Port au Prince – The Initial Days

To see more images click here (some may be graphic)

Perhaps this disaster represents the greatest accumulation of orthopaedic injuries to ever occur in one place at one time. Here in Santo Domingo it felt just like another California earthquake, but soon word arrived that it was far worse. Having made 19 previous trips to operate in Haiti over recent years we were able to rapidly prepare our armamentarium and make plans to mobilize to Port au Prince, 160 miles to the west. By the time we departed on Thursday afternoon less than 48 hours after the earthquake, the chaos of early response teams was just beginning. We lifted off without knowing if we would be able to land in PAP or if there would be anyone to receive us. It was like going into a black hole as we had no information aside from what we were all seeing on CNN. We were prepared with food and water to survive for 2 days and no return ticket.

Team members were:

Steve Bostian – Executive Director CURE DR

Dielika Charlier MD – Pediatrician

Lucia Hernandez RN

Scott Nelson MD - Orthopaedic Surgery

Susan Beemer RN – anesthetist

Dielika grew up in PAP and was able to get a single text message through to Johnny Boulos a friend of her brother. After circling the airstrip 20 times we were able to get clearance to land the plane for 3 minutes. We made a steep descent and dumped our equipment onto the airfield and our pilot quickly returned to the air. Fortunately, Johnny had waited for us all afternoon and was there to greet us. To make a long story short we are indebted to the entire Boulos family for their hospitality and generosity in facilitating everything that we were able to accomplish during the last 2 weeks.

We initially made some brief visits to assess the operating facilities at approximately 6 different hospitals. 48-72 hours after the quake there was still not a single operation going on at any of the hospitals that we visited except for Hopital Adventiste d’Haiti where the innovative local medical director had created an operating room tent out of surgical drapes and was performing life saving amputations in front of the hospital. His nurse in the yellow short sleeve dress had just returned to work. She had been comforting her 10 year old son for who was trapped under a cement girder for 36 hours after the quake. A UN crane finally had come to free him and as the heavy cement girder was lifted it slipped from the grip of the crane… Another worker was at the hospital looking for 8 body bags for her family members. At every facility there were hundreds of languishing patients, most of whom were laying outside due to fear of aftershocks. Many of them were developing gangrene, some dying, and others already dead. It was utter chaos and no help was in sight. Where should we start…

With promises to return and help Dr. Archer, the medical director at Adventist Hospital, I returned to the Hopital de la Communaute Haitien where our team had already begun setting up. Here we had earlier discovered two operating rooms with electricity, running, water and even air conditioning­ a luxury in Haiti under normal circumstances. Due to our timely arrival and preparedness we were able to establish a leadership role at this facility and coordinate subsequent surgical teams who arrived to help. I began operating on Friday afternoon – 3 days had now passed since the quake. For the first several days operations consisted of life saving amputations and debridements. Injuries were far worse than they appeared due to the extensive soft tissue damage from crush injuries. This caused compartment syndromes (uncontrolled swelling which leads to vascular compromise) and then to gangrene. Patients were dehydrated, decompensated, and anemic. There was no mechanism or time to get labs, nor anything we could do differently had we been able to accurately assess their status. Patients were dying in the hallway outside the OR while waiting for surgery. Some who were operated died as well, as they were already too critical to save. This presented another difficulty in deciding whether to operate the most serious patients first or concentrate on slightly less critical patients who had a better chance of survival.

After 24 hours of operating, a team from the Hospital for Special Surgery in New York City arrived. They had flown down on the Synthes plane fully loaded with an extensive array of donated implants and materials. Their expertise and equipment combined with the momentum we had already established allowed us to continue operating in both rooms day and night for the next 3 days catching only a couple hours of sleep here and there. We are deeply indebted to the Synthes company and the timely arrival of this team which allowed us to salvage many severe injuries that would have otherwise been amputated. It was an operative marathon like none other and as the hours passed periods of daylight and nighttime melted into one long day. Emotions were high and fatigue was intense. I worked day and night for 6 days until I felt like I was starting to loose my focus and was able to escape the hospital and get a full 6 hours of sleep.

During the first few days the situation went from bad to worse. The many injured patients were developing infections and gangrenous limbs faster than we could operate. A couple days after we began operating the stench of death strengthened and permeated the hallways and courtyards of the hospital. Dead limbs still attached to patients, dead bodies, and amputated parts all contributed. Slowly we were able to overcome this and each day the hospital seemed to metamorphose. Patients were operated, volunteers showed up with bleach, halls were cleaned and chaos was organized little by little. An entire hospital infrastructure was to be created in the ensuing days. Masking tape was used on the foreheads of the victims to delineate OR 1 – emergent cases, or OR 2 – operative but less emergent cases. The first 4 days were spent operating only on OR 1’s which consisted of open fractures, compartment syndromes, and treating severe open wounds and infections.

Wednesday morning one week after the quake the 6.1 aftershock hit and all the patients rapidly cleared the hospital building. We took advantage of the situation by mopping the halls and slowly bringing all the patients back in to the building one by one in an organized fashion. Luckily we had arisen 15 minutes before the shock as part of the cement wall above our heads had collapsed where we had been lying.

Over a period of one week we were able to convert several adjacent rooms into operating rooms and the 2 room OR suite became a 6 room operating facility where we coordinated surgical volunteers from all over the US, Sweden, Jamaica, and Korea and other countries. The arrival of the Dallas team on a chartered 737 with several tons of equipment was a great boost our dwindling operating room supplies and fatigued OR crew. We had to stop surgery for several hours to organize, but in short order we were almost equipped like an American style operating room. During the subsequent 24 hours we treated more than a dozen femur fractures using the SIGN intramedulary nail system. The SIGN nail is a state of the art implant system design for use in resource challenged environments where intraoperative x-ray is not available. We were privileged to be operating with the founder and inventor of the system, Dr. Lew Zirkle who had previously treated a record number of 5 patients in a single day using the implant. In most cases these severely injured patients with femur fractures could immediately begin unrestricted ambulation.

We continue in collaboration with the Hopital Adventiste d’Haiti where the situation is very similar to the Hopital de la Communaute Haitien. The arrival of Dr. Brad Walters from Georgia and Andrew Haglund from Loma Linda University established coordination efforts at that facility. Initial plans are being made to create a large scale ongoing project to treat the generations of people that will be affected with orthopaedic needs for years to come at this facility.

It did become necessary to place armed security at the entrance of the hospital and other strategic locations to provide crowd control and resolve some looting that began to take place as food and supplies arrived on site. However, I personally never felt unsafe and would dare to say that with the additional military and NGO presence, most parts of Port au Prince may be more secure now than they have been in a long time. Of course many render my opinions on security as worthless as they consider me to have a lack of risk aversion.

It was a trip of physical endurance, emotional intensity, and spiritual contemplation. It brought my mind back to a scene several years ago of one of our Haitian patients who fell asleep with her Bible open to Psalm 46.

God is our refuge and strength,

an ever present help in trouble.

Therefore we will not fear, though the earth give way and the mountains fall into the heart of the sea, though its waters roar and foam and the mountains quake with their surging.

Ps 46:1-3

On January 25 I returned to Santo Domingo for several days to be with family and attend to my responsibilities. On Saturday January 30 Marni and I will be driving back to Port au Prince to continue the work and relieve those that are on the scene at the moment. We are living day by day and will focus our efforts where we are most needed during the ensuing months.

I would like to acknowledge the efforts of our team members not mentioned above who were also working day and night to support the efficiency of our operation both in Port au Prince and around the world. These in include my wife Marni in Santo Domingo, Robbie Jackson - Cure DR, Erin Card - Cure US, Jeff Douglas and Andrew Haglund in Port au Prince and the many other medical personnel who rapidly activated the delivery of their expertise and medical supplies.

To see more images click here (some may be graphic)

September 2008 Haiti Trip 14

With needs more desperate than ever, the Haitian people once again inspired us to set our own corporal desires aside. We worked day night to relieve just a small portion of their pain and suffering. Making a difference one life at a time we operated on 46 patients with a variety of complex problems. In spite of a broken down infrastructure, lack of electricity, and fuel we were able work around these obstacles and treat more patients than on any previous trip. I was privileged to have along with me two of my mentors Dr. Terry Dietrich a devoted mission doctor responsible for my original introduction to the Dominican Republic and also Dr. Doug Benson from northern California.

Each and every one of these patients came with a special story. There was the man with an external fixator on his leg which had become infected after having navigated the floodwaters of Gonaive. He was accompanied only by his 7 year old son. There was the 11 year old boy who had lost most of his leg due to the brutaine traction methods used by the local doctors for a simple femur fracture. Then there was Presler (pictured) a sweet natured 16 year old boy intentionally burned 3 months ago by his father, for not listening to him. His neck shoulder and elbow had all become severely contracted leaving him with a monster like appearance. Due to providential circumstance, Dr. Duncan Miles (Loma Linda University Plastic Surgeon) was able to come to Haiti for one day to help us with this case. Tuesday night he performed a sophisticated latisimus dorsi rotational flap and z-plasty to complete the first stage of several reconstructive procedures that will be needed. In spite of a painful operation the next day Presler smiled at us from under his mosquito net and said “thank you”. After doing several more cases the following morning, Dr. Miles flew home to Los Angeles leaving us an extra $200 to buy some more diesel for the generator so we could continue operating without delay.

Jean Role director of clubfoot Haiti was also able to join us after riding 4 buses and wading through 3 rivers to get to Cap Haitien coming from the capital. Nonetheless he showed up the next morning dressed for business with his shirt ironed and pants clean. We made significant progress with the Ponseti clubfoot program casting more than 25 feet and doing percutaneous tenotomies on 9 cases. With the help of Robbie Jackson significant strides were also made on the administration and documentation necessary for the success of this program.

There will be 2 new Haitian orthopaedic residents joining the Cap Haitien residency program. We have been asked to become an integral part of their training and possibly increase the frequency of our visits. Both of them have worked with us in the past and are motivated and responsible which is very encouraging as it will allow us to enhance our training program as well as the efficiency and quality of our work for the patients.

Click photo above to see more pictures from this trip.

Orthofix

The generous donation of Orthofix to CURE International is revolutionizing deformity correction, limb lengthening and trauma care at our Dominican Republic and Haiti sites. Some of the common uses for these devices are bowlegs, other angular deformities of the lower extremities, lengthening for congenital short femur, osteomyelitis, fractures, nonunions, and bone transport for bone deficiency after trauma.

Pictured is a 12 year old boy named Laudy who lives in a destitute part of the Dominican Republic about 4 hours from the capital. When he came to CURE he was diagnosed with pseudoachondroplasia a type of dwarfism with this typical “windswept” deformity of the lower extremities. The angular deformities were analyzed and 6 osteotomies were performed along with the application of 4 Orthofix Paediatric LRS rails. Prior to this 4 hour operation Laudy was hardly able to walk. Today he is elated to be running for the first time in his life. Now he has brought the first of several cousins who are also affected by this rare type of dwarfism. Click here to see pictures of his cousin Yini along with some other patients treated at our center.

Because of the hundreds of thousands of dollars worth of Orthofix equipment that has been donated to CURE International we are able to provide our patients care that is equal to the best centers in the United States and Europe. Because of this type of generosity, our personal sacrifices, and economization we perform these many complex operations at a fraction of the cost that they would cost in the developed world. Also, relatively unique to CURE is our permanent or long term presence in the countries in which we serve making possible these operations that involve a process of close follow-up for procedures such as limb lengthening, bone transport, and deformity correction.

Thank you and congratulations to Orthofix and those of you who work for this generous company which is making a positive difference in this world.

Small Country Church - Big Hearts

“The church is in Philadelphia, MS, my hometown. It's a small country church, with mostly country people, but they have big hearts” describes Terry Winstead a recent visitor to CURE International Dominican Republic. After visiting our hospital, Terry, an occupational therapist from Mississippi returned home inspired to make a difference. He presented the Bethsaida Baptist Church with a report of his trip and a challenge to donate for surgical care of disabled children in the Dominican Republic. In addition he promised to make a matching donation for whatever was placed in the offering plate. After doubling their Sunday morning offering the amount reached over $3500. Each and every one of those dollars will be again multiplied as the lives of the children and families that we serve are changed through medical and spiritual healing. By personal sacrifice, corporate equipment donations, and harvesting wasted excess of medical supplies in the United States we are able to provide state of the art surgical care for our patients at a fraction of the cost normally required. Not everyone is called to leave the shores of their comfort zone to serve, but these simple folk from Mississippi have stepped forward as an example of what Christ has repeatedly asked us to do. Call it an investment, moral obligation, or Biblical principle, the rewards of sacrifice are great.

Give and it will be given to you... Luke 6:38

Roynelis, a 4 year old girl born with a nonfunctional thumb on the left hand underwent reconstructive surgery to create a thumb by transplantation of her index finger. In addition to a wrist repositioning surgery a similar operation will be performed on the right side where she was born missing a thumb and one of her forearm bones. Thanks to support from people like the members of the Bethsaida Baptist Church CURE surgeons and staff are able to transform the lives of children around the world. Click here to see pictures of similar operations performed at CURE Dominican Republic.

Biomet Donation Saves a Leg in the Dominican Republic

Multiple surgeons in Santo Domingo had recommended amputation, but when 43 year old Marineris came to CURE International’s hospital she was given a new hope. She had been diagnosed with an advanced giant cell tumor which had completely destroyed the bone just above her knee. In spite of working in an environment of limited resources I very seldom compromise my surgical indications. But in this case I knew it would be difficult to provide state of the art limb salvage reconstruction surgery for this patient whose resources were already exhausted with a few simple preoperative imaging studies.

The first step was to confirm the ambiguous pathology report with Dr. Craig Zuppan at Loma Linda University a ‘virtual missionary’ who gives his time and expertise for people he never meets. Thanks to FedEx and email, one day later, Dr. Zuppan had received the specimen in southern California and confirmed the diagnosis. Lung metastasis were ruled out and with a marginal resection her prognosis would be good. I presented the situation to some of my contacts at Biomet who had helped one of our patients a couple of years ago. Not much hope was initially given due to new government restrictions on any donations that could be construed as physician enticement. After a month long approval process government monitors determined that my practice does not represent any lucrative incentives for corporate donations and Biomet approved the donation. When I announced the news to Marinerys and her husband, tears came to their eyes and hope of living a relatively normal life was restored.

Multiple emails were exchanged with Mark Bollinger and Troy Hershberger of Biomet, Warsaw, IN. Final preoperative planning was wrapped up with a meeting at Starbucks Santa Monica, CA between myself and Tyler Jolley the Los Angeles Biomet limb salvage specialist. I returned from my trip to California loaded with instruments and implants.

After maximal preparation and a prayer… the operation was initiated. The absence of a vascular surgeon, vessel clips and a Biomet rep added to the difficulty of the case. But after 3 hours of surgery the tumor was resected and the prosthetic reconstruction begun. The innovative Biomet Compress prosthesis addresses the problem of loosening at the implant bone interface by loading the bone with up to 800 lbs of continuous spring loaded force to invoke an incredibly strong biologic bond between the metal and bone. We released the spring loaded force and placed the $20,000 implant without difficulty. Her recuperation phase was begun.

It does not matter that Marineris knows nothing about Warsaw, Biomet, Loma Linda, Lemoyne, bone ingrowth, or all the work and resources that multiple people around the world have invested to make this operation a success. She appreciates her leg and her life. Worth more than a insurance reimbursement are the two mangos and a hug that I pass on to all who have given unselfishly to make this possible.

Purpose

Keeping in mind Christ's words in Matthew 6:1-4

"Be careful not to do your acts of righteousness before men, to be seen by them...when you give to the needy, do not let your left hand know what your right hand is doing, so that your giving may be in secret.

it was with careful deliberation and intentions to avoid self-glorification that I decided to create this blogspot for the following purposes:

• To express gratitude to the donors who so generously have supported CURE and our work in the Dominican Republic and Haiti
  
• To repay the encouragement and support given to us by our CURE home office family who deserve to see the images and read the stories of the lives being changed by their efforts in a nondescript Pennsylvania warehouse
• To inspire others to understand the benefits of sacrifice and engage themselves in caring for those less fortunate
• To give information for visitors planning long or short term work with CURE International in the Dominican Republic and Haiti
• To provide contact information for patients and organizations seeking high quality orthopaedic treatment in the Dominican Republic and Haiti
  

As the Medical Director of CURE International Dominican Republic and Haiti this site is authored by myself and other authorized persons but is not an official publication of CURE International and although it is written with discretion it does not strictly adhere to HIPAA regulations.