The ninth installment of the May, 2015 Loma Linda University Health Orthopedic Team visit to Nepal was written by surgical technician Elaine Lewis.  In addition to her duties in the operating room, Elaine has many years experience as a midwife back home in California and was able to participate in the birth of two lives shortly after the second biggest quake in Nepal when so many more lives were lost.  This was a phenomenon also noted in Haiti where many deliveries were precipitated associated with the stress of aftershocks.

Life in Nepal is certainly difficult, but the poverty doesn’t seem to compare with what I’ve seen in Haiti.  Many of the people I saw in Nepal lived in rural settings with gardens and often animals.  I felt like I was looking at the world through a pair of prescription lenses that were in a time warp.  One side of the glasses viewed century-old practices and the other side viewed modern times.  Women in colorful Nepalese clothing walked to the fields with huge baskets strapped to their foreheads while others rode motorcycles in western clothes.

Blue door

As the five of us from LLU walked, hiked, and ran through the hills surrounding Scheer Memorial Hospital (SNH) in Banepa, Nepal, we witnessed the devastation of a 7.9 earthquake that struck on April 25 and wondered how anyone survived and the death toll wasn’t much higher.  A 7.3 quake followed while we were there and we saw a new wave of patients coming in for treatment with fractures and lacerations.  Buildings that were severely compromised in the first quake came down in the second one.  We saw dust clouds in the hills surrounding the hospital as buildings fell.

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Newly injured patients began to pour into the emergency room at SMH after the 7.3 quake that occurred on May 12

But there were many bright spots surrounding the devastation.  New life began for two pregnant mothers at Scheer shortly after the second quake.  I was able to assist in the birth of two babies born just four minutes apart in the same room while I was there, and I watched with pride as none of the midwives or nurses bolted for safety during a 6.4 aftershock.  All the new mothers slept outside in a tent with their babies in the chilly night air in case any more earthquake activity threatened.

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Elaine giving water to a new mother whom she helped deliver a little baby girl after the May 12 earthquake

Finally, a trip to a mountain village where every single home was leveled and two children died, was one I’ll never forget.  A clinic was set up in a concrete building of newer construction with minimal damage.  While Dr. Lou from Tennessee examined patients with varied ailments, the children played yard games with the young team of grief counselors from Kentucky that Dr. Lou brought with her.  Someone told us that it was the first time the community had felt light-hearted since the quake.  I have no idea how a people rebuild from nothing and with nothing, but it was clear that the Nepalese will do exactly that.

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Part 8 of the May, 2015 Loma Linda University Health Orthopedic Team visit to Nepal.  In addition to the April 25 7.8 magnitude quake, the devastated Nepali people were dealt another blow in the form of a 7.3 magnitude trembler on May 12.  Please consider donating to Adventist Health International’s Nepal Earthquake Fund as there is still much work to be accomplished.  Scheer Memorial Hospital is depicted in the banner image above on the edge of fields of crops.

Most mornings we were able to get up around 5:30 and go for either a run or walk through the hills behind the hospital and interact with some of the villagers.  It was then that we became even more impressed with the resiliency, fortitude and warmth of the Nepalese spirit that I hope is reflected in the following photo essay.

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2 girls

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2 old ladies

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2 little kids

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Market peeps

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doorway

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Old men

Part 7 of the May, 2015 Loma Linda University Health Orthopedic Team visit to Nepal.  The following post was written by Andrew Haglund, logisitical supporter for our team.  Andrew’s eyewitness account was also posted on CNN’s iReport.  (This and subsequent updates from Nepal will be intermittent and delayed due to marginal internet access at SMH).

The 40 some odd seconds during the magnitude 7.3 earthquake that struck here yesterday, were undeniably the most frightening of my life. No amount of preparation or even 42 years of Southern California shakers can prepare you for something quite like that. I’ve been here in Nepal for about a week now and was growing rather accustom to the frequent aftershocks, but it didn’t take long to realize this was different.

I am here in Nepal serving as logistical support for a small surgical team from Loma Linda University and Adventist Health International. Our team was assembled and deployed at the request of the Scheer Memorial Hospital administration based on our experience responding to the 2010 earthquake in Haiti at Hopital Adventist d’Haiti. We arrived with 22 cases of surgical instruments, medical consumables, medications, and all of the other supplies needed to function as a surgical unit. Since our arrival our surgeons have been operating both here and in another hospital close by, while I have been working with the Scheer administration to improve disaster readiness, increase communications channels, and consult on future NGO partnerships for the longterm recovery.

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We had just completed a readiness exercise on hospital incident command with the Scheer administration in the 3rd floor conference room of the hospital. One of our team’s surgeons and I had decided to stay in the room for a few minutes to check emails on our laptops. When the room started to shake we instinctively locked eyes in an effort to force collective decision-making. Two other expatriate female mission workers were suddenly in the room with us. With few words shared the 4 of us sheltered in place for about 15 seconds, then the violence of the shaking increased. Again, with only a word or two exchanged we shifted for a doorway. The next few seconds presented an incredible set of choices, but when the shaking intensified yet again it was unanimous; “Okay, lets go”. Running past our shoes, we headed for the 3 flights of slick tile stairs in our socks. My mind was racing with thoughts of the previous day’s health cluster meeting where it was shared that it was the stairways that were “slicing” victims and should be avoided. We ran down those stairs with one thought in mind; get to open space.

As we exited the hospital and regained our composure, it was imperative to get back to our objective of assistance. The noise was incredible, birds were screeching, dogs were barking and people were wailing. Patients, family members, doctors and staff, were streaming out of the hospital. We spent the next few hours shifting basic hospital operations outside under tents, providing food, water, shelter, and as best possible, assurance that this too will pass.

Pray incessantly for the people of Nepal.

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Immediately after the quake occurred, employees and patients began to exit the hospital building
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One by one, tents were erected to protect the patients from the elements
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Eventually some of the patients chose to return to the hospital building to spend the night
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Most of the patients elected to spend the night under the tents away from the danger of falling buildings

Part 6 of our May, 2015 Loma Linda University Health Orthopedic Team visit to Nepal.  A new earthquake of 7.3-magnitude hit devastated Nepal on May 12, just 17 days after large parts of Nepal were leveled and more than 8,000 had died.  The following post was written by Dr Scott Nelson who was operating at Dhulikhel Hospital when the second biggest Nepali quake this year occurred.  Dr Nelson’s eyewitness account was also posted on CNN’s iReport.  (This and subsequent updates will be intermittent and delayed due to marginal internet access at SMH).

Earthquake victims crowded the entrances, rooms, and hallways at Scheer Memorial Adventist Hospital and Dhulikhel/Kathmandu University Hospital east of Kathmandu. Operating room schedules overflowed with orthopaedic surgery cases as doctors and nurses have been working tirelessly to treat the seemingly endless stream of injuries since the April 25 earthquake. As the task at hand was being steadily accomplished and time was found to operate on some of the less emergent cases the country was again hit with a powerful tremor centered approximately 35 miles to the northeast of these hospitals.

Patients already suffering mentally and physically from the recent quake were terrified, some were able to get out of the hospital buildings where they felt safe and others that were bedridden were taken out by family members and healthcare workers. Two women went into labor minutes after the quake and one patient who was being weaned from the ventilator was able to be immediately extubated and then was moved out of the building.

I was performing a spine surgery on a victim that had suffered two vertebral body fractures from the first earthquake when the room began to shake. I paused as I was placing a screw into the spinal column thinking that this was just another aftershock and would soon pass. When the shaking strengthened I had little choice but to brace myself and finish inserting the screw. Half of our sterile pedicle screws fell on the floor, but we were able to finish the case in record time with the remaining implants. My Nepali assistants were stoic and stood strong throughout the operation during which four more tremors occurred. Shortly after the shaking stopped someone offered to relieve my nurse but she said she would not abandon the patient and her surgeon.

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A triage center was once again set up outside of the hospital and patients began to flood in. Most were injuries from people who had jumped out of buildings or fallen in efforts to escape danger. By nightfall some patients had been moved back into buildings however others preferred to stay outside under tents and tarps.

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With already hypersensitive reflexes, patients outside of DH immdiately vacated the building when the new quake hit

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Drs Nelson and Shrestha reviewing an xray at the triage center outside of DH

Part 5 of our May, 2015 Loma Linda University Health Orthopedic Team visit to Nepal.  Some readers may find it unusual that we are posting trip reports from Nepal on a website devoted to a project in Haiti.  However the precipitating circumstances (major earthquakes) are similar and currently a team that frequents Hopital Adventiste d’Haiti are working at Scheer Memorial Hospital (SMH) in Banepa, Nepal.  (This and subsequent reports from Nepal will be posted in a straggled fashion due to inconsistent internet access).

Due to postquake patient flow, a nearby hospital received more trauma victims than SMH did.  After finishing our cases last Friday we headed a few kilometers east on the road to China to Dhulikhel Hospital to determine if our team could be of assistance.

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From L to R: SMH orthopedist Prameed Pilli, Scott Nelson, DH orthopedist Deepak Shresha

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There was an impressive list of cases at DH waiting for surgeons to tackle

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Second page of cases on the orthopedic surgical list for the same day at DH

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For the remainder of our time spent in Nepal, we elected to spread out our team between SMH and DH which proved to be a very rewarding option for both facilities. Here Dr Phil is working with Dr Pilli at SMH.

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Scott and Jim stabilizing a spine at DH with allstar scrub tech Roshni on the left

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Patient in traction patiently waiting for surgery at DH

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Scott Nelson making rounds with an orthopedic PA at DH

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Dr Phil performing an open reduction and internal fixation of a bothbone forearm fracture at DH

Part 4 of our May, 2015 Loma Linda University Health Orthopedic Team visit to Nepal.  On Saturday evening we had the opportunity to take a walk through Bhaktapur, a town just a few miles from our home base in Banepa.  Up until the earthquake 2 weeks ago, Bhaktapur had the best preserved palace courtyards and old city center in Nepal, and is listed as a World Heritage Site by UNESCO for its rich culture, temples, and wood, metal and stone artworks.  As pictured in the banner image above, much of the damage can be attributed to the fact that most of the older structures were made of mud bricks without reinforcement.

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Supports

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Color destruction

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Black destruction 1

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Phil pulling rope

On more than one occasion we witnessed large groups of people gathered to try and topple precarious buildings teetering on the brink of total collapse. The strategy was to tie a heavy rope to the top of an endangered structure then elicit members of the audience (including our own Dr Guillen with the green backpack on the left) to help pull it down.

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Part 3 of our May, 2015 Loma Linda University Health Orthopedic Team visit to Nepal.  Please consider donating to Adventist Health International’s Nepal Earthquake Fund.

There were several surgical patients waiting for our team when we showed up for morning report.  Although all cases were “quake-related”, at least half occurred in the 1-2 days after the Big One and were secondary to jumpers out of 1-2 story buildings responding to aftershocks.  As with the post-quake Haiti victims, many patients with open wounds are arriving to area hospitals on a delayed basis making it difficult to perform definitive open reduction and internal fixation (ORIF) because of concerns for infection.

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The newly expanded Scheer Memorial Hospital Orthopedic Surgery Team from L to R: Phillip Guillen, Scott Nelson, Prameed Pilli and Jim Matiko.

Crush inj to foot

This patient had a crush injury to his foot with open wounds that were infected necessitating debridement and washout.

External fixator

The aforementioned patient also had a closed, ipsilateral distal tibia fracture. However because of the infection in his foot we could not perform the preferred ORIF but applied an external fixator instead.

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Jim Matiko and Scott Nelson performing a closed reduction and percutaneous pin fixation on an elderly lady with a closed distal radius fracture. This pair last worked together in this operating room 16 years ago so it was a unique experience to have the opportunity to do it again.

Distal tib

This patient presented with a closed, comminuted, intra-articular fracture of the distal tibia after jumping from a 2-story window during an aftershock.

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Drs Nelson, Pilli and Guillen performing the distal tibia approach.

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The 2 operating rooms were beautiful and in much better condition than when we last visited.

Organization

Operating room supplies and back tables were well organized, a significantl improvement from our experience in Haiti.

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The C-arm image intensifier worked flawlessly and produces beautiful images. To our amazement, this machine, manufactured in India, cost the hospital less than $20,000. Even a bare-bones C-arm in the US will set us back $75K.

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The vast majority of cases appear to be performed under regional anesthesia which is safer for the patients and diminishes time spent in the recovery room.

Paperwork

Unfortunately, even overseas there is paperwork to be done, much less than at home, but present none-the-less.

Wall cracks

Surgical tech Laxman on the left pointing to a crack in the wall from the quake in the operating room. Anesthesiologist Steve Mulder evaluating a patient in the preop holding area. Note the crack in the wall above and behind him. Overall, Scheer Memorial Hospital sustained relatively minimal damage compared to other facilities located closer to the quake’s epicenter.

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Patient lying in a creative traction setup awaiting surgery for a complex fracture/dislocation of the pelvis.

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Dr Pilli performing a postoperative check with an ortho nurse on our distal radius fracture patient.

Part 2 of our May, 2015 Loma Linda University Health Orthopedic Team visit to Nepal.  The banner image above is a shot of the tracking screen in front of each seat on Etihad Airways.

We finally made it safely to our destination, Scheer Memorial Hospital in Banepa, Nepal, almost 37 hours after leaving Loma Linda, California.  Two Super Shuttles picked us up by the Medical Center at 1 am Wednesday and we sped down a relatively vacant freeway to LAX.

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Unloading our bagss off the 2 Super Shuttles

Processing 23 bags at the check-in counter was challenging but our overweight surcharge could have been much worse.

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Nepali Weight Loss Program…Lose pounds in seconds!

At this point we need to give Jerry Daly and his crew at Global Health Institute a shout-out for the meticulous preparation of our gear and paperwork.  All of the packaging, particularly of heavy and/or delicate surgical equipment, came through unscathed and we had no problems clearing Customs and Immigration in Nepal.

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Global Health signage on all of our baggage

It was great to have anesthesiologist Steve Mulder join us at LAX finally making the team complete.  Steve left Templeton in central California at 11:30 Tuesday evening and he had a close call on the freeway narrowly avoiding being hit by an obviously confused driver traveling the wrong way in his lane.

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From L to R: Surgical technician Elaine Lewis, Orthopedic surgeons Scott Nelson, Jim Matiko and Phillip Guillen, Logistical Support Andrew Haglund and Anesthesiologist Steve Mulder

Our flight left Los Angeles at 5 am taking us 3 1/2 hours to reach Chicago where we boarded an Etihad Airways flight ultimately landing in Abu Dhabi 13 hours later.

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Sheeks Andrew and Phillip enjoy a cappuccino in the company of the real thing

The third leg of our journey took us 4 1/2 hours to reach Kathmandu in part because of heavy traffic in an already earthquake-compromised airport delayed our clearance for landing.

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Excited to land in Kathmandu

As noted previously, passing through the authorities was a breeze but it took us over 2 hours to obtain all 23 pieces of our luggage and board the bus for our new temporary home.  We are grateful for the safe passage to Nepal and look forward to a challenging experience here at Scheer Memorial Hospital over the days to come.

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Waiting for bags in Kathmandu

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Bus transport from Kathmandu airport to Scheer Memorial Hospital

Although this website is primarily dedicated to the advancement of Hopital Adventiste d’Haiti from time to time we will feature reports of trip experiences outside of Hispaniola in hope of stimulating interest in the concept of volunteerism in general.

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Rodding femur at SMH with Greg Dietrich in 1995

Heading back to Nepal this coming Wednesday morning.  My first trip was in 1995 when I went to Scheer Memorial Hospital (SMH) in Banepa accompanied by Orthopedic Surgery Resident Greg Dietrich.  The banner image  at the top was taken from my airline seat as we cruised by Mt Everest seen faintly in the background.  It was an amazing trip with beautiful vistas, incredibly hospitable people and challenging cases.  I vowed then to return and had the opportunity to do so a few years later when I went with then PGY-4 Orthopedic Surgery Resident Scott Nelson.

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Scott Nelson examining a newborn’s hips for instability at SMH

I like to think that brief experience influenced Scott’s future course of action but I knew even then that he was destined for a life of service irrespective of that exposure.  On the same trip I was privileged to take my son Matt and two of his senior high school classmates Tyler Wilkins and Tom Soeprono.  All three boys later claimed that mission elective had a profound effect on their lives and contributed to them ultimately choosing careers in healthcare, Matt an anesthesiologist, Tyler an interventional xray PA and Tom a psychiatrist.

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The 3 boys helping Scott reduce a hip in the operating room

We even had time to take a brief excursion on a small portion of the Annupurna Circuit trail before heading back home in time to celebrate the holidays with family and friends.  It was an “expedition” remembered by all with great fondness and we all longed to return but Scheer Memorial was more or less placed on the “back burner” as we concentrated our efforts at other venues including Hopital Adventiste d’Haiti after the quake of 2010.

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Dinner at a tea house while trekking in the Himalayas

On Saturday, April 25, 2015, at 11:56am, a 7.8 magnitude earthquake hit Nepal. The epicenter was approximately 50 miles west of Kathmandu, and about 65 miles west of Banepa, where Scheer Memorial Hospital is located. The initial quake was felt at the hospital as well as the continuing aftershocks.  Because buildings were not considered safe, the medical staff immediately set up an emergency operating room in the hospital courtyard even performing an emergency c-section.

epaselect epa04719891 People free a man from the rubble of a destroyed building after an earthquake hit Nepal, in Kathmandu, Nepal, 25 April 2015. A 7.9-magnitude earthquake rocked Nepal destroying buildings in Kathmandu and surrounding areas, with unconfirmed rumours of casualties. The epicentre was 80 kilometres north-west of Kathmandu, United States Geological Survey. Strong tremors were also felt in large areas of northern and eastern India and Bangladesh.  EPA/NARENDRA SHRESTHA
Earthquake victims in Kathmandu

None of the Nepalese or foreign doctors and staff were injured in the earthquake. However, everyone who lives on the compound slept outside the first night because of aftershocks.  Only one wall in the oldest part of the hospital was cracked, otherwise the buildings are intact. However the quake and aftershocks caused damage to many homes and businesses in the villages around the hospital. Some of the staff who do not live on the compound have lost their homes.

The medical staff has worked tirelessly to treat the injured however there are pressing needs, including numerous fractures and dislocations, that remain untreated due to lack of equipment, particularly implants.  Scott Nelson was contacted late last week, the need expressed and now a team has been mobilized through Loma Linda University and we are planning to leaving for Nepal midweek.

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The Team from L to R: Scott Nelson, Andrew Haglund, Jim Matiko, Elaine Lewis in Jerry Daly’s storehouse

Yesterday we spent several hours gathering and sorting equipment and supplies at the Global Health Institute warehouse managed by Jerry Daly who is one of those “can-do” type of individuals who just seems to make things happen…if Jerry doesn’t have it, he will make every reasonable effort to get it for you.

One of the emails that we received from SMH stated, “We have no incident command structure.  Our hospital is lacking the many policies and procedures associated with even routine medical care, so our disaster response has been make it up as you go along.”  That is one of the reasons that we are so thrilled to have Hopital Adventiste d’Haiti’s (HAH) former Incident Commander, Andrew Haglund, joining us.  Andrew currently works as a Director of Marketing for Loma Linda University’s Office of Enrollment but formerly served as the primary relief coordinator at HAH for several weeks after the Big Quake in January of 2010.  Logistically speaking he makes life much easier for the medical staff as all we have to worry about is taking care of patients.

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“The IC” Andrew Haglund

After leaving Jerry we moved on to Whittemore Enterprises in Rancho Cucamonga which is a world leader in the refurbished medical equipment industry since its inception over 30 years ago.  Owner Bill Whittemore has been a generous supporter of our mission programs and personally came in on a Sunday to sort through countless bins of used gear to help us complete our instrument, implant and power equipment trays.  Bill’s shop is a veritable “candy store” for orthopods and we greatly appreciate all of Bill’s efforts on our behalf.

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Bill Whittemore working with Elaine Lewis to complete our equipment lists

We are excited and optimistic that we will be able to make a difference in the lives of many of the souls who have been traumatized by this devastating event. Though far away, Scheer Memorial Hospital is in need of your help. Every small contribution can make a huge difference.  Please consider donating through Adventist Health International’s website.

Philip McClure recently graduated from the Orthopedic Surgery Residency at Brown University in Rhode Island and will soon be entering a Pediatric Orthopedic Fellowship at the Texas Scottish Rite Hospital in Dallas.  Phil has volunteered at Hopital Adventiste d’Haiti on two separate occasions and I am quite certain that they will not have been his last trips.  Phillip is bright, articulate, contemplative and a gifted surgeon, we look forward to his return to HAH. 

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From L to R: Scott Nelson, Phillip McClure and Francel Alexis

Pediatric Orthopedists have a unique opportunity to serve in areas of the developing world where severe deformity remains disproportionately prevalent, resulting in disability and human suffering.  A carefully planned and executed procedure can resolve deformity and improve a patient’s function for decades, without the need for expensive prosthetics or ambulatory aids.   My first trip to Haiti took several months of planning as I worked to make contacts with Dr. Scott Nelson at Loma Linda and Dr. Francel Alexis at the Adventist Hospital in Port Au Prince. Needless to say, it was well worth the effort.

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Phil making rounds with Scott Nelson

A popular theme in Haitian art after the earthquake in January of 2010 is to mirror the images of the national palace before and after the earthquake.  The collapse of such a magnificent building has been a powerful image of the suffering in Haiti.  Many dedicated orthopedic volunteers spent time helping to treat the traumatic injuries suffered in the catastrophe.  As the acute injuries stabilized and other needs arose around the world, the plight of the Haitian people slowly faded from the public eye.  Fortunately for many patients in Port Au Prince, a group of orthopedists lead by Scott Nelson continues to provide orthopedic care at the Adventist Hospital in conjunction with Dr. Francel Alexis, a local orthopedic surgeion.  The well established relationship there allows for advanced orthopedic care despite a struggling health system in the country.

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Reviewing digital xrays with the team

When I entered the field of orthopedics, my previous training in physics left me yearning for a chance to apply the field of mechanics to patient care.  The parallels between reconstructing a complex deformity and the continued reconstruction efforts in Haiti are easy to draw.  Both require careful assessment, planning and execution.  Successful execution generates a durable improvement in quality of life in both cases.   Slowly, by righting one structure at a time, a staggering transformation comes to reality.  In my three weeks in Haiti, I was fortunate to assist in the care of nearly three dozen surgical patients; each a unique challenge.  To be integrated into the surgical team there was the greatest privilege of my young career.  My experience assisting in the care of Haitian children has been one of the most formative of my life.  I hope to have the privilege to continue to work in that capacity for many years to come.  It is our unique opportunity as orthopedists to help relieve human suffering due to musculoskeletal disease. May we seize the chance utilize and teach our advanced techniques in the places that need them most so the people of the developing world can maximize their own potential as they build their societies.

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Dr Phil adjusting a fixator with JJ and Elaine Lewis looking on