Sunday, October 14, 2012

Port au Prince October 2012

With a calculated defiance of gravity we ascend above the unknowing sprawl of Cite de Soliel in a 200 million dollar alien vehicle.  A diet coke is offered in a climate controlled cabin, while below people sell charcoal in the oppressive heat of Port au Prince.  The Boeing 767, a symbol of American technology and wealth, transports people in possession of the small blue book back to a land where it is largely unknown that the price of a latte exceeds the average daily income of nearly half the world’s population.

Many stories could be told, but I want to tell you in particular about Mozoule.  Her nursing education was abruptly ended on that Tuesday afternoon January 12, 2010 as she found herself trapped between two dead bodies on the third floor of the collapsed nursing school where several hundred students perished.  Unconscious for an unknown period of time she was left for dead by rescuers who assumed she would not survive.  Some time later, struggling for life this 32 year old girl was pulled from the rubble and taken to an MSF (Doctors Without Borders) hospital where she was treated for a large thigh wound that had been pierced by rebar.  Although this wound eventually healed, she continued to have severe back pain.  Some months later she presented to Hôpital Adventiste with a T12 burst fracture and severe kyphosis (hunchback).  Luckily no neurologic injury had been sustained, however the pain was so severe that she was not able to walk without crutches or perform many activities of daily living.  On each of several previous trips she presented to me with this painful spinal deformity.  Other visiting doctors had written prescriptions for fancy studies and medications that she could not afford with notes indicating that surgery for this problem was not possible in Port au Prince.

Lucia and Andy
Jon Allen and Bonhomme transport post op patient
After seeing her again on my last trip I decided to call my good friend Howard Place in St. Louis who has done more spine surgery with me in the Dominican Republic than any other surgeon.  Howard – experienced, reserved and stoic, always puts safety first.  He conceded to taking on the challenge and we began to plan for the formidable task of correcting this spinal deformity as well as treating several other patients with complex spinal injuries.  To do this safely and well a team of key personnel had to be orchestrated.

Mick O'brien Depuy Spine
Dan Malave and Mick O’brien of DePuy Spine offered to come along and help organize a donation of spinal implants.  Martin who is a spinal cord monitoring technician at Loma Linda University came to monitor motor and sensory evoked potentials.  Howard brought his wonderful wife Jeanne who is a nurse to help with the recovery room.  My cousin Andy Magan CRNA came to help Dra. Adrian with anesthesia.  And Jon Allen one of our senior orthopaedic residents and future spine surgeon came along to keep us sane.  Lucia is my nurse from the DR who organizes, assists in surgery, sterilizes, cooks, and prays, has become an essential element of all Haiti trips.

Martin De La Huerta neuromonitoring technician from LLU monitors spinal cord function during the case
Both motor and sensory (MEP and SSEP) tracts are monitored
We strategically planned the case for Tuesday – adequate time to synchronize the team and also enough time to see her through the most critical post operative period.  She went to sleep, was placed on special IV medications that are compatible with spinal cord monitoring, wires were placed all over her head and toes and she was positioned for surgery.  At that moment our intra operative x-ray machine started flickering and quit working, then Martin started having problems with the monitoring system.  After 3 hours of anesthesia, live phone support from Cadwell neuromonitoring equipment, an in depth dissection of the x-ray machine and Lucia’s prayers the operation finally got underway.  Howard methodically led the operation through a series of steps leading up to the spinal osteotomy (cutting the vertebral column and repositioning it), after which we all breathed a sigh of relief and offered a silent prayer of gratitude.  Jeanne brewed some coffee and stayed up with her all night just to make sure she had a smooth recovery and continued to move her toes.  The next morning on rounds we expected Mozoule to be in severe pain as we purposely kept her undermedicated to increase the safety margin and prevent respiratory depression.  With only mild discomfort she had greeted us with a big smile and thanked us profusely, her sister was in tears and her mother was giving us hugs and blessings.

Implants and instruments generously donated by Depuy Spine

Correction of kyphotic deformity with pedicle subtraction osteotomy

Mozoule on post op day 2

4 year old girl with knee deformity
After surgery

Edward going in for clubfoot surgery

On the final day we bought some bulk food items and visited Mary Lou's orphanage.  These 16 children are cared for by her in a small two room house near the hospital.  The excitement and hugs from these children are one of the most memorable events of the week.

Howard and Jeanne Place
Lucia and Dan
This story is just a representation of the challenges, emotions, and blessings that we all experienced this week.  There is not time to tell all the stories nor to tell about the amazing contribution of each team member.  However, I just want to mention Jeanne Place and Dan Malave who worked tirelessly with the patients after surgery.  It was not just their hard work, but their enthusiasm and compassion that made them especially popular with the patients and staff and impacted our entire team.