainly does seem as if those signs of Christ’s imminent return are happening in the last several years. Earthquakes causing unprecedented damage and death as well as severe storms, volcanic eruptions, AIDS and its unbelievable death toll across Africa and India and the internet with the worldwide availability of undreamed of amounts of knowledge could certainly be the fulfillment of many of those Biblically predicted signs. I certainly am looking forward to the day when there will be no more sickness, sadness, pain and death. No more intramedullary rods for broken tibias and femurs. No more wound vacs for open lesions and infections, no more Taylor Spatial Frames for severe bowlegs, no more ACL reconstructions, no more clubfoot casts, no more hip fractures or chronic back pain. No more kids with short deformed legs, scoliosis, myelomeningocele or cerebral palsy. I can lay down my scalpel, turn off the C-arm, put away the SIGN nails, and throw away cast padding, plaster and fiberglass. What will I do with no fractures to fix or deformities to correct? The possibilities are nearly limitless. Reading, music, travel, gardening, reading, woodworking, sporting activities and more reading. We are also promised to be reunited with our loved ones who have died. What an experience that will be! That day just cannot come soon enough for me.
We followed that with rounds including the wound vac change. Everybody is doing well. The afternoon was tranquil. I was able to do some reading and emailing family and friends. A 90 y/o lady with an intertrochanteric hip fracture was transferred in this afternoon. We have an anesthesiologist coming tomorrow so we should be able to do her surgery as soon as she has blood ready and is cleared by the internist.
On the ground report from Dr. Dietrich
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.
On the ground report from Dr. Dietrich
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
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.
Special Thanks
Once again, a special thanks to Amistad International and their teaming up with our doctors on the ground!