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.