The first case of the day was a left tibial plateau fracture sustained in a motorcycle accident a few days ago.    After touring the orthopedic ward at the University Hospital downtown yesterday we are once again reminded that trauma, particularly the musculoskeletal variety, remains a neglected epidemic in developing countries like Haiti causing more than five million deaths each year, roughly equal to the number of deaths from HIV/AIDS, malaria and tuberculosis combined.

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Comminuted, intra-articular fracture of the proximal left tibia

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From L to R, Drs Francel Alexis, Eldine Jacques and Noam Bor applying an external fixation frame across the knee joint of the young man with the proximal tibia fracture. The fixation was augmented with several percutaneous screws.

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Postop AP C-arm image showing acceptable restoration of the knee joint line

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The next case was a 13 y/o girl with severe bowlegs secondary to rickets These deformities are never purely one dimensional and are always multiplanar which complicates the reconstruction

The surgery was long and complicated.  First both femurs were osteotomized (broken), straightened then the rotation normalized.  Both “broken” femurs had the correction stabilized with locked intramedullary nails.

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Then Taylor Spatial Frames were applied to both lower legs and the tibias osteotomized. The tibial deformities will be corrected progressibly over time as previously described.

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We have all been once again greatly impressed with the resilience of the Haitian people. Barely a teenager, this young lady withstood a 6 hour surgery with nary a complaint.

The next and last case of the day was the older sister of the patient I just finished describing above who had similar, but not as severe, bowleg deformities secondary to rickets.

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Two sisters with bowleg deformities secondary to rickets

No femoral osteotomies were required in the older sister, but the Taylor Spatial Frame application on the tibias was very similar to the younger sister’s surgery.  It is estimated that the correction in both girls will take approximately 3 months before the hardware could be removed.

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Orthopedic surgeon Francel Alexis (L) and surgical tech JJ (R) pose at the conclusion of the older sister’s surgery

Since Hopital Adventiste is a Seventh-day Adventist sponsored facility, no elective surgery is performed on the 7th day Sabbath.  Obviously, this mandate is set aside when it comes to emergent cases that present to the trauma bay.  Around midnight this morning we were awakened by the Chief of Surgery, Dr Alex Coutsoumpus, who informed us that there was a gentleman admitted to the hospital who presented with a severe crush injury to his left hand sustained while unloading grain from a ship.

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Unfortunately, the patient presented with most of his hand missing including the thumb, index, middle and ring fingers. The small finger was the only digit that remained viable. The small white tubes are Penrose drains that will be removed in a couple of days.

We got back to bed around 2 am and slept well until rising to attend the Sabbath service down the road from the hospital.  All of the service was conducted in French but we were inspired by the boisterous which was boisterous and heartfelt.  When we first arrived the Sabbath School was in full swing and lesson study was a cacophony of loud and enthusiastic discussion (click on audio clip below) which apparently didn’t seem to distract from the overall experience for most worshipers.

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The Adventist church we attended is known as the “Sinai Temple” which amused our guests from Israel

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After church we navigated through the streets to return to the relative safety of the HAH campus. Note the “no guns allowed” graffic.

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After church then lunch we embarked on Scott’s infamous “Death March” consisting of a 7 mile hike up into the hills in 90 degree heat and seemingly close to 100% humidity. Survivors from L to R are: Noam Bor, Saif Zaman, Jim Matiko, Scott Nelson, Peter Nelson, Alex Nelson, Roosevelt and Mark Eidelman.

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In in the afternoon we all drove downtown to visit a large trauma hospital in the midst of Port au Prince. There we had the opportunity to review some of the xrays of patients awaiting operative intervention

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This young man with an open tibia fracture and subsequent external fixation begged me to take his photo. He had already been in the hospital for over two months and seemed perpetually optimistic.

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The Haitian’s are very resourceful people demonstrated by the use of the homemade traction setup with the the recycled plastic bottle weight lying dysfunctional on the bed

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Hospital mini-ambulance

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We stopped off to view the ruins of the Cathedral of Our Lady of the Assumption. The church was built between 1884 and 1914 and was destroyed in the January 12, 2010 earthquake.

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Francel, Saif and Scott posing outside of the Cathedral of Our Lady of the Assumption

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View from the patio at Hôtel Montana in Port-au-Prince

After dinner we wound our way back to the hospital through the streets of Port au Prince in a thunderstorm which clogged the roadways with debri rendering progress virtually impossible.  Still 3 miles from HAH, we elected to abandon the vehicles and walk the remaining distance through the chaos on the streets finally getting to bed around 1 AM.  Not much rest on “Rest Day.”

We spent time sorting through and organizing gear in the new orthopedic equipment room.  Again, we were expecting to have a much bigger task in front of us but Elaine Lewis and JJ had performed wonders prior to our arrival so all that was left was taking care of a few small details.

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A portion of the well-stocked and organized orthopedic equipment room adjacent to the main operating theater

We performed several smaller cases and 2 relatively big ones.  The first big case was a young man with skeletal dysplasia with resultant marked bowleg deformities requiring application of bilateral Taylor Spatial Frames.

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25 y/o male with severe bilateral bowleg deformities secondary to skeletal dysplasia

The Taylor Spatial Frame (TSF) is an external device for limb correction, lengthening and/or straightening that is based on the Ilizarov Method. This device and technique is a mainstay of pediatric musculoskeletal deformities at Hopital Adventiste. This external fixator takes advantage of the body’s natural ability to grow healthy new bone tissue and gives the surgeon the ability to accurately move bones to their correct precise anatomic alignment.  The TSF fits around the patient’s limb and is attached to the bone with pins or wires that extend from the rings, through the skin and bone to the other side.

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The Team working on applying the Taylor Spatial Frame to both lower legs

To be more specific, the TSF is a circular, metal frame with two rings that connect with six telescopic struts that can be independently lengthened or shortened relative to the rest of the frame. This allows for six different axes of movement, which gives the TSF the ability to correct difficult congenital deformities and trauma cases.

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These larger, bilateral cases often benefit from two “subteams” to divide and conquer the load by working simultaneously. From L to R: Noam Bor, Jim Matiko, Francel Alexis, Mark Eidelman, Saif Zaman, JJ, Scott Nelson

When using the TSF, the surgeon inputs information about the patient’s original bone deformity into an advanced web-based computer application. This information is then interpreted by the software and a day-by-day treatment plan is created. The software also creates an image of the patient’s deformity on-screen and shows how the bones should be moving each day, until the bones are completely set in proper alignment. The patient then makes daily adjustments to the struts, depending on the prescribed course of treatment. As the adjustments are made, the rings are repositioned with respect to each other, moving bones in the directions necessary for treatment.

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Our patient’s computer deformity profile pictured in the left image depicts the marked bowleg and internal rotation deformity on the right leg and the projected correction in the image on the right

The second big case involved a young man who underwent intramedullary nailing of a right femur fracture sustained in a motorcycle accident 3 years ago. Unfortunately the patient developed a marked extension contracture of the knee (couldn’t flex greater than 15 degrees) secondary to postoperative adhesions.

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An extension contracture of the knee is a well known complication following  femoral fractures.  Traditional management consists of a quadricepsplasty which is comprised of a controlled, sequential release of the soft tissue structures, primarily the quadriceps muscle.

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This procedure can be seemingly somewhat barbaric as the incision is usually lengthy accompanied by a great deal of blood loss and frustration on the part of the surgeon secondary to slow progress.

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The surgeons pictured may seem overly triumphant in this image but gaining an increase of flexion from 15 to 90 degrees involved a great deal of effort accomplished with tedious incremental steps over 2 hour time span

We performed several small surgeries today including a bilateral 8-plate application for pediatric lower extremity angular deformities, a Girdlestone procedure (femoral head resection) in a paralytic patient, debridement of chronic tibial osteomyelitis and removal of a tibial external fixator with debridement of infected pin tract sites.  We also slogged through another clinic which is always a challenge primarily due to language barriers and xray logistics.

The highlight of the day was the arrival of two new team members from Israel, Drs Noam Bor and Mark Eidelman from Israel.  Dr Bor is the Head of the Pediatric Orthopedic Unit at Central Emek Hospital in Afula.  Dr Eidelman is the Director of Pediatric Orthopedics at the Meyer Children’s Hospital in Haifa.

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Scott Nelson (L) is giving Drs Noam Bor (L) and Mark Eidelman (R) the royal tour of the new operating rooms

Collaboration with international team members on overseas trips like this is one of the outstanding fringe benefits.  Not only do our perspectives get changed as we entertain new ways of addressing problems, we make new friends that enrich our lives for years to come.

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It didn’t take long for the new team members to get to work. Mark’s enthusiasm and Noam’s introspective comments have been greatly appreciated by all.

Day 2 of the Fall, 2015 Orthopedic Surgical trip from Loma Linda University.

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There are no two ways about it, clinic is long and hard. This young man was one of the last patients to be seen but he couldn’t take the delay any longer without a nap. Haitian patients rarely complain about the wait, they are some of the most longsuffering souls on the planet.

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One of the inefficiencies in the clinic is that we typically sort through a group of patients, order their xrays then go view the images en masse on a digital machine apart from the clinic area. We discuss the patients and frequently formulate a treatment plan in that room then go back to the clinic to present options to the patient and/or family.

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Today also happened to be clubfoot cast change day at HAH. There are a couple of well-trained cast technicians who are very skilled in the Ponsetti technique for conservative clubfoot management.

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At the end of clinic we had 3 cases scheduled which we were anticipating as we had never operated in the new theater before. The first was a 3 y/o with bilateral hip dysplasia. Here Scott (R) and Saif (L) are viewing images on the C-arm monitor after performing bilateral hip arthograms.

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The arthrograms demonstrated that this little boy’s hip sockets were too “vertical” thereby not providing enough coverage for the femoral heads. Because of this finding it was elected to proceed with bilateral pelvic osteotomies to correct the deformities.

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Orthopedic surgery resident Saif Zaman trying out the new scrub sink

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As we were scrubbing for our case, a New Haitian life came to fruition as in the room next to ours, Dr Coutsoumpos assited one of the local obstetricians in the delivery of a baby girl

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At this point, we must acknowledge Dr Maria Adrian, anesthesiologist extraordinaire who frequently travels from the Dominican Republic to join the team, more about this amazing woman in a post to come.

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Scott and Saif performing a Dega opening wedge pelvic osteotomy

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Bilateral iliac bone grafts in place rendering the hip sockets more horizontal providing better femoral head coverage

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Haitian technique for applying protective postoperative hip spica cast

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Team photo at the end of the case. From L to R, Maria Adragon, Saif Zaman, Scott Nelson and Francel Alexis, HAH Chief of Orthopedic Surgery. The following two cases, a fracture/dislocation of the foot and a postoperative tibial wound infection, went well and we left the operating theater at around 9pm and went home for dinner. It was a good day.

Due to spotty and slow internet access, reports from our Fall trip will be delayed and sporadic.  This has been an exciting trip for us so far and hopefully will be encouraging to the many supporters who read this blog as we witness the incredible progress that has been made to date.

Three of us (Scott, Peter and Jim) left LAX at 11:35 Monday evening and took the red-eye to Miami where we met the rest of the team, Alex and Saif.  After a brief layover, enhanced by a tasty breakfast at the American Airlines Admiral’s lounge, we took the close to two hour flight to Port au Prince.

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View of Hispaniola from Boeing 767-300

Clearing immigration was a breeze but clearing customs was problematic once again as two of us had our baggage searched because the phrase “medical supplies” triggered a search for contraband medication.

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L to R: Jim Matiko (orthopedic surgeon), Alex Nelson (high school student), Scott Nelson (orthopedic surgeon), Peter Nelson (retired dentist) and Saif Zaman (orthopedic surgery resident)

Driving to Hopital Adventiste took much longer than usual due to a torrential downpour that flooded the the streets with debri washed down from the hills.

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A classic Haitian meal of rice and beans was waiting for us when we arrived in our new home for the next week

In spite of being tired from the all-night flight, we were eager to view the new operating theater to see what progress has been made.

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The nursing staff are making a concerted effort to maintain a clean environment in the new oprating theater

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Our tour guide was Alex Coutsoumpos, MD, the new Chief of Surgery at Hopital Adventiste d’Haiti

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Entrance to operating rooms 2 and 3

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Fully operational operating room 1

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Sterile processing department. Many of the rooms in the new operating theater have natural light which is a great improvement over the dark and gloomy environment that existed prior to the new rennovation.

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Dirty room where contaminated instruments are cleaned then sent over to be autoclaved in the sterile processing department

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The new break room with refrigerator and computer set up for future electronic medical records system

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I was truly impressed with the organization of the new equipment room, thanks in large part to the efforts of JJ under the tutelage of former volunteer Elaine Lewis. Scott and I were prepared to dedicate hours to sorting through bins of instruments and supplies but much of the work had already been accomplished.

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While on tour, we met Wintley Phipps, a well known gospel singer (second from R), who was filming a fundraising documentary sponsored by Florida Hospital in Orlando

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We would be remiss to fail to acknowledge Dan Brown, the incredibly talented, always upbeat project manager for the restoration of Hopital Adventiste. Here he is pictured on the left pointing out some of the features of the new lab to Monty Jacobs from Florida Hospital.

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One of the reasons that Scott’s retired dentist father, Peter Nelson (R), returned to HAH was to eplore the possibilites of establishing a dental clinic. Here is discussing options with project manager Dan Brown (L). The proposed site for the new polyclinic, including dentistry, is the building in background to the left of Dan.

The following post was written by Dr. Alex Coutsoumpos (far right in banner image above), a newly graduated general surgeon who, along with his family, has made a several year commitment to Hopital Adventiste d’Haiti.  After months of anticipation, the big day has finally arrived and the first surgical case was successfully performed in the newly renovated operating theater.

For the past couple of weeks the halls of Hopital Adventist d’Haiti have been abuzz with excitement regarding all the visible changes going on at our hospital.  Dan Brown, our facilities manager/construction extraordinaire, has been orchestrating simultaneous projects for the renovation of one hospital wing, building a new clinical laboratory and renovating the operating rooms.  This past week one of those projects was completed.

On Thursday, October 8, 2015, the operating rooms were opened for surgery after a special prayer of dedication (see banner image above).    This event would not have been possible if it were not for the operating room staff that tirelessly worked in between surgical cases to complete an inventory and organize a myriad of surgical items in preparation for the move to the new operating rooms over the last month and a half.  The move itself occurred over a period of three days, in which new donated equipment was transported in from storage, old indispensable equipment was refurbished, surgical supplies stocked and the new space cleaned from top to bottom.

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Drs. Thierry Rosarion (L) and Francel Alexis (R) perform a knee arthroscopy

Following the dedicatory service, Dr. Alexis, and his assistant, Dr. Thierry Rosarion completed the first two cases in the new operating rooms.  The first case was a knee arthroscopy and the second case was a forearm debridement in a young child who had developed osteomyelitis after surgical repair for an ulnar fracture at an outside facility.  Fortunately, both cases were completed without any major glitches.

The determined work of Dr. Elie Honorie, Dr. Scott Nelson, Dan Brown, Edward Martin, the hospital administration, the donors and the hospital staff is truly appreciated.  Without this group of people the completion of this important project would not have been possible.

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Dr. Alexis (center) performs a forearm debridement with the assistance of JJ Boyer (L) and anesthesiologist Dr. Elkine (R)

Though the hospital still faces many difficulties there is a burgeoning sense of optimism for the institution.   Many staff members have approached the administration to share their words of affirmation for the work that is currently being done to improve the hospital and its future.  For many, the opening of the new operating rooms is not a just a symbol of change to come, but the realization of a new chapter for the institution.

More than 2 billion people are unable to receive surgical care based on operating theatre density alone. The vision of the Lancet Commission on Global Surgery is universal access to safe, affordable surgical and anaesthesia care when needed. The study aimed to estimate the number of individuals worldwide without access to surgical services as defined by the Commission’s vision.

The Commission modelled access to surgical services in 196 countries with respect to four dimensions: timeliness, surgical capacity, safety, and affordability and found that at least two-thirds (4·8 billion people) of the world’s population do not have access to surgery. The proportion of the population without access varied widely when stratified by epidemiological region: greater than 95% of the population in south Asia and central, eastern, and western subSaharan Africa do not have access to care, whereas less than 5% of the population in Australasia, high-income North America, and western Europe lack access. Interpretation

The bottom line is that most of the world’s population does not have access to surgical care, and access is inequitably distributed. The near absence of access in many low-income and middle-income countries represents a crisis, and as the global health community continues to support the advancement of universal health coverage, increasing access to surgical services will play a central role in ensuring health care for all.

Although Haiti was not specifically addressed in this article, it would be safe to assume that it would be included in the category where 95% of the population does not have access to adequate surgical care.  Please reference a related post titled, “I’d rather have HIV than a broken leg.”

Received a note today from Hopital Adventiste Project Manager Dan Brown stating, “If all goes well we will be moving in on Tuesday, Sept. 29th!”  He was referencing, of course, the long-awaited renovation to the new operating theater.  To all past and future volunteers and staff, this is great news indeed.  The banner image above shows the newly installed doors leading to the 3 new operating rooms.  Dan and his crew have managed to pull off a first class effort as evident in the images below.  We are looking forward with great anticipation to our trip next month.

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The following article was written by Merrill Chaus, RN and was originally posted on the Team Sinai Haiti blog.  Merrill has visited Haiti on numerous occasions and recently wrote an article titled “Dark Side of Doing Good” for haitibones that is well worth reading if you have an interest in volunteering overseas.

On August 2, 2015 Operation Rainbow/Team Sinai conducted a nursing workshop at Hôpital Adventiste d’Haiti in Carrefour.  The idea for this conference evolved in response to research and interviews for my MPH thesis, in which I explored local health care worker perceptions regarding short-term surgical missions.  Recommendations from the local healthcare workers included a desire for more nursing education in the local language.  The purpose of this 2-day conference was to honor this request.   Topics of interest suggested by the nursing director included: Infection Prevention, Role of the Operating Room Nurse, and Care of the PACU (Post-operative Care Unit) patient.  In addition to these presentations, Dr. Francel Alexis gave an informative lecture on TSF (Taylor Spatial Frame).  There were 70 participants, which included nursing students from the university, HAH nurses, housekeeping, PT and a physician.

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An educational highlight was Dr. Alexis’ patient demonstration on dressing change and pin site care for the TSF patients

Our nursing instructors Johanne Sequin and Nadine Henry, both from Shriners Hospital in Montreal, Canada gave 6 talks in French and Creole.  Johanne has 40 years of experience as an Operating Room Nurse and Nadine has 30 years experience in pediatric and adult PACU. Recruiting experienced instructors that spoke the local languages was key.  Brittany Herzenberg, our administrative assistant, kept us on time and organized.  She even secured a small generator when we lost electricity to the LCD projector.

The handrub formulation is evidence-based, utilizes local resources and provides access for healthcare providers at point of care. Four local nurses formed an infection prevention committee to oversee production and utilization of the handrub.

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HAH nursing students showing the results of the handwashing test

After a hospital wide assessment, dispensers were placed at strategic locations away from electric outlets, medical gases and light switches.  According to Mac, the Haitian volunteer coordinator, dispensers are actively being used and refilled when necessary.

Break out sessions were arranged so participants could practice: donning and doffing PPE (Personal Protective Equipment), proper hand hygiene technique and simulate real case scenarios that may occur in the OR, PACU or wards. Course certificates were given at completion of each workshop (see banner image).

The conference concluded with a demonstration on how to make alcohol based handrub according to World Health Organization guidelines. We are thankful for the invaluable support of the administrative staff. HAH provided two air conditioned rooms and lunch for all participants.

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Merrill and Nadine teaching the local infection committee how to create Hand Rub from alcohol, glycerin and hydrogen peroxide

Team Sinai will be returning to HAH this January for our annual surgical mission, this time with an emphasis on foot and ankle surgery.