On the ground report from Dr. Dietrich

“Bonjour, Haitien!”

Aug 28
It has been two weeks since I made the hole in the roof over the small
balcony outside our room for the AC and it still hasn’t been hooked
up. At least a third of the nights are hot enough that it makes
sleeping somewhat difficult. Sometimes I will read for an hour or two
in the middle of the night until sleep finally becomes inevitable.
Most nights do eventually cool off a bit by 3 or 4 in the morning.
The green duplexes have finally been emptied of the occupants who have
no relationship with the hospital. They aren’t very large but are a
bit bigger than our current unfinished hospital room. They have a
very small bedroom and tiny kitchen area and bathroom. There is a
fair sized living room and another small room that could accommodate a
bunk bed and serve as a second small bedroom. They are in awful
condition. Besides some obvious earthquake damage, they are dingy and
dark. The doors and windows need to be replaced. The electrical and
plumbing is nonfunctional and there are no working sinks or commode.
AC will be needed and then a complete paint job done. Jeannie thinks
it could be made “charming.” Obviously a fair investment will be
needed. The four units could probably accommodate all of the long
term volunteers for a few months. That would then allow the
unfinished wing where we are all currently staying to be emptied and
finished. The lost revenue from the hospital not being able to use
them for patient care has been significant.

Our little balcony really needed some greenery. A banana plant from
down behind the peds clinic building was about the right size. It
needed to be dug up with roots and all but now is nicely decorating
one end of the balcony. There are at least two or three dozen more in
the area it came from. The balcony gets a lot of direct sun in the
morning. This will provide some nice natural shade. Randy gets to
harvest any bananas that grow over onto his side of the balcony.
Emmanuel had told me that Stephanie’s father had found a reasonably
priced lot about “twenty” minutes away. It took nearly an hour to get
there and then the traffic on the way back made the return a half hour
longer. It is in a nice place on a hill overlooking a small pretty
valley as well as a view of the sea iin the distance. A very nice
breeze was blowing. An American organization is building a fair sized
school about a block away. It is definitely much too far away from
the hospital for us to be interested.

There was a concert at Emmanuel’s church this evening that he had
invited us to attend. It was an interesting eclectic mixture of
music, poetry and choreographed movement.

There was another very heavy rain tonight. We were prepared and able
to fend off the water that wanted to come in from the balcony.
I dug up another banana plant and brought it up on our little balcony
to add some more greenery. It is about nine feet tall and I had to
lean it over so it wouldn’t rub against the ceiling. I’d really like
to get a couple of other plants including a hibiscus to add some

Orthopedist, Mark Slovenkai, unable to make it today d/t Hurricane
Irene. He will arrive on Tuesday. Edith Newberry our anesthesia
provider for the week made it fine from Nashville.

Aug 29
My early morning run took 28’ 20” . That is 15 sec slower than my
fastest time so far.
1. my calf is still bothering a bit.:)
2. It has rained heavily the last two days and the roads/trails are
slippery and there are big puddles to negotiate.
3. A big dump truck slid partway off the trail near the top and I had
to go in the mud to get around it.
4. I got a “Bonjou Haitien” from a man that I greeted with “bonjou”.
It caused me to lose focus. (it is the first time I have been called
a Haitian)
5. I still detest running uphill and refuse to do it(my SLOW jog is
hardly running).
6. I ate too many Hot Tamales last night while Jeannie and I were
watching an episode of “The Guardian.”
7. I ran by myself so had no one to spur me on.

Big Clinic(>50) for just ZJ and me. I also had 4 cases to do. They
all went fine but kept pulling me away from the clinic. I was on the
home stretch in the clinic at about 6:30 pm when I suddenly got
sweaty, dizzy and nauseated. I had to stop in the middle of a patient
evaluation and go upstairs and lay down. The symptoms lasted for
about 4 hours. 7 Up seemed to help settle my stomach. I hope it
isn’t a relapse of whatever organism invaded my system a few months
back. We’ll see what tomorrow holds.

Aug 30
Jeannie and I had to go to the US Embassy to get more pages for our
passports. We have been warned a couple of times now as we pass
through immigration that we have very little space left to stamp. We
got up and left the hospital shortly after 6 am. We dropped a person
off at the airport and then went to the Embassy for our 7:30
appointment. After two levels of security, we finally made it in
nearly 15 minutes late. It took them almost 2 hours to do the job.
Maybe that was really speedy. It just seems like it would only take a
few minutes to look over the applications that we had filled out and
then add the pages in. There must be many important details that have
to be looked at and thoroughly checked out. After waiting about a
half hour, I was called to a window and asked if the Social Security
number I had given on the form was my actual number. I checked the
number written on the form and I assured the person with the skeptical
look on her face that, yes, indeed, it was my correct number. Then
she read it out loud over the intercom so the 6 or 8 people including
the Haitian guard could hear it clearly and asked again if it was my
correct number. I found it odd that such a thing should happen and
wonder if perhaps someone there has some type of scam going to steal
identity. The traffic was very congested coming back but finally made
it around 10:30 to start our first surgical case of the day.

The cases all went well including the 83 y/o with the hip fracture.
We set up the fracture table again and it worked like a charm. Dr
Slovenkai and his 17 y/o daughter arrived part way through the case.

Our last case was the man with the lateral tibial plateau fracture. Mark helped me. I was very glad for his help. It was a difficult one. The lateral tibial articular surface had a coronal split. The anterior 2/3 had partially buttonholed through the anterolateral capsule and was just under the skin. The part of this fairly large fragment still in the joint had already started to heal to the underlying intact tibia. There was a second free fragment with the remainder of the lateral articular surface. The lateral meniscus had a complete radial tear out to the rim and the entire tibial spine was in many fragments with the ACL nothing but mush. The articular fragments went back together and held well with two threaded K-wires. A lateral buttress plate and screws held well sandwiching it to the intact medial side. Everything was solid and I could flex it to past 90 degrees. I put him in the CPM for immediate range of motion. I’m glad he was only 3 weeks post injury. It seems that so many of these types of injuries are delayed in coming here for a month or more. It makes it so much more challenging when the fragments have already healed and started to remodel.

A few days ago, I had asked Randy to see if he could find a newer pickup to replace the “taptap.” I have come to the conclusion that putting more money into the old one is just going to be throwing good money after bad. He found a Chinese pickup that has the same size box. It is a 2010 model and is 4WD and diesel. The make is JMC(GMC?) and there is a dealer here in Port au Prince. We had a mechanic check it thoroughly. It seems to be in excellent condition. The price the owner was asking seemed reasonable. We would really like the hospital to have a vehicle that can serve several purposes. Picking up groups at the airport, transportation for groups on outings, hauling items
for the hospital, and a vehicle for the orthopedic director to use at his discretion are all important uses. The front and back seats can carry 4 or 5 passengers and another 6 or 8 could ride in the back. Most importantly, the taptap cover that I made will fit. We finalized with the man selling it yesterday. It should be a fairly good vehicle for trips to the Dominican Republic from time to time.

There were no more of the odd symptoms today that laid me out yesterday for a bit.

Aug 31
The run this morning went well. There were still some obstacles including the dump truck which had been pulled back up onto the road but was clearly not working since it was just at an angle sitting there. It made progress slow to get around it without falling off the hillside. The road is just dirt at that spot and fairly muddy still. The bothersome calf has healed and wasn’t an impediment. Overall, it was my best time ever by 20 seconds. The uphill part definitely presents a major psychological effort but the flatter section at the top is ok and the downhill part is even kind of fun. Surely there are health benefits that make the negative parts of the run worth it.

The clinic wasn’t as big as the one on Monday and of course, Mark was here to do the cases in the OR. There were a couple of smaller cases and then the below knee amputation on the man with the large malignant melanoma. It was an option to do a much wider excision with margins. That would have involved removing about the lateral ¼ of his midfoot with some of the forefoot and the heel. Getting coverage of such a large defect would have been a big challenge. The patient and his family decided to have the amputation which I think was a good decision. Mark did a very nice job with both JJ and Jeanty assisting him. Edith said that he spent time teaching both of them and letting them suture as well. The clinic finished before 5 pm thanks to ZJ’s strong help. The C-arm still needs to be used for x-rays. It isn’t ideal but the clinic unit is still not functioning. Nathan continues to try to get the Fuji techs to try for an online fix. Patients do have the option of paying for their xrays in the radiology department. At least 20% have the money. Perhaps those patients should also be paying something for their surgical care.

Jeannie and I wanted to have more time with Mark and his daughter so we walked with Edith and
Irma to the Auberge where they are staying. We ate dinner together and Mark generously offered to pay for the meal. They wanted to know all about how the program started and of course, about Scott. It was a very good evening together. He seems very interested in continuing to periodically come and help with the work at HAH. Edith has been a great anesthesia provider. She comes from Nashville and knows several of the people who came and worked with Dr Lovejoy earlier this year. Mark was anxious to do plenty of cases and we put 7 on the schedule for him. Some are small but one is a bit of a challenge. She is a patient I put a TSF on about 2 months ago for a malunited tibia fracture that occurred in the earthquake. She hasn’t followed up well and has developed a significant plantar flexion contracture. Her correction is quite good and she only has a few days left on her strut
adjustments to finish the prescription. The plan is for Mark to do the final strut adjustments under anesthesia and then do a TAL and then put an Ilizaroff frame to hold the foot/ankle in neutral while
the tendon heals. I built the frame for him and it is being sterilized tonight. I wish I could be there for the case but tomorrow, Jeannie and I leave early to go to Ben and Sarah’s wedding in Southern California. They are a great couple and we think it is important for us to be there. Ben is an outstanding resident. He really made an impression on everyone during his time here in March.
Sarah is doing an OBGYN residency. She is a member of the LLU School of Medicine Class of 20010 that adopted Haiti Adventist Hospital. I think they would be a great team to work here at HAH. We fly back Sunday pm/Monday am on an overnight flight. I should be back for a good share of the clinic on Monday. The DeMuth team arrives on Sunday. ZJ and Lynne can get them started with rounds and then seeing patients in the clinic. I haven’t scheduled any patients for surgery for Monday. A patient or two may show up for cast changes or something may come in tomorrow to clinic or over the weekend that might need to be done on Monday. We have a fairly full schedule of surgical cases for the week and I am sure that more will come in during the week.

On the ground report from Dr. Dietrich

A Tour on the USNS Comfort

Aug 22
The big Monday clinic went fairly well in spite of our xray machine
not booting up. We brought the C-arm out to the front of the OR and
kept it plugged in to the invertor and used it for most of the films
we needed. It worked reasonably well. I saw another 4 y/o old boy
with severe knock knees. He should do well with 8 plates for
correction. We have a lot of cases besides the tumors for Dr
Zuckerman so we arranged for Dr Adrian to come over from the DR to
give anesthesia. Francel was able to arrange Haitian
anesthesiologists for only Tuesday and Wednesday.

Jeannie and I had another distraction today – Hurricane Irene! The
initial trajectory had it hitting the DR on the southeast and then
becoming a tropical storm as its strength was diminished by the hills
and high mountains. The storm changed course a little bit as it
crossed over the Virgin Islands and headed just a bit farther north.
It just touched the north coast of Puerto Rico and headed for the DR.
It stayed slightly offshore as it continued WNW. It became a Category
2 hurricane as it honed in on Cabarete. 100+mph winds can do a lot of
damage and carry heavy objects through windows. Then the horizontal
rain floods the interior. Of course, the storm surge with that sized
hurricane can be 10-15 feet. Hurricane Katrina’s was 27 feet. Our
place on the beach is only about 8-10 feet above sea level. The math
is easy. LOTS OF DAMAGE!! Fortunately, the surge was only about 4-5
feet and the wind didn’t carry any heavy objects through our windows.
I tracked the storm for 2 or 3 hours during the night. Cameron was
somehow able to sleep through the worst of it. Another bullet dodged
by the grace of God.

Aug 23
We had 10 cases scheduled and did almost all of them. Doctor
Zuckerman worked with Adam most of the day on the tumor cases.
Everything went well. I helped Francel with a hip hemiarthroplasty.
Dr Adrian came over on the bus from Santo Domingo. It is a good thing
we arranged that since the Haitian anesthesiologist told us today that
she wouldn’t be able to come tomorrow. We have another 8 or 9 cases
on the board for tomorrow as well as Wednesday clinic.

Aug 24
We had more than 50 patients in the general ortho clinic. Then there
was the club foot clinic as well. Francel and I did most of the
clinic while Lee and Adam stayed in the OR most of the day. I saw a
12 y/o boy with severe knock knees. Each side measures 40 degrees.
He will need femoral and tibial osteotomies. A 17 y/o girl came to
the clinic with marked bowleg on one side only from Blount’s disease.
I’ll be able to put on a TSF and osteotomize the tibia and fibula.
She won’t be ready to have her TSF taken off before I leave in November
but it should work out for when I come back for a week in January.
I evaluated a man with a large knee effusion. He has moderate degenerative
arthritis. I aspirated 60 cc’s of joint fluid then injected the joint with
steroid. I showed him the fluid I took out and told him it was a very
good lubricant. I jokingly offered to go into business with him s
elling lubricant. He got a great big smile.

The orthopedic pathology continues to stream in. The surgical
schedule was interrupted by a general surgery emergency. It just
helped us to be able to focus on the big clinic better. The clinic
xray machine still isn’t working. We are hoping that Fuji can fix it
remotely but haven’t been able to reach critical mass yet with the
people that need to give input. We again used the C-arm for a few
clinic xrays. Of course, we keep it plugged in with an extension cord
to the invertor to avoid voltage fluctuations which could take out a
circuit board. Several of the patients had enough money to pay to
have their xrays taken in the xray department on permanent films. I
did another arthroscopy with Francel. He still has a ways to go
before he can start doing them on his own but he is making progress.
We also did an above knee amputation. The clinic finished a few
minutes before 5 pm and we finished the cases before 8:30 pm.

Aug 25
Our surgical schedule looked good until we were informed as we were
starting our first tumor case that there were two emergency C –
sections. The first one may have been somewhat urgent but the second
looked suspiciously as if it was being done to follow the first for
the convenience of the doctor. C’est la vie! I wasn’t able to start
my first case with Francel until after 1 pm.

Meanwhile Lee did the case of the week if not the year with Adam. The patient has a grapefruit sized mass in his wrist. He had some type of unknown tumor removed and the wrist fused with a plate and screws about five years ago. The mass has been steadily increasing in size for the last year or more. Hours of meticulous dissection were necessary to identify the tendons and neurovascular structures and separate them from the tumor. Lee is unbelievably patient. It is hard to believe that he is a surgeon. Most surgeons don’t have even a fraction of the patience that he has. Adam kind of zoned out a bit periodically during the case. I was able to close the BK amputation stump over a couple of drains. We then lost water to the hospital – something about the pumps not surviving the brownout in the middle of the night last night. We had to cancel two SIGN nails. We hope to do at least one tomorrow. I also have a patient tomorrow with a large herniated lumbar disk. Hopefully the water will be back on.

Aug 26
Randy actually got the water on late last night. He activated the old system. It doesn’t have great pressure but it is way better than nothing. Lee did a tumor case and then I did the spine case. The
patient fell 8 months ago and has had back and leg symptoms since. His foot is numb and then 3 weeks ago he lost control of urination. He actually came in with a CT scan that Francel had ordered which showed a large disk herniation at L4-L5. I found an extruded disk the size of a large grape. I got several more good sized fragments out of
the disk space. He was moving his toes and feet nicely after he woke
up. It will be interesting to see if he gets bladder function back.
I did one of the SIGN nails with Adam, the resident. It was an
antibiotic cement coated job that went well. The patient had had
several prior operations and drained for a period of time after at
least one of them. Both Dr Zuckerman and Adam leave early tomorrow.
Lucia and Dr Adrian also leave in the morning.

Arrangements have been made by Ron Anderson for us to tour the USNS
Comfort tomorrow. Ron is part of a church group that is doing
surgical cases on the ship this week and next. The ship was here
about a week after the earthquake last year and stayed for nearly 3
weeks. We have seen several patients that had surgery on the ship
last year.

Aug 27
We got up early to see everybody off then went down the street with
Emmanuel and caught a taptap. We had to change taptaps in the middle
of town and that took a while. I was getting a little nervous because
we were supposed to be at the terminal for the boat pick up at 8:30.
The second taptap dropped us off on the road near Cite Soliel. The
walk to the terminal and then to where the boat came in was over a
mile. We had to go through 3 checkpoints. We got there at a few
minutes after 8:30 and found a fairly large crowd of Haitians waiting
to go out to the boat for medical care. The boat came about 15
minutes later and loaded all of the patients and a few navy personnel
and there wasn’t room for us. The Petty Officer in charge apologized
for us having to wait for the boat to come back. Meanwhile, who
should come to wait also but Bernard Nau. He is a prominent Haitian
orthopedic surgeon. He has been coming to work on the ship nearly
every day. Several patients on the boat with us are his. I had a
nice long talk with him. Emmanuel had never been on a boat before and
was a bit apprehensive. His life jacket gave him comfort and the trip
only took about 15 minutes. The Comfort is huge – nearly 900 ft long!
We were met by Amanda Dolittle who has been in the Navy 19 years.
She started us on the tour and then Ron came out of surgery and joined
us. We also met Bill Todd who is the chief medical officer and a
pediatric orthopedic surgeon. I was disappointed that Dr Tim Mickel
and Dr Mark Swiontkowski were still in the OR doing a case. The tour
was fascinating. The ship has 1000 hospital beds and 80 ICU beds.
There are 10 operating rooms including an angiography suite. They
have a very nice CT scanner and the lab and pharmacy are very
complete. There is a nice rehab area as well. We met the lady
pathologist who has been working on our specimens. The dental clinic
is nicely equipped. They even have veterinarians as part of the
staff. They do all of their work on shore. After the tour we were
unexpectedly invited to join all of the orthopedists for lunch. Both
Mark and Tim had finished with their cases and were able to join us.
We had a great time getting to know each other. I had taken a book
with me in the hopes I could share it with Tim Mickel or someone else
who might be interested. I showed it to all of them and told them
about the opportunity we have to really establish excellent orthopedic
care for the indigent. I signed it and presented it to Dr Todd. The
others all plan to get at least one book. I hope they spread the
word. They are all interested in coming here and helping with the
work. Bill then gave us a personal and quite emotional Powerpoint
presentation of his experience being the only orthopedic surgeon on
the ship when it arrived one week after the earthquake. He worked
nearly nonstop for about five days. The whole day was a really neat
experience. I got a lot of pictures.

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

Fixing legs, changing lives

Polio patient in Cabaret
May 22
This turned out to be a very special day. I had wanted to visit my patient with the partially paralyzed leg from having polio as a child. Today was the day. Emmanuel arranged for Stephanie’s dad to drive us to where he lives near the town of Cabaret. It is about an hour from the hospital unless the traffic is bad. Sunday it is usually fairly light. He lives with his mother and other members of his family just outside of town. He has several huge mango trees in front of his house. He only owns half of the trees. The other half belongs to his neighbor. The mangoes from his half of the trees were large and according to Emmanuel very tasty. I have a very bad allergy to mangoes so I abstained. Just being so close to them makes me start to itch. I can’t shake hands with someone who has had mangoes in his hands nor can I touch the outside of a bag that has mangoes in it. The rash, swelling and itching is remarkable and requires parenteral (IV) steroids. My eyes have swollen nearly shut on two separate occasions.

A couple of brothers of my patient were there working on vehicles. There was also a very cute 1 1/2 y/o girl. She was totally shy and wouldn’t look at the camera. I got some pictures of most everybody including a video of my patient walking with his polio affected leg. I want to get a video of him also post op. He took us to his banana/plantain farm a couple of miles away. It is very well kept. He mainly grows plantains and his mother takes them to Port au Prince and sells them. He also took us to see his little girl who is 5 years old. She lives with her mother. We left after about 1 1/2 hours and drove back to the Brice home. I was expecting to greet everyone and check on Stephanie. They had prepared another big meal for us. It was even bigger and better than the last one. The home made ‘sos pice’ was outstanding on the rice and beans and vegetables and plantains. Stephanie’s little brother had a great time playing with my camera and taking pictures. After the great meal, we left for what I thought was the hospital. Actually, Emmanuel had arranged for us to go see one of our patients. She is a 19 y/o girl who was injured in the earthquake when her school collapsed and she lost her leg above the knee. She was much luckier than her best friend who always sat next to her in school. Her body has not been found. She really seemed to appreciate us coming down to her house to see her.

On arriving back at the hospital, I found that a lady had been admitted with a fairly fresh midshaft femur fracture. She had a hemoglobin of >13 and was still NPO so we took her to the OR. Dr Dennis McCarthy had arrived earlier and was raring to go as was Erin Kawasaki the fifth year ortho resident from southern California. The case went well. Erin did a very nice job. She got the locking screws in the SIGN nail with minimal difficulty

May 23
Another large clinic today. Dr Kawasaki saw several patients after watching me for a bit. We scheduled several cases. Dr McCarthy observed the action in the clinic also most of the morning. We slipped in a debridement/wound vac change under anesthesia so Dennis wouldn’t get too bored. A heavy rainstorm hit in the late afternoon. Water came flooding into our room from the balcony. We put all of our towels on the floor to control it as much as possible.

May 24
Surgery had some challenges today. We had quite a few cases scheduled but several can canceled for various reasons. Our 90 y/o hip fracture still has not been cleared by the internist. The inverter stopped giving us power for some reason. Randy tried to figure out the problem and finally disconnected the power source and it started working. I don’t know what will happen when we try to recharge the batteries. I was reluctant to do a whole lot of cases without the batteries recharging. I finally did one of the cases of club foot miter TSF that needed to be revised. It was more complicated than I had anticipated. It looks like it might be ready to program now for the equinus correction. Scott needs to help me with that. It rained heavily again later in the afternoon but this time it didn’t flood in our room.

Emmanuel finally found someone to fix the brakes. I tried it out in the rain and they work much better now. It wasn’t cheap but I consider brakes to be important. Emmanuel also had the pickup all washed and cleaned up inside. The doors and windows still don’t close or open properly. We have an appointment with a guy who does good body work who has agreed to fix things to my satisfaction for an agreed upon price.

May 25
The inverter worked just fine today after turning on the charger for the batteries. I waited for about an hour and it was working fine so we went ahead with the patient with the SI separation and symphysis fracture separation. The case went very well. The C-arm doesn’t go low enough to get a lateral sacral view so I made some 6 inch blocks to elevate the table. With the blocks, the lateral view was excellent. I also set up the traction to the C-arm table and attached it to the femoral traction pin. It worked very well. The hemipelvis came down perfectly. Erin had done several percutaneous SI screws and was careful about the guide pin placement. We got X-rays with the C-arm in the lateral and both pelvic inlet and outlet views. We had the right length 7.0 cannulated screw and corresponding screwdriver. Much of the morning was over by this time and I had a large clinic waiting. I left Erin to put on the pelvic external fixator. The clinic seemed to go more slowly than usual but was still able to finish before 5 pm. I scheduled another case for Ron for next week. It is a tibial nonunion from an earthquake injury. I have an arthroscopy scheduled every day for him as well. I hope to get another case or two from the clinic on Friday also.

The tap tap top for the bed of the pickup is being worked on. It is an old rusted top that was leaning on a tree behind the hospital. The owner was one of the hospital welders and her agreed to sell it to me as well as cut it to size and put a tire carrier on the top of it. I’ll have to find someone to paint it. I have a couple of old external fixators that are corroded. I plan to make a couple of bones out of wood and then cut them to simulate fractures and then put the ex-fixes on them and use them as decorations on the taptap.

This evening Jeannie and I were invited to dinner with the Maranatha group by Dick and Brenda Duerksen. They are here to finish the wall around the University. They are also making a video documentary of the project. Their group is staying at the La Plaza Hotel. Emmanuel agreed to go with us and show the way. I would have never found it without him, especially in the rain. We had a great time getting reacquainted after more than 20 years. It rained hard on the way back. We took Emmanuel to his home even though he didn’t want us to be driving without him at night. We made it back just fine. We have a full day of surgical cases tomorrow.

May 26
We started the day with our big case. The lady is very large and had a femoral fracture that she sustained in the earthquake. She was treated with an external fixator and had a mobile nonunion. There were several centimeters of shortening. She was not anemic to start with which is a good thing when the case has potential for significant blood loss. We did have blood ready to give if necessary. Erin did a nice job of controlling blood loss with the cautery. We had to shorten her a bit to get the fracture reduced. The SIGN nail went very well. We used the bone from the shortening to graft her as well. The case took a good share of the morning. I anticipate that she will do well. A second patient with a miter TSF for clubfoot also need to have some adjustments for her second stage to correct her equinus. We changed the necessary wires and Scott sent me the new program for her prescription. It will be fun to watch the foot finish the whole process of becoming straight. We had another small case to finish the day. We finished early enough to go to the Auberge for pizza. We took Dennis, Erin, Lynn and JJ. We had a lot of fun talking about our families. The pizza was excellent as usual.

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.