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.

Morning Roosters

Roosters crow in the distance, the sky is beginning to turn pink, and a mother hen and her babies walk by as I sit in front of the guesthouse on a tropical Sabbath morning.  Soon it will be time to wake up the residents and take them for a run up the hill.  Even in Haiti we try to respect the ACGME guidelines to make sure they get enough rest.  These peaceful moments in the early morning are one of my favorite.  The warm humid air is reminiscent of our time living here in the West Indies.  Soon music will be permeating the campus as worshipers enthusiastically crowd into the local churches.

As I look over this campus – an oasis in the middle of an area of urban squalor, I wonder what it would be like if Albert Schweitzer the well known African missionary doctor were in charge.  Dr. Schweitzer was an advocate of preserving life and protecting nature.  He did not even allow flies to be killed in the dining room or a tree to be cut down in order to make a new entrance into the hospital.  Here at HAH there has been some new construction and some improvements but the deforestation of banana trees in the front corner of the campus has made visible all the trash that did not get hauled away with the foliage and now one looks out to the block wall topped off with razor wire.  It is a scenario representative of many processes here.  Nonetheless work is being done…

Kids Sabbath School at church next door

Dr. Ian Alexander

On a brighter note patients are still arriving from near and far for some of the most sophisticated orthopaedic operations in the country.  Perhaps to the people in Haiti we are analogous to a Cleveland Clinic or Baltimore International Center for Limb Lengthening.  Dr. Ian Alexander, an internationally recognized foot and ankle surgeon joined me this week, in addition to Dr. Sull, resident from Loma Linda, and Dr. Nepple, resident from Washington University in St. Louis.  Dr. Alexander said he came to learn more about pediatric orthopaedics, but all the rest of us learned far more from his breadth of knowledge and surgical expertise.  We even had a a little extra time for a world class lecture on foot and ankle surgery after finishing surgery on Thursday evening.  This was followed by an excellent spaghetti dinner made by Lucia and Maria.

Kati recovering from surgery (see previous post)

Wilner after surgery and before

 Tim Gerke and his two friends Leah and Andrew were a great help in our operating and recovery room.  Tim and Leah are ICU nurses in Portland.  While in between hospital duties they were busy running back and forth to local orphanages, buying food, supervising construction projects and hugging kids.

Tim, Leah and Roosevelt at orphanage

Many of our patients with the most severe deformities are treated with external fixators which in many cases can be programmed with special software to do gradual corrections.  Gradual correction of severe deformity permits safer, less invasive surgery and is often times less painful.  This has a lot of advantages however does require close patient follow up and these operations really are not “over” until the correction is completely corrected weeks to months later.  We did a lot of follow up and fine tuning on cases from our previous trip as well as some checking on expertly performed cases from the Team Sinai trip last month headed up by John and Merrill Herzenberg.  It has been incredible to have surgeons like John come down and put their vast experience at work on exotic and difficult problems. The most incredible part is the lives that are changed by these operations.

View from top of ridge

The week was finished off by a motorcycle ride through Carrefour and up to the top of the ridge.  Some think I tolerate risk, but Dr. Alexander asked if he could go along with me on the back, superseding any risk that I would likely have taken.  Being the driver was enough for me.  To put it in modest terms the road is a rutted, steep track up the hill with loose softball sized rocks covering much of it.  Anyhow we survived the trip unharmed, with appreciation for God’s grace and the $2 a day travelers insurance policy from AHI.

Initial Report Haiti June 2012

This is my 8^th trip to Haiti since living on the hospital porch for the 6 months after the earthquake.  Sometimes intermittent visits can be quite encouraging since even slow progress can show dramatic improvements.  The volunteer housing has been upgraded to a bunk house on the front of the property, new air conditioners are cooling the operating room and considerable construction has been completed in the private and new pediatric wards.

New Private Ward

 

Each time I return I am again reminded of the importance of our long term presence here and the dire needs of our patients.  Several weeks ago I was emailed about a 14 year old girl who had fracture dislocation of her spine.  In addition to being paraplegic she was hardly able to sit up due to the severe angulation and pain in her spine.  Kati’s father died several years ago and then her mother was killed in the 2010 earthquake.  She was living with some relatives in a house that had been condemned due to earthquake damage when a wall fell on her last August.  Her friend was also in the house and suffered an amputation of her leg.  When her uncle found out that Kati was permanently paralyzed, he abandoned her at a local hospital.   An operation had been performed by a visiting doctor but this had only made the situation worse.  Fortunately some workers at a spinal cord rehab unit adopted her.  A recommendation had been made for her to go to the United States to have a surgery to straighten her spine, but they were grateful to hear that the same quality operation could be performed right here at Hôpital Adventiste.

Due to the severity of her deformity, the previous operation and the time since injury the spine straightening operation was somewhat of a formidable task.  Her preexisting paraplegia dramatically reduced the stress of the operation, and Lucia’s prayers were appreciated by all as we carefully mobilized the vena cava and aorta around the front of the spine in order to completely straighten her back. 

Spine fracture dislocation before surgery

Straight spine after surgery

Tonight, an 87 year old man who was in a car accident, arrived in our emergency room with an unstable tibia fracture and some severe lacerations that required an urgent operation.  We were able to treat him with a SIGN nail and we just finished at half past midnight.  We have an amazing team consisting of Alan Sull MD ortho resident from Loma Linda and Jeff Nepple MD ortho resident from St. Louis.  Tomorrow, Dr. Ian Alexander who is a foot and ankle specialist will be arriving.  Tim Gerke and Leah are ICU nurses from Portland who are still with our patient in recovery room.  And as usual Lucia and Maria came over from the Dominican Republic.

Haiti March 2012

Caribbean Sea

Once again we are fluently rising up into the lower stratosphere overlooking urban decay interspersed with tents and a few shiny new roofs. A glass of orange juice is served and a few peaceful moments ensue as we cross over the tropical blues and greens of the Caribbean Sea… This is the second of three consecutive Sabbath mornings looking out across this dynamic tapestry of creation - a sacred time more inspiring than most church services.

FAQ’s

Who went on the trip?

Maria (MD anesthesia) and Lucia (RN) from the Dominican Republic

Dr. Paley - The most experienced limb deformity surgeon in the world www.paleyinstitute.org

Dr. Dror Paley and team

Dr. Craig Robbins – Jackson MS

Wendy Wong – LLU resident

Dr. Tan keeping cool during a case and her sister Josephine on R

Shirley Tan MD anesthesia and Jennifer Barker CRNA – LLU

Rose PA Arrowhead Regional Medical Ctr

Luis – Stryker Spine

Josephine Wong RN

A film crew from Journey Films who are producing a documentary about Adventist international healthcare outreach

Also visit from Dr. Dick Hart and Dr. Elie Honore early in the week to evaluate progress and host the film crew

Are things getting better down there?

This is a complex question. Progress is being made at the hospital. A housing project for long term volunteers is almost finished. Workers are vigorously working on the private ward remodel and doing a high quality job. New fixtures are being mounted and the walls are being chiseled out to accommodate new plumbing which will correct the hot water circuit which was previously connected to the toilets. This project was made possible by an $85,000 grant from the AIMS foundation and should help to create a source of revenue at the hospital.

Workers remodel private wing

The earthquake destruction around the city is less evident but the grinding poverty and ubiquitous trash make the new visitor still ask if it was really this bad before the earthquake.

We were fortunate to have constant electricity this trip but the importance of having a constant water supply at the hospital is still lacking, sometimes requiring volunteers to limit their fluid intake and pee on banana trees and the back fence.

Who is in charge of the orthopaedic program?

Francel Alexis MD is the local full time orthopaedic surgeon who we are so fortunate to have. His pleasant demeanor and reliability are assets that allow us to do complex cases with the confidence that the patients will have good follow up.

We are still looking for a full time foreign surgeon to help lead the surgical program and coordinate international resources and educational programs.

How is all the equipment down there?

This is my first visit since Terry Dietrich left last November so I was expecting some chaos and disorganization, but Jean Joel our local ortho tech has done a remarkable job at keeping things organized. I was pleasantly surprised to see that the organizational scheme that we set up 2 years ago is still continuing to function

Dr. Craig Robbins uses Stryker cordless power drill recently donated

Before my arrival Francel had warned me that the C-arm was not working as there was a problem with the interconnect cable between the workstation and the C-arm. This is a $2320 replacement part which we were able to obtain and when I installed it the day we arrived x-ray function was restored. Unfortunately, 2 days later the monitor began flickering and the machine would not boot up. After 3 phone calls to GE headquarters in Salt Lake City where there are some technicians sympathetic to our cause, we were able to do some calibrations and get the system functioning again.

Where do you sleep there?

This time we bunked up in one of the new modular buildings out in front. I actually prefer my previous location on the porch with my cot, but perhaps some will be comforted by the air conditioning and hot showers that are now available for visitors.

How many cases did you do?

Thirty-nine. But it actually does not really matter because what is most important is the relationships we fostered and the quality of care that was given. On Friday we finished early and enjoyed a dinner with 40 of the employees at Hotel Auberge hosted by Josephine and Shirley. This was a real treat for many of the employees who rarely if ever are able to enjoy something like this.

Employee luncheon at Hotel L'Auberge

Nursing students review patient records

What kind of patients did you treat?

Ronald a 22 year old with severe R leg bowing

Spatial Frame placed for gradual computer driven deformity correction

Walking down the hall on Monday morning is a strong motivator for our continued commitment to this program. Children and adults of all ages were waiting for the clinic. Some had clubbed feet, some had severe limb deformities and others could not walk. They waited patiently. One by one we saw them and made treatment plans. The weeks seemed it would be overwhelming, but thanks to the expertise of Dr. Paley as well as a strong team effort from all members we were able to treat a wide variety of exotic cases. A couple of orphans brought by Annie an American woman who runs an orphanage were cancelled on our last trip. We scheduled them as our first cases this time and it was great to have Dr. Paley to operate on these difficult cases. We operated on a number of patients with clubfeet and other challenging limb deformities. The week ended with an operation for a T8 burst fracture in a man who had been in a bicycle accident.

Dr. Paley pre operative planning for a case of arthrogryposis with severe knee flexion contractures

R clubfoot in a 32 year old woman

What is the vision of for the future?

There is so much need and so much potential. I certainly do not have the answers but I have realized there are at least three key factors essential for the success of mission hospitals. These are:

• Excellent services
• Focus on caring for the poor
• Sharing the love of God

There is no reason to do anything with mediocrity. This is essential for maintaining support from volunteers, donors, and patients with and without resources. We can never forget that the main reason to have a hospital is to care for those that are most in need. Profit is important only for the sustainability of offering our services to the underserved. And sharing the love of God extends our finite abilities to move forward with courage and boldness to accomplish formidable tasks.

Operations Update Hopital Adventiste

Chaos, hard work, excitement and challenges usually eclipse my ability to write reports until the controlled rage of the GE turbines on the 757 pull me into my seat and I start assimilating my thoughts. We fluently lift off into the sky leaving behind a different world, looking down at shacks and rubble with a few new roofs decorating the landscape.

Terry and Jeannie Dietrich spent a year working at HAH

It was a week of mixed emotions. Terry and Jeannie Dietrich moved out on Wednesday to go back to Wisconsin. I felt a sense of defeatism and disappointment that we have not been able to inspire any surgeons to make a long term commitment towards the international orthopaedic program that has blossomed since the earthquake. It has enabled many talented surgeons to come down and effectively use their expertise to give a level of care to the Haitian people, that in some ways is beyond even that in the US. They both did an outstanding job of hosting this flourishing program. Amongst many of their contributions was the training of a couple of orthopaedic technicians – Jeanty and Jean Joel have been well trained to prepare the cases, assist in surgery, and maintain organization of the equipment.

Francel Alexis, myself and Wade Faerber

Francel Alexis is a recent graduate of the Haitian orthopaedic residency and is finishing a year long fellowship sponsored through Cure International. He is now at HAH and will hopefully stay there to help anchor down the orthopaedic program and provide follow up for our patients. His affable personality and motivation are real assets to the program.

Thanks to a donation from Stryker we were able to operate this unstable L2 spine fracture in a 22y man who was struck by a car. Fortunately he had no neurologic deficits.

Natalie before surgery. The Spatial Frame was applied to her R foot in March.

Natalie's feet now, 1 month after frame removal. Gradual distraction has given a complete correction without any open surgery. Hopefully her L foot can be operated on our next trip March 2012.

A beautiful correction of genu valgum from rickets performed by Dr. John Herzenberg June 2011.

An entire family with familial hypophosphatemic rickets presents for treatment of lower extremity limb deformities.

Patients are coming from near and far for treatment of a variety of challenging orthopaedic problems. My visits seem to have progressively selected out more and more of the most challenging cases. The complexity of these cases demands intense follow up which will be difficult to obtain without the experience and organizational skills of Dr. Terry Dietrich. For this reason we had to scale back our enthusiasm for treating some of the more complex problems.

Felancia an 11 year old girl with severe tibia vara. After bilateral femoral and tibial osteotomies using Orthofix external fixators she now has normal alignment of her lower extremities.

Todd Nelson with Chantal and her family. Chantal is a patient who had multistage surgery starting in 2009 in Cap Haitian. They found us in Port au Prince after the earthquake and treatment was completed. Her mom now works at HAH.

On this trip I was joined by Marni for the first few days which of course was a delight, as well as Todd Nelson (physical therapist), Wade Faerber (orthopaedic surgeon), Mike Suszter (orthopaedic resident) and Lucia (nurse) and Maria (anesthesiologist) who come from the Dominican Republic. Unfortunately the beginning of the week started off with multiple episodes of power failures which made it unsafe to operate larger cases and required us to cancel many of the patients who had come from far and near and waited months for their operations. A backup gravity flow water system was decommissioned several months after the earthquake and still has not been revitalized which created problems for washing instruments, bathing and even having drinking water during these prolonged outages. It was disappointing to see the deterioration of this infrastructure from previous experiences. Fortunately a 200 KW generator was purchased for USD $41,000 and installed providing utilities during the last 2 days. The challenges prompted me to reevaluate my own weakness in spirit and rely on a higher power to proceed with boldness and force in the face of adversity. Terry introduced us to his jogging route which provided an invigorating start to the day (especially when we could take showers afterward). As usual, friendships were strengthened, professional growth and interaction was enjoyed, and we were all blessed beyond our services and sacrifices.

Mike returns from shopping at Delimart

The future of the orthopaedic program is a bit fragile at the moment. A synergistic long term commitment between local and international surgeons is needed to continue with the current level of charitable services, quality care and educational opportunities. Many people are committed to short term service which has contributed significantly to the program, however strong surgical leadership is needed to effectively coordinate the efforts of this short term expertise. With our past heritage and current momentum it is my hope that we will be able to revive the mission hospital purpose to serve the poor with high quality services and multiply our blessings through education and empowerment.