Monday, September 15, 2014

Hôpital Adventiste September 2014

Dr. Francel Alexis Chief of Orthopaedics at HAH pauses with patient before surgery

Islande is an 8 year old girl with an enlarged left upper extremity.  She has macrodactyly that caused her middle and ring finger to be grotesquely enlarged  requiring amputation of these digits at a young age.  She came to Adventist Hospital with her mother for further treatment of the deformity because they heard that there were some doctors that may be able to help her.  She said the first surgery was done in Cap Haitien by a surgeon named Nelson in 2009.  At first I did not recognize her but after a brief search of my database I found her pre operative images.  This again was a reminder of how sparse the resources are for these patients, how diligent they are in travelling to various parts of the country to look for help, and how important it is for us to make long term commitments in order to build a reputation worthy of the God we serve.
Islande 2009 in Cap Haitien
Islande 2014 HAH

A brief update on the hospital and construction is warranted:
  • Edward Martin was inaugurated last week as the hospital CEO after the resignation of Mdme. Clotaire.  He is taking on the daunting responsibility of creating a financially solvent institution, which requires a major downsizing of staff and the development of some new and innovative business plans.  While paradoxically not loosing the priority of providing top quality care to those who cannot afford it. 
  • Operating room construction is progressing well and the new facility looks beautiful.  Staff will scarcely recognize the layout of the new operating rooms, recovery room and ancillary areas.
  • The new lab is also well on its way to completion and will drastically elevate the level of services offered at the hospital and the perceptions that build our reputation.
  • We were able to perform the same quality and complexity of operations in the provisional operating room in spite of power outages, C-arm malfunctions and an occasional stray fly.

Operating by flashlight in the provisional operating room

There were many dramatic cases this week – each with stories to tell.  Kenn a crippled 7 year old boy with part of his tibia missing from infection was sent by a 16 year old American girl who raised $3000 to have his leg fixed.  Julie who is a 13 year old girl had her right leg injured in the 2010 earthquake causing a partial growth arrest and subsequent development of a severe knock knee deformity.  Marie is a 28 year old women who had a developmental bowed leg since a very young age.  And Phanord a 10 year old boy with a type of dwarfism that causes knock knees.  Each of these people who took just a few hours of our time this week have started down a dramatic pathway of healing that will change their lives. We must remember that it is not our own power that is creating this miracle of healing.  A common thread to all major world religions is the importance of compassion to our fellow man and the acknowledgement of something greater than self.   It is a privilege to be a part of something much greater than ourselves – the God of our fathers and Creator of the universe.  It is also a privilege to be part of a group of people that have contributed so generously to this work in Haiti.  This trip was largely funded by the Foundation for Orthopaedic Trauma  We are grateful for the generosity of this group which makes a huge difference in the lives of each of these children that have been operated.  It also helps us to direct additional funds into the much needed capital expense projects. 

Kenn before and after surgery.  This bone transport procedure will take 47 days to correct the deformity and begin filling in bone which will then consolidate over the next several months.

Icons on the computer programmed prescription show before and after images
Marie before and after surgery for her L tibia Blount's. This case not amenable to acute corrections is treated with Taylor Spatial Frames which operate on the principle of gradual distraction.  This device is adjusted on a daily basis by the patients which allows for extremely precise corrections and less operative morbidity due to minimally invasive surgery.  It will take 44 days to straighten her leg.
Julie prior to surgery

Dra. Adrian giving anesthesia

Genu valgus seen with Ellis Van Creveld Syndrome
Phanord before and after acute correction of B leg deformity

The team (L to R):
Patrick (local host)
Philip McClure MD Orthopaedic Surgeon Brown University RI (planning pediatric orthopaedic fellowship)
Alex Nelson and Austin Thompson (students and carpenters – building furniture for Haitian schools)
Djuro Petkovic MD Orthopaedic Resident PGY-4 Loma Linda University
Robin Kamal MD Hand and upper extremity surgeon, Stanford University
Maria Adrian MD Anesthesia
Scott Nelson MD Team leader
Francel Alexis MD Chief of Orthopaedics HAH (not pictured)
Richard Michel MD Anesthesiologist (not pictured)
Lisa Hwang PT Physical Therapist Loma Linda University (not pictured)

Alex and Charles with one of the desks they built out of recycled pallet wood for a local school

Sunday, March 23, 2014

Renovation Update 23 March 2014

Major changes are taking place at HAH with renovation of the operating room suite and installation of a new laboratory.  I travelled this past weekend with Ken Breyer, Assistant VP for Construction and Planning at LLU to assess the progress of the project.  We arrived at 9 am on Friday morning after an all night voyage from Los Angeles.  The progress that has been made is remarkable and the quality of workmanship is impressive.  We spent the entire day going over each detail of the plans with the construction foreman.   A multi faceted team coordinated by Ken has lent expertise in the design and engineering of every detail.  Although the complexity of the project has progressively increased, as well as the time and resources required to complete it; the final results will be worth the extra efforts.

Originally I had envisioned moving a wall or two, repainting and resurfacing the floor.  With the intention to create a first rate facility some additional expertise was consulted and it became evident that a more sophisticated plan would be worthwhile.  Additional storage, larger operating rooms, replacement of entire electrical system, too much to list new pieces of equipment, HVAC design with positive pressure airflow, plumbing changes, new lighting, shelving, new doors, central distribution of medical gases and other details have been added.

Francel and the workers have created a provisional OR suite in the previous emergency room which is quite adequate to handle a variety of cases.

Volunteer surgical teams are anxious to know when the project will be completed.  I won’t guarantee any completion dates but the first construction phase will likely be wrapping up in about one month.  At least two months will be required for the remaining acquisition and shipping of equipment in a container from Loma Linda.  Installation of fixtures, furnishings and special equipment will then likely require another two months.  Best case scenario currently puts us well into July.

Pictured below is a photographic update the progress.

Front Entrance - Desk will be resurfaced and modified
Main hallway inside OR suite - all flooring removed
Ken in front of existing OR 2.  OR 1 on the R is being renamed OR 3
Pile of rubble from tile removal with 8 inches of lime rock
The new OR 1 (was old small OR on the L, now twice as big)
OR 2 showing removal of med room in between OR's
OR 3 also bigger without intervening med room
Ken going over details with foreman Alfredo

Enlarged storage room (only partially shown)
Break room/Kitchen

Workers take a break
Corbels with rebar designed to withstand major quake
View down hallway from near scrub sinks
Central sterilization
Recovery room (inside OR suite)

Provisional OR - central sterile
Provisional OR
Additional provisional OR

Laboratory area under renovation.

Tuesday, January 21, 2014


A monumental event in the recent history of HAH occurred Friday… 

Since the earthquake 4 years ago there has been continual discussion about the deficiencies in our operating room facility.  Various plans have been made to renovate it but do to various challenges none have yet to materialize.  About 6 months ago Dr. Geneus the medical director asked me if we could move forward on getting the job done.  I committed to doing it and a few minutes later called my friend Jean Marc who runs a construction company here in Haiti.  I asked him when he could come over and take a look at the project and he happened to be in the neighborhood and told me that in 5 min he would be at the front door.  This was actually quite coincidental because often when I call him he is not even in the country.  Initial plans were made and the collaboration of many people began to take place.  The leadership at Loma Linda has enthusiastically supported the project and several experts participating in the design and engineering have made trips down here.

I originally scheduled this trip with the idea that I would be here for a few days to check on the mid construction progress.  Not surprisingly start dates have continued to be pushed back and construction has yet to be started.  I thus made it the goal of my trip to set up a provisional operating room and have everything removed from the existing operating suite so construction can begin.

Mdme Clotaire and Francel
When I arrived on Friday I first met with Madame Clotaire who let me know that she was excited about the idea of getting construction started and that they would schedule some meetings next week to finalize design plans for a provisional operating room and then try to create a budget.  I let her know that we had already conceptualized the design and just needed to have her come up to the emergency room to have the workers create some space as demolition of the OR was to start on Monday.  There was a pause and a smile and within 15 minutes she was in the ER giving orders.  Immediately the workers started moving the furniture and groundbreaking was officially begun!

I then called Jean Marc to see if it might be possible to launch the demolition on Monday.  Fortunately he said yes and that he would send his foreman over to review the plan on Saturday night.  By sundown Friday evening only a fraction of the work was done, but much had been accomplished.

Workers Activate
After a Sabbath afternoon hike up the hill we came back to the hospital and worked late into the night disassembling shelves, moving equipment, organizing materials, and setting up an entire new operating room.  Fortunately by the time we had to leave for the airport the previous operating room was cleaned out and ready for renovation.

On Monday January 20 the construction crew arrived and started demolition.

Moving Out

Ready for Construction

Haiti Update January 2014

Okay, we all know that I have fallen behind in my reports on the latest news from Haiti Adventist Hospital.  I am sorry.  Generous donors, eager volunteers, and interested supporters have been patiently awaiting this long overdue report. 

This report is prompted by some exciting projects that are taking place as well as some generous end of year donations that will bring them to reality in 2014.  It should be remembered that January 12 marked the 4th year anniversary of a day that changed the landscape of Haiti.  Many lives ended that day; many were changed forever, including my own.  The question I get asked the most frequently is “are things getting any better down there?”  A hard question to answer.  Are things getting better anywhere in the world?  Will it be good that soon you will be able to stay in a Marriott Hotel in Port au Prince rather than staying at a locally owned place where dinner takes 3 hours to be served, they are out of 3 items on the menu and you might get sick the next day?  Maybe that is good.  Maybe it will give local workers some low paying jobs.  Maybe it will stimulate economic activity.  Or maybe it will just return the majority of your tourist dollar to corporate America.  Do we measure improvement in terms of GDP and creature comforts or strong faith, interpersonal relationships, and love for God?  If it is the latter then don’t forget that Haiti is already more advanced than the United States.

Independent of these difficult questions is the fact that health and healing is always needed and in the last 4 years many people have participated in providing this to the Haitian people.  The hospital has recently faced some significant economic challenges.  Part of this is due to the fact that charity care does not provide salaries for the nurses, pay the utility bills, and maintain the infrastructure.  The amount of volunteer services has had a significant impact on medical economics throughout the country making it more difficult to provide profitable services in the health care industry.  Balancing affordable care for the poor with profit generating health care services is always a challenge.  In the last 4 years the emphasis has been much more on the former than on the latter.  Sound business plans have yet to be developed.  Two very important concepts are necessary in order to successfully take care of patients with and without resources in a mission hospital:
1.      Excellent Services
2.      Provision for charity
With top quality services people with resources can be attracted and charged for services.  Donors and volunteers will want to participate in something of quality but it must be made available to people even if they have limited resources.

In the interest of both of these concepts, construction is scheduled to start this month to renovate the operating room suite, create a new clinical lab, and create an outpatient clinic area in the polyclinic building out front.  I have been most closely involved with the operating room project.  This will include enlarging the two existing theatres and doubling the size of the third minor procedure room to make three reasonably sized theatres.  Other improvements include:

  • ·         Operating room lights
  • ·         Central suction
  • ·         New autoclaves
  • ·         New flooring
  • ·         Recovery room
  • ·         Expansion of storage space
  • ·         Staff male and female toilets
  • ·         Dressing room
  • ·         Break room
  • ·         Centrally plumbed medical gases
  • ·         New doors
  • ·         New cabinets
  • ·         Electrical update with backup power system

The space requirements will be accommodated by moving the front set of double doors towards the central nurses station which will significantly increase the amount of available space.

The new clinical lab will be on the main floor at the end of the hall on the right which was used for a period of time as a central depot.  As with the operating room, professionals of various disciplines have been involved in the layout and design of this project.  The challenge of creating a top quality facility with the given space constraints and other considerations of practicality has not been easy, but I am confident that the hard work we have all been putting into making this a success will pay off and that our operating rooms and lab will be some of the best in the entire country.  A big thank you to all who have supported this project with your generous donations, time and expertise.  Stay tuned.