Mark Mildren Trip Report
The following post was written by Mark Mildren, MD, a PGY-4 Orthopedic Surgery Resident at Loma Linda University who was part of Dr Scott Nelson’s team that visited Hopital Adventiste d’Haiti earlier this month. Mark is planning on pursuing additional fellowship training in total joint replacement surgery upon graduation. Mark’s sense of humor has assumed legendary status amongst his peers and is evident throughout his report below.
We fly from LAX to Miami on a red eye, and get back on the plane from Miami to Port Au Prince (PAP). I slept all of 30 minutes because I was watching the fx series “The Americ–“…I mean, reading …. Greens textbook of hand surgery. There was some confusion at the PAP airport regarding where we were staying, which made for an interesting introduction to a country in which I had no idea what to expect to begin with. More on that later. We make it off the plane and find our bags which come out on a carousel about 1/5th the size of Ontario’s and Dr Nelson had us pack bags…and i mean BAGS! I had two giant duffel bags of medical supplies including some Stimulan (biocomposite), arthroscopy equipment, and a bunch of Nafcillin (antibiotic) which I’ve been told will be confiscated at the airport if found. I’ve tried my best to hide it among the more disposable equipment…do we really need ACL stuff? It’s just going to get bovied by a charmingly handsome joint surgeon in like 20 years anyways. We make it through Customs with only a preliminary search, after seeing 80 boxes of stimulan, they decided not to open up them all). After clearing Customs we proceed to a hallway in which some dude holding a an Adventiste sign says “You! Adventeest! Come with me!” So we did. I generally wouldn’t recommend jumping in a car in Haiti with a random dude that tells you to come with him after he sees you carrying large duffel bags, but hey, what else were we supposed to do. So he leads us to the HAH ambulance. Think of a Datsun with 2 bench seats in the back. And that brings us to the tap taps.
Haiti passport worker (HPW): What’s the address of where you’re staying?
Me: I don’t know, it’s the Adventist hospital.
HPW: I need to know the address, are you with the team that just came through here?
Me: No, we’re a different team.
HPW: Okay, is this your address? (shows me the address of the person in front of me)
HPW: Is this your address? (Shows me the address of the person before that)
HPW: Is this your address? (Showing me another address)>
HPW: (Writes down that address) Very good! (Stamps passport).
The Tap Taps
The Haiti public transportation system is comprised primarily of tap taps. They consist of trucks or buses that the backs have been converted into people carriers. One thing I’ll give the Haitians, the efficiency of the tap taps is mind blowing. They will fill the truck bed, have people hanging off the back and on top of the roof. They’re generally brightly painted with some sort of religious wording across the front and back such as “merci Jesus” or “je taime dieu”, which from what I can figure does two things. The first is to differentiate the taptaps from each other. The religious word is the equivalent of which bus line it is. The second is that if you’re riding a taptap, you undoubtably want God on your side because of the traffic. And if you ride the tap taps long enough, statistically speaking, you’re going to end up in our operating room.
The Operating Room
There are 2 operating rooms at the HAH, a big one and a small one. They are lighted by room lights and a stand-alone lamp on wheels which I named ‘Pixar’ because it looks kind of like the light from the Pixar movies. The operating table is a radiolucent table which was hand built by Dr. Nelson and is basically a flat Jackson except without anything but the table. It goes up and down by twisting the pegs on the bottom of it. It raises intraoperatively by standing at the foot of the bed and lifting. The suction is run by a loud motor driven machine, so we just don’t use suction 98% of the time as lap sponges do just fine. The arm boards are literally, arm boards.
What struck me about the operating room there is that it’s cramped, not technologically advanced, we don’t have near the amenities that we do at home, yet somehow, it works just fine. We did spine cases, Taylor spatial frame cases, congenital deformity cases and all went off without a hitch.
That last fact is most likely attributable to the Domina.
In ancient Rome, a Dominus was the equivalent of master, or of a person who had sovereignty, or ruled over an area. A domina was the female equivalent. It means something else according to urban dictionary, but let’s not go there. On each Haiti trip, there are two critical participants which both come from the Domincan Republic, they don’t speak a word of English, French or Creole, yet are probably the most important members of the team. They refer to Dr. Nelson as ‘Jefe’ (Spanish for boss) but it’s pretty evident by the afternoon of day #1 that these two ladies are running the show. They are Adrian, and Vieja.
Maria Adrian, MD is an anesthesiologist from Santo Domingo who can do a caudal block in exactly 52 seconds from the break of the prep stick to the withdraw of the needle. She’s kind, patient, works harder than the rest of us, is a great cook and unbelievably efficient in the operating room.
Lucia Hernandez (aka Vieja) is an RN, and functions as a circulator, scrub tech, xray tech, anesthesiologist from time to time, and also can cook a mean pancake. She knows neither me nor Corey speak a word of Spanish, but that doesn’t stop her from talking to and scolding us regularly. And once she has spoken, she has spoken.
Seeing as how these two ladies were by far the most seasoned of Haiti trip veterans, we should have paid more attention when they refused to go on the hike.
I had an isolated radial styloid fracture my intern year that I should have recognized as a harbinger of perilunate pathology, but I just missed it. Likewise, there were warning signs prior to the hike of the pain that was to come. Dear Lord there were signs. The two domina refusing to go. Dr Nelson having running shorts on. The fact that it was called a hike and not an “easy walk”. So we ventured off into the Haitian hills around noon.
It wasn’t too bad at the start. We went to an old dilapidated resort like area where there used to be a pool, a miniature golf course, an amphitheater and a small zoo enclosure complete with alligators, monkeys and birds. Nowadays the cement walkway is cracked and grown over, the entire place is in disrepair. Corey and I catch lizards to pass the time while waiting for the group. From there we venture up the hillside along what passes for a road although it wouldn’t be passable by most American cars. The grade is probably close to 8% over about 3.5 miles. A group of boys join us of for a couple of miles, one is 3 feet tall and carries a rusty machete that’s 2 feet tall. I’m not sure why they walk with us, but they do for a while. It becomes clear that this is not a walk for the faint of heart, the pregnant, or anyone else that isn’t currently training for a marathon. We eventually end up at a Catholic church at the top of a beautiful hill. We rest in the shade, and look out over the beautiful valley. Charles plays angry birds on my phone for 25 minutes while I do what I do best…sleep. The hike was one of the high points of the trip for me, the other was the day that we went to the Cathedral and the local hospital.
Construction in PAP used to be mostly made of wood, but due to several disastrous fires, wood construction was banned from PAP in 1925 thus most buildings were constructed of weak concrete with no real building code present do to the rampant poverty. This is one of the reasons why the earthquake was especially lethal.
After the conference on bone healing, Francel took us around town and showed us some of the government buildings and sites. One of these was an old cathedral in the center of town. It looked like the roof had completely collapsed as everything above the first level was completely absent. Only large cement slabs hanging precariously from strings of rebar bared testament to the sheer magnitude of the 2010 quake. We made our way to the outside which had been completely sealed up…except for a gate which had an unlocked padlock on it. Help ourselves in? Sure.
At the front of the cathedral two staircases lead up a flight of stairs, and after climbing 20 or so vertical feet, the stairway was waist deep in rubble. Keep going? Of course. We finally came to the top level of the the front of the church 40 feet up, completely covered with rubble.
Seeing this behemoth of a structure being absolutely demolished by the earthquake, it was the first time that the gravity and the strength of the natural disaster was evident to me. It was a life changing experience.
The Downtown Hospital
On the last day of our trip around 8 PM, we drive through a 10 foot high green sliding gate with broken glass that acts like makeshift barbed wire. There is a man puking on the side of the road with an IV in place, his friend just kind of stands by. We park on the side of the main road, and talk to the security guard and he motions us to come inside the ER, but I’m not exactly sure where we’re going because theres no light on in the room in front of us.
It takes a horrifying couple seconds to realize that this IS the ER. The entire ER is out of power. No backup generator, no auxiliary power, nothing. It is probably 2 times the size of LLU’s ER, with cots 3 feet apart in rooms holding 20-30 patients each. Occasionally a family member turns on their phone flashlight to accomplish some task.
There are patients with long leg casts, external fixators, and skin traction. Most are awaiting surgery for what appears to be long bone (femur, tibia, humerus) fractures. Currently no one in Haiti does pelvic trauma surgery. No one.
We then make our way outside to the orthopedic wing which for some reason has power. Some woman adjusts her dress a little bit and pees on the ground in front of us on the sidewalk.
The orthopedic ward consists of 4 rooms each again holding 20-30 patients with 3 feet between cots. There is no air conditioning, only one rotating fan in each room. Patients are again in external fixators, casts or in skin traction. We are informed that if a patient has an external fixator in place, they are not allowed to leave the hospital due to the possibility of losing the hardware, so in the hospital they sit, for weeks. Furthermore, the patients have to pay for everything except for their food. The implants, the surgical gowns, the gloves, the sutures, everything. Considering 80% of Haitians make $2 a day or less, this is no small financial undertaking. Debridement seems to be surgery of choice due to the high infection rate. We meet a young man who started with a simple distal tibia fracture, who now has had most of his tibia removed after being in the hospital for 8 months. What should have been a 60 minute surgery with weight bearing as tolerating the following day for the patient will instead now require a below knee amputation. He smiles when he talks to us and shows us his bible at the bedside.
Dr. Nelson informs me that BKA patients do not do well here.
Our host tells us that typically 3 orthopedic cases are done a day. If you’ve been following along, they have over 100 orthopedic inpatients. 3 cases a day.
We then get to the peds ortho ward. It looks…exactly the same. Kids in ex-fixes for things that would never be externally fixed in the states. I count 5 kids younger than 5 in skin traction. For the life of me, I have no idea what the indication for traction on a 3 year old is. If it’s a femur fracture, it should either be spica casted or flex nailed. We have both at HAH. If it’s a tibia, it should be casted. We have that at HAH. There are reasons why the downtown hospital doesn’t transfer patients to HAH, but when kids are suffering they’re all unacceptable.
At the HAH, we had the supplies, we had the anesthesiologist, we had the OR time to probably clear this entire ward. Watching children suffer while knowing you had the time, the tools and the opportunity to help them is over the past 2 weeks… I’m not sure what the stages of grief are, but I can tell you I went through 3 in that peds ward. Pity. Anger. Resolve.
I’ve been told that Dr. Nelson is the most prolific traveler, which I sort of dismiss… and then I come across this:
The flight back is altogether uneventful.
Coming back to the US, it takes a certain amount of acting and feigning empathy to fit in. And let’s be honest, most of the issues we have in the US compared with what we’ve witnessed over the past 2 weeks are complete bullcrap. “Oh, you’re son didn’t play pitcher in his game today? That’s awful!” “Starbucks didn’t make your drink right again? Oh man, that sucks.” I watch a grown woman throw a fit at legoland because her 3 year old can’t go on a ride that’s clearly marked ‘4 years and up.’ Sigh.
Lizette was already there when we got there. She was 20 years old, and had 3rd degree burns over most of her back, torso and upper extremities. In Haiti there are very few formal gas stations, and if you’re driving a tap tap and run out of gas along the road, walking 20 miles to the next one isn’t really an option. So every so often there’s a roadside stand that sells individual gallons of gasoline, enough to get you back on the road long enough to get to a gas station. Around 8 months ago, Lizette was selling these gallons of gas when some kind of spark ignited the gas behind her giving her the burns she was currently under our care for.
Her hair had started to fall out as she had no appetite for food, her abdomen had started to take on the look of the malnourished. She had been undergoing dressing changes of her still very open wounds for the greater part of her recovery. Dressing changes were no small undertaking, involving scraping off any dead tissue that remained, cleaning the area with betadine, and applying new gauze and Kerlex gauze to the area. It was heartbreakingly painful for the patient.
Lizette passed away quietly last night.
I am convinced that the care that Lizette got at the HAH was far above and beyond that which she would have received at most other hospitals in Haiti, yet it still wasn’t good enough. She was suffering. There is no shortage of people suffering in Haiti. We needed to be able to do more for Lizette. We need to do more for the people and children of Haiti.
“Human suffering anywhere concerns men and women everywhere” Elie Wiesel
Dietrich/Mulder/Gerke Trip Report
The Dietrich/Mulder/Gerke orthopedic/anesthesia team spent April 19 – 24, 2015 at Hopital Adventiste d’Haiti (HAH) and the following is their report. Terry and Jeannie Dietrich have established the Dietrich Haiti Indigent Patient Fund through Amistad International to create an endowment that will sustain itself to facilitate patients who don’t have the means to pay for life-changing surgeries.
The OR remodel project a HAH is not finished however the new hospital administrator, Ed Martin, and Scott Nelson encouraged us to take a team to the hospital. It is especially important to continue to support Francel and the orthopedic program. Our planned trip 6 months ago was suspended at the request of Mr Martin due to the financial and staffing issues he was struggling with at the time. Fortunately a semblance of stability has been regained.
Francel Alexis is a young Haitian orthopedic surgeon. He was born and raised in Le Caye on the south coast. It is about a 4-5 hour drive from Port as Prince. He did an orthopedic residency in Haiti. Scott first told me about him in 2011 when he was doing a pediatric orthopedic residency at the CURE hospital in Santo Domingo. Dr Alexis had been planning to return to his home town to practice pediatric orthopedics. Scott thought he might be a good candidate to work and perhaps even be in charge of the orthopedic program at HAH. We contacted him and his CURE sponsors and arranged for him to spent the last several months of his fellowship at HAH with me. He would also be able to learn pediatric orthopedics from Scott and the other orthopedic teams coming to HAH. At our encouragement, he has stayed to work at HAH. He has been a great addition to the orthopedic work at HAH. We continue to sponsor him and support him with expertise, and orthopedic materials, supplies, equipment and implants. I contacted Francel and requested that he find as many patients as possible for arthroscopy. He made good progress with his arthroscopy skills during our last trip here in April of 2014. Our plan was to build on that experience and help him to reach a new level of comfort and skill doing arthroscopy.
The new administration of HAH headed by Ed Martin has been tasked with paring down the hospital staff. Many workers have been laid off in this challenging time since the loss of the Embassy clinic. Additional challenges continue to present themselves. Slow but steady progress seems to be occurring. The plan still continues to be for the hospital to be financially stable with all overhead covered by the paying patients. Then the “true costs” for the additional nonpaying patients will be minimized with the visiting teams bringing disposables, medications, supplies and implants. There is even hope the Embassy contract might be regained. The Emergency Room is currently located in the area where the Embassy clinic was held.
Volunteer housing for the visiting teams remains in the small building just below the rehab center. Some good changes have been made. The 6 bunk beds have been replaced with 6 single beds. Obviously, this change limits the number of volunteers able to stay on the hospital compound. A second small table has been added as well as a small couch. The biggest and nicest change is the kitchen sink and counter with cabinets. Now we have adequate space for food preparation and clean up. The tasty meal provided daily of rice, beans, vegetables and salad has been nearly twice as much as the four of us can eat. The internet connection is pretty good although a bit slow. I was able to use the internet most of the time but Tim never got it to work. The small air conditioner cannot keep up with the heat generated by the Haitian midday sun. We are only there for brief periods at that time of day so it doesn’t really matter much. It is plenty cool at night and in the morning. Two strong oscillating fans keep the air moving. Jeannie made nice curtains for all of the windows at Scott’s request. They look very nice. Jeannie also brought nice sheets and blankets for each of the beds. It is beginning to look and feel much more homey. The afternoon sun hits the side and roof of the building directly. The idea occurred to us that shade would keep the house cooler and use less energy in the process. Steve generously paid for a nice grafted mango tree. If it grows fast, it will be making shade in a couple of years. The fruit will be an added benefit.
Our Anesthesia providers for this trip to HAH consisted of Dr Steve Mulder and Tim Gerke student CRNA. Tim is our son-in-law. He and our daughter ,Summer, live in Portland Oregon. Tim has about 8 months left in his 27 month training program. He has already completed 3 ½ months of clinical rotations. Dr Mulder is a graduate of the Loma Linda University School of Medicine. He has been practicing anesthesiology nearly 30 years in Central California since finishing his residency training. This was Steve’s seventh trip to Haiti, all since the earthquake. He is an excellent specialist. He is well acquainted with the challenges of providing high quality anesthesia in a third world country. The anesthesia machines do not receive regular servicing. The ventilator was missing from the machine in OR #2. Reliable pediatric laryngoscopes were hard to find. The normally used supplies were missing or hard to find in the anesthesia carts. The touniquet pressure control alarm continuously sounded its high pitched beep. Heart sounds were nearly impossible to hear especially when combined with the racket from the suction device. Muffling both of those very loud sounds provided partial relief. Our temporary OR situation at HAH does not give us space for anesthetic recovery. Both Steve and Tim kept very positive attitudes and continued giving excellent anesthesia in spite of these challenges. They both have such a heart for this type of work. Their wives, Victoria and Summer, deserve lots of kudos for their willingness to let their husbands come to Haiti without them.
Tim arranged with the Sonosite Company to let us use an ultrasound unit during this trip. Many of our patients, large and small, were able to get a regional or nerve block. Post operative pain control is much easier. Many patients awakened from the anesthesia with little or no pain. The general anesthetic used is almost always much lighter and there is less or even no postoperative nausea. The immediate post op recovery is also much smoother with much less respiratory depression.
I had arranged for Francel to bring as many patients as possible with knee and shoulder problems so that we could focus on him learning arthroscopy. The first several cases took longer and he was somewhat more tentative. Movements didn’t seem very confident and at times seemed somewhat counterproductive. With more time and as more cases were done there was a clear improvement in the ability to obtain good visualization. Movements were much more confident. His ability to place instruments in the visualized areas improved significantly. I am sure that Francel will now start doing arthroscopy cases on his own and progressively improve as time goes on. A vigorous sportsmedicine/arthroscopy program would undoubtedly be beneficial to both the hospital as well as Francel. Almost all of the patients are outpatients. They use few hospital resources. None of the other local orthopedic surgeons do any significant arthroscopy. A strong program here will not have a negative impact on their practices. It is conceivable that patients with ability to pay could be attracted to HAH. This could help Francel’s private practice to grow. It could also help to stabilize the hospital financially.
James Jean Baptiste is an orthopedic surgeon who is a good friend of Francel’s. He works for Doctors Without Borders here in the city. They studied together through med school and residency training here in Port au Prince. He came several days to learn as much as possible. He scrubbed with us on some of the arthroscopy cases. He has a strong desire to learn arthroscopy skills. He might be a very good candidate.
Dr Eldine Jacques is a young colleague of Francel’s. She is a bit younger than him. She did a fellowship in Pediatric Orthopedics and currently is the orthopedic director for CURE in Haiti. She is in charge of the clubfoot program. She does all of her surgical cases at HAH. She is very likable, has a beautiful smile and adds a real touch of class to the whole program.
JJ, Emmanuel, Roosevelt and Joseph are four of the original translators that we have maintained fairly close contact with since we left after our year volunteering at HAH. We had a closer relationship with them because they frequently would accompany us on the occasional trip away from the hospital. We went to Jacmel on a couple of occasions. We went above Petionville to Fermathe more than once. We even made it all the way to Furcy one time. Roosevelt came with us when I arranged for us to go on a boat ride in a “cannot” to the Acardin Islands. That was an amazing day. We had a great time looking for shells, eating our picnic lunch and then getting great photos of the whole experience including the homemade boat and sails and our captain. JJ, Emmanuel and Roosevelt came with me on our long weekend trip to Mirabalais and then down the Artibonite valley to Molina sur Mer resort. We had a great time hanging out and enjoying the pool, beach and other amenities of the resort. None of the three had ever been to a resort before.
All of them are doing very well. JJ and Roosevelt have finished with at least the first phases of their training and are working at the hospital. Roosevelt is a PT tech and really is enjoying his work. Emmanuel continues to organize and run the ortho clinics. He remembers the patients very well and communicates with them frequently. He is still studying business. He would like to eventually work as a hospital administrator. Joseph Rika is nearing the end of his PT tech program. JJ, Emmanuel, Elaine and others planned a great evening at the Auberge. We celebrated Jeannie’s 33rd birthday by stuffing ourselves with pizza and birthday cake. It was a great evening.
Elaine Lewis is an amazing person and is doing a remarkable job. Her life journey has brought her to HAH as a volunteer for at least 6 months. After more than 30 years working as a homemaker and caring for her husband and their seven children she started working part time teaching English as a second language. A lifelong desire to participate in overseas medical mission work led to a training program as a surgical tech. Providentially she found haitbones.org and contacted Dr Scott Nelson. Arrangements were made for her to come to HAH and use her organizational and teaching skills. Fortunately she was able to convince her husband, Jeff, to take a sabbatical from his teaching responsibilities as an assistant professor of Intercultural Studies at California Baptist University.
The ongoing delay in the OR remodel has now given Elaine the challenge of making the temporary ORs as clean, organized and efficient as possible. Identifying the employees that are suited to the operating room is key and training those that are a good fit is essential. She has clearly identified JJ as highly trained and motivated. He understands the orthopedic equipment and setup much better than anyone else and is also doing a remarkable job.
The C-arm image intensifier is absolutely indispensible for doing high quality orthopedic surgery. Our OEC has been worth its weight in gold. It was donated through the generosity of several American orthopedic surgeons shortly after the earthquake. For more than 5 years it has served the visiting orthopedists faithfully for the most part at HAH. On a couple of occasions the screen gave us an “ERROR” message and we were left hanging. One of those incidents led to a 45 minute phone call to the OEC tech in Salt Lake City. Scott in his inimitable fashion boldly disassembled parts of the unit to gain access to the “potentiometer.” That particular item has a touchy adjustment. A new potentiometer and some fine tuning later, it started to work again. Current fluctuations which are daily if not hourly occurrences in Haiti probably were the cause. Keeping the unit always plugged into the invertor circuit protected all of our electronics including the C-arm from those fluctuations.
The OR crew knows that the C-arm must be handled carefully so that it doesn’t hit walls or other obstacles when it is being moved. The old ORs had an irregularity in the tile floor that made it difficult to move the C-arm from room to room easily. The temporary OR floor is smooth allowing easy movement of the C-arm. We were able to use it in both rooms and even the hallway without any issues this trip. I am confident that the new ORs will have perfectly smooth floors. They are nearly done with only the last couple of rows of tiles to be laid at the very entrance to the OR suite. The C-arm worked without a single hiccup this trip. It must be the grace of God that has protected it from the power issues for the last year while we have been in the temporary OR. The Fuji digital xray machine had not been working for about 2 months. That placed a bigger burden on the C-arm which was used a lot more to keep the costs down for the patients unable to pay. A tech from Fuji repaired it last week and it worked better than ever during our week.
The OR suite remodeling project is making slow, agonizingly slow, progress. It has promise to be an exceptional facility, possibly the best in the country. The entire rewiring and control panel in the shop area under the ORs is certainly an impressive change from the preexisting ratsnest of wires that were clearly very dangerous. The air exchange system that is essential for a good environment that will be acceptable for joint replacements has also been installed. Scott included pictures of the units in his latest blogpost. Major dollars must have been spent to accomplish both of those feats. The three ORs are currently getting the overhead lights installed. (WHAT? No more headlamps?) The designated area for post anesthesia recovery looks very nice. I am excited along with everyone else for the project to be finished.
The current temporary OR is just that. It occupies the natural space of the emergency room. I am writing this in the back storage area and am being attacked by hordes of tiny ants. They chase across my computer screen randomly. Not a day has passed that mosquitoes have not been flying through our sterile fields. The flies have yet to invade which is good. The job of organizing the ortho equipment, implants and surgical supplies has been done in an outstanding fashion by Elaine, JJ and Scott and his team. The C-arm is running beautifully (knock on wood.) The printer even works nicely now that it was discovered to have the paper roll wrongly inserted. We utilized the smaller OR for several of our cases. Even when we needed the C-arm, we were able to get it far enough into the small room to xray the part being operated on. Of course, the monitor had to remain in the hall. A bit inconvenient, but it works.
We had a great mix of patients. The prior problem of patients being signed up for surgery but then not showing up after their interview with administration seems to have been solved. We had no “no-shows.”
Aside from the arthroscopies, we did nearly 20 other cases during our 4 days of operating. Several kids with genu valgum and varum got 8-plates. An older teenager had closed epiphyses and got a femoral osteotomy and Orthofix. A 30 y/o had a large mass on the plantar surface of her foot measuring 8×6 cm. Previous biopsy at the General Hospital had showed it to be a hemangioma. Complete excision with wound closure was possible.
While I was busy with the foot tumor, Francel and James did an IM rod removal from a patient with a malunited (30 degrees of ext rotation) femur fracture. He did a derotation osteotomy and fixed it with a locked SIGN nail. A patient with a dislocated patella came for surgery. She had had a prior patellar tendon advancement and proximal realignment for “patella alta”. It had obviously not stabilized the patella sufficiently. She had not had recent trauma. I did an aggressive open lateral release, medial plication, VMO advancement and distal realignment with a Roux-Goldthwait procedure. The patella was very stable when the case was finished and the knee flexed easily to 130 degrees. I also did a patellar nonunion. The trauma occurred 7 months ago. The open reduction and Fig 8 tension band wiring went well.
My last case was a patient injured in the earthquake Jan 12, 2010. She sustained an open tibial fracture from a crush injury. Three operation later she was “free” of infection. The tibia finally healed as well. 4 days ago, she had a sudden spontaneous pain in her mid/distal tibia. The entire middistal pretibial area was very tender and swollen. She was febrile. The xray was very suspicious for a small middistal tibial sequestrum. Clinically the infection had flared up. The incision released more than a half cup of pus under pressure. The 15 centimeter window in the tibia showed a sinus leading to a fairly small sequestrum. The thorough debridement, washout and antibiotics may perhaps cure her. It wouldn’t be surprising though if more similar events will occur in the future. It is not uncommon for this type of bone infection to be a lifetime condition.
A major problem surfaced when we did a case with plans to place a wound vac. We were unable to use any of them as they all required an “access code” to be activated. All efforts to put them in use were stymied. Many calls to LLU and to the company could not solve the problem. We are going to try to reconnect with Jan a nurse from SanDiego who is a vac specialist. She solved a similar problem for us several years ago on our first trip to HAH.
Overall, this trip was one of the best for Jeannie and me of our seven weeklong trips to HAH. Much can be attributed to Francel and his hard work. He relates very well with patients and gets along very well with hospital workers, administration and volunteer team members. His progress in learning arthroscopy is really exciting to me. The two young orthopedists that are working with him can add strength to the program. The equipment, with the exception of the vacs, was all in good working order. The temporary ORs are adequate although incapable of being sealed to prevent insect invasions. It is exciting to see the OR remodeling project well on its way to completion. JJ now has formal training to give him credibility as a health care worker. Elaine’s hard work and contributions have been priceless. With God’s continued blessings, HAH will continue to provide excellent orthopedic care to all Haitians regardless of their ability to reimburse the hospital for the services rendered.
Beginning with a trip to Africa when Terry was a senior medical student, the Dietrichs have compiled an impressive resume of volunteer service. Over the past 40 years Terry and Jeannie have worked in numerous countries including longterm stints in Puerto Rico, the Dominican Republic and Haiti. Most volunteers do so at the beginning or end of their careers but the Dietrichs have managed to weave in a commitment to overseas missions while maintaining a thriving practice back home. Terry was asked to present their experience below at Loma Linda University’s recent symposium on Global Orthopedics. (In the photo above, Terry is helping an orthopedic surgery resident rod a tibia)
Our dirt poor little farm in North Dakota was the starting point . My dad was a farmer as were my grandparents. All of my uncles and cousins were farmers, laborers or petty criminals. That was my destiny as well. Well, hopefully not the criminal option. A book changed that destiny. The story of Dr Stanley Sturgis in the book “In the Valley of Seven Cities” captured my imagination. I would be a “missionary doctor” like Dr Sturgis. Nearly two decades later, my lovely wife and I embarked on the first phase of what for us has been an incredible journey. Our twelve years of full time mission work at Hospital Bella Vista in Puerto Rico were a wonderful experience both professionally and personally. Living in another culture, learning a new language all the while experiencing an orthopedic practice with amazing variety was unbelievably enriching for me and my family. It formed the basis for a skill set and comfort level that made all of the subsequent international experiences possible.
The SDA hospital in Puerto Rico initially was equipped with only outdated orthopedic equipment. Working with those somewhat primitive tools during the first 2 or 3 years gave me a much greater appreciation for nice, modern power equipment and imaging to manage the steady stream of ortho cases. Modernizing the orthopedic department was made possible by the addition of a well trained hospital administrator coupled with frequent requests to upgrade our equipment including C-arm acquisition. Nearly a decade later, I left Puerto Rico with the experience of several thousand cases of scoliosis correction, children’s deformity correction, total joint replacement, tumor and infection cases, fracture fixation and arthroscopy. The breadth of that practice would be virtually impossible to replicate.
The private orthopedic practice that I enjoyed for the next 16 years in the little town of Walla Walla, Washington was, needless to say, “tame” by comparison. The desire to continue with international work had not been extinguished. The opportunity to develop a quality orthopedic service in the Dominican Republic became available at a small Christian hospital. Nearly thirty week long trips over the next 15 years provided more opportunities to do many of the same types of orthopedic cases that a small town practice never sees. Ultimately, I had the great fortune to meet Scott Nelson. We were able to work together in the DR for several years. I even joined him for one of his short trips to Haiti. Scott’s legendary appetite for work became totally apparent during that week. More than 50 cases left me as exhausted as I’ve ever been and vowing to leave Haiti to him.
The disastrous earthquake struck Port au Prince and environs more than a year later. Scott was the first orthopedist to enter the country 48 hours later. In the milieu of near total catastrophe, he organized human resources and orthopedic equipment and developed an amazing program at Haiti Adventist Hospital. Synthes announced plans to send a corporate jet with $10 million of implants and equipment. Much of that donation found its way to HAH. Other organizations made major donations. More than 200 members of the AAOS volunteered in Haiti in the weeks after the disaster. Several helped Scott at HAH. I have been privileged to be part of that program.
It is nearly mind boggling to see what has been done in the poorest country in the Western hemisphere. Correction of unbelievably severe long standing deformities has become fairly routine. The TSF is a great example. To have such a powerful internet controlled tool to deal with these severe deformities in Haiti is almost unimaginable. Scott taught me the principles as well as surgical technique. I was able to follow his cases as well as use the device on a number of mine during the year I volunteered at HAH.
The arthroscopy program that we have is another important addition to the program. Now teaching Francel Alexis is a major focus. He has the potential to be the best arthroscopist in the country. He came to HAH to finish a fellowship in pediatric orthopedics during the middle of my year in Haiti. He remains there serving as the important bridge between teams of visiting orthopedists. He has become adept at placing the TSF and doing many other types of deformity correction especially in children. We believe he is the key to the future of the orthopedic program at HAH.
37 yeas of living and working full and part time in these two nonAmerican cultures has been a very interesting and satisfying experience. Learning another language is a byproduct of the situation. La lengua de Cervantes is considered by those with whom I lived and worked for many years to be la lengua del Cielo. I have also been privileged to meet and work with many other incredible orthopedic surgeons who dedicate much of their time and expertise to international orthopedic work. I think of Dr John Herzenberg, Dr Kaye Wilkins, and Dr Lew Zirkle. There are a host of others as well. An orthopedist doesn’t need to leave his own culture and “comfort zone” to find poor people with significant orthopedic needs, For me, it has been a special journey to be involved in other countries.
Stay tuned for the upcoming trip report from the Dietrich/Mulder/Gerke team who recently returned from another trip to Hopital Adventiste d’Haiti earlier this month. Please consider donating to the Dietrich Haiti Indigent Patient Fund’s goal to raise $500,000 for an endowment to facilitate the care of indigent patients at HAH.
Corey Burke Trip Report
Corey Burke is a 3rd year medical student from Loma Linda University with an interest in pursuing a career as an orthopedic surgeon. He recently returned from spending 2wks volunteering at Hopital Adventiste d’Haiti.
When I think about HAH, I see a young girl waiting in the pre-op room smiling at me. She can’t contain her enthusiasm over the hope she has been given by the hospital staff. She has never even met her surgeon before this week, yet she has complete trust in his ability to make her whole again. There were so many children like this. Although their lives are far from easy, their joyful and lighthearted spirits can’t help but inspire those around them.
With this being my first time on a medical mission trip in Haiti, I wasn’t exactly sure what to expect. I remember the excitement and apprehension I felt as I stepped off the plane onto Haitian soil a little over three weeks ago. Little did I realize then the immense impact that this trip was about to have on my vision for my life as a medical doctor.
I can’t even put into words the immeasurable amount of poverty I saw on a daily basis. Although I knew that Haiti was an impoverished nation, I didn’t anticipate being so affected by this reality. Large piles of garbage lay wherever I turned my head. The amount of pollution was shocking. There was evidence of poverty all around us.
Each day as we walked to the market, we would pass a man with only one leg who was crutching around the streets. Each day I wondered what his story was. How did he lose his leg? When did it happen? Could this ailment have been prevented if he received the proper care at the proper time? I found myself asking these questions time and time again. I still can’t wrap my mind around a boy we saw at another local hospital who had been inadequately treated for a tibia fracture and had been lying in a hospital bed for eleven months. Although no one at the hospital has said it yet, he will most likely need an amputation and not have the opportunity to grow up experiencing the vibrancy of young adulthood with both legs. Countless other patients lie in their hospital beds waiting to be treated, having no idea when or if they will be able to have the surgery they need. I found myself feeling incredibly thankful for the work of HAH. The country of Haiti is truly blessed to have HAH selflessly serving those in need. The work they have done and continue to complete is tremendous. But the need in this country remains remarkably great.
My Experience at HAH
I had the honor of working with a team that came from all different backgrounds, yet were unified as one for the common good of the people of Haiti. How neat it was to experience the genuine camaraderie of a group of profoundly talented individuals. Our surgical tech and head nurse, Elaine, did an extraordinary job of keeping everything moving quickly and in an orderly fashion. Her constant encouragement, phenomenal work ethic, and heart for service all stem from her love for Christ. Maria (anesthesiologist) and Lucia (nurse) traveled from the Dominican Republic to join us. Maria displayed her expertise and confidence with each case. Lucia worked tirelessly to care for our patients. The way they both worked with our patients made it evident how much they cared about them and wanted what was best for them. On the last night of our time together, our group went to the roof of the hospital and Lucia led us in prayer, lifting up the patients of HAH. She also shared about how she has a special place in her heart for the people of Haiti and how she prays for them daily.
What a humbling and valuable opportunity it was for me to work under such an exceptional team of orthopaedists: Dr. Nelson, Dr. Anderson, Dr. Mildren, & Dr. Alexis. Seeing the way they responded to the different cases and how they thoughtfully worked through each one is something I will take with me throughout my career and training no matter where I go.
There was one case in particular that I’ll remember for years to come. A young girl had been burned on the back of her leg by a motorcycle exhaust pipe a year ago and hadn’t been able to walk due to contracture of her leg. We performed an excision of the scar and casted her leg in extension. This was not a complicated surgery, yet this child had to endure a year of pain and difficulty not knowing if she would ever be able to walk again. How incredibly rewarding it is to know that a simple procedure will have lasting effects on her life.
Another case etched into my memory involved a teenage boy with tibia osteomyelitis. His infection had been worsening over the past year to the point where the old, dead bone was sticking out through his skin and new bone was growing in behind it. We were able to remove the dead bone and put in antibiotic beads so that it could begin to grow properly. This procedure was unlike any I’ve had the opportunity to assist with before.
Not only did I amass valuable knowledge of orthopaedics from the doctors I worked under, but I also learned about the importance of servant leadership. In order to keep matters running efficiently, our team spent time each day performing tasks around the hospital. This often meant preparing for surgeries, but also included a lot of organizing, cleaning, and even painting. Our team was up late into the night on one occasion finishing painting and preparing the new preop room. The following morning, a hospital worker approached me about how he could not believe that he saw Dr. Nelson, a respected surgeon, take the time to paint one of the rooms in the hospital. He said that it made him think, “If Dr. Nelson is willing to paint a room for the hospital, why can’t I? What else can I be doing to help?” This is merely one example of the many instances in which the team of orthopaedists took the time to serve in whatever capacity was needed in the hospital. It was truly a blessing to partner in their work for two weeks.
I have been to Africa, Central America, and South America on mission trips, but never did I realize the massive need in this small country of Haiti, a place in America’s backyard. The doctors, nurses, technicians, and patients I worked with at HAH have inspired me as I step into the remaining year of my medical school training and as I continue on into residency. My mind will never cease to remember the images of those men, women, and children at local hospitals lying in beds for weeks at a time waiting for treatment. This has served as a reminder of why I chose to enter the field of medicine and has given me a picture of what I am working towards. As I stepped on the plane to come home, I left with a renewed sense of purpose, motivation, and hope that I will have the opportunity to return to Haiti someday soon.
To Our Donors
The following is the seventh and final installment of Scott Nelson’s March, 2015 Trip Report Series.
The accomplishments and plans mentioned in the previous posts do not happen without the support of our generous donors. I would like to thank those who have contributed in a special way and remind you that your investment is making a difference for the people of Haiti. It is being used in a judicious and efficient fashion to rejuvenate the hospital physical plant in order to more adequately reflect the quality of medical work and the healing ministry of Jesus Christ that we represent. The permanence of physical plant restoration is satisfying but even more substantial is the lasting effects of the operations we perform on the lives of our patients. The physical burdens lifted by the operations we perform often make a lifetime of difference and even affect subsequent generations. In the cosmic scheme of life you could argue that these acts of kindness last forever, going well beyond the short span of our lives on this planet. We are especially grateful to the Foundation for Orthopaedic Trauma for their support of this trip and the operations that were made possible. Continued support is needed and again past support is appreciated.
The following is Part 6 of Scott Nelson’s March, 2015 Trip Report Series.
Since the loss of the US Embassy contract to provide history and physical exams for Haitians applying for a visa, the hospital has been in a severe financial crisis. This provided about $60,000US per month, which is around 60% of the hospital overhead. Soon after that, Mdme. Clotaire hospital CEO stepped down and Edward Martin assumed the position. His first 6 months in office have been fraught with many difficult challenges one of which is a major staff reduction. The financial viability of the hospital has continued to struggle and many workers have not been paid for months. The volunteer program has continued to attract patients who are unable to pay for services and further add to the deficits. Up until this point it has been difficult to use donor money to fund this program because of a lack of accountability and the natural tendency of these subsidies to only enable continued fiscal irresponsibility. A new Haitian CFO named Bob is changing this and Mr. Martin is steadily gaining control of the situation. Due to these recent changes we spent significant time on this trip designing a business plan that would enable the hospital to maximize their income from patients who have resources and also to develop a formula where an equitable subsidy can help patients that are unable to cover the direct costs of their care and prevent the institution from incurring further losses.
Estimates for the allocation of total hospital resources attributable to each orthopaedic operation performed at HAH are approximately $1500USD per operation. This includes administrative expense, generator fuel, facility maintenance etc. (indirect costs) As volume of operations increases the per case indirect costs decrease. However,direct costs, which make up a relatively minor portion of total costs remain relatively constant. These are expenses like dressings, medications, and additional anesthesiologist expenses relating to any given case. Our subsidy formula seeks to cover the direct costs of each operation which are approximately $300US for an average case. At the end of the year we know that this will come nowhere near the amount of income needed to economically sustain the hospital. The hope is that the volunteer program will enhance the reputation of the hospital, attract paying clientele, and encourage donations of materials and supplies and with a good business plan the hospital can become financially viable. Volunteers should understand that the hospital may charge some of the patients receiving operations. Donated supplies are brought to help offset hospital expenses and our spirit of charity must be intended to help build capacity of the institution and medical community and not only to give free operations to patients.
The indigent patient subsidies will be given with some criteria for the hospital to be accountable and also have a social work department in the business office to assess the economic needs of the patients and give discounts accordingly. All too often simple pricing schemes in Haiti are used to target upper or middle class paying patients and poor people are turned away. On the other hand if token prices are given and potential income is not collected then donors are subsidizing care for wealthy patients who could easily afford to pay. In addition resentment is created in the medical community when wealthy patients are given discount services as this undermines the income sources for other surgeons in the city.
Where will this money come from?
- Indigent patient endowment fund which has the potential to produce approximately $15,000 per year based on a principle of $300,000.This will be largely used to fund a portion of Dr. Alexis’ salary for the portion of his work attributable no nonpaying patients
- Volunteers – Surgical teams will be encouraged to donate sufficient funds to subsidize the operations they are performing.Operating 20 patients who pay nothing would require $6000 of subsidy, which would be the suggested donation for a typical volunteer team. Sometimes more or less patients will be operated, sometimes patients may be able to pay part or all of their direct costs. Although accounting will be kept, and year-end balances will be reviewed, these subsidies will be suggested tax-deductible donations.
- Patients themselves – even if a patient can pay $10 this will be collected and decrease the reliance on donor subsidy while also creating responsibility and commitment on the part of the patients.
No plan is perfect and in this environment where there is a large difference in affordability of services it is difficult to create an equitable system that serves the richest and the poorest as well as all of those in between. The general concept will be what I call the “American Airlines Model”. That is where all passengers arrive safely at their destination at the same time, but if you want a wider seat, warmed nuts, a washcloth and hot meal then you may be willing to pay 3x more for your ticket. Even in economy class people may pay different amounts for equivalent seats. At HAH we will not discriminate but if patients are willing to pay for premium rooms then let’s maximize our opportunity and provide first class service. If they want the cheapest economy rate then let’s give them a timely and safe operation – and maybe we can add a free orange juice and a handful of peanuts.
Update On Current Projects
The following is Part 5 of the March, 2015 Trip Report Series written by Scott Nelson.
Although our previous operating room was recently reported to me as being one of the best in Haiti, in reality it was not adequate for doing the quality and volume of work that we envision. A major renovation was started in January 2014 and continues at this time. The outcome of this project is beyond my highest hopes, the time and resources required for this have also exceeded my expectations. Things are progressing and although I hesitate to mention it, I have been told that by July 1st we should be able to move in. They actually said June 1st but in reality at the current rate I think July 1 is a much more realistic goal. The one thing for sure is that the attention to detail, quality of work, and improvement from the previous facility will not be a disappointment to anyone. Dan Brown who is managing the project is a perfectionist after my own heart…Dan’s well organized workshop is the feature image above. The lab is also in beautiful condition and as soon as some cabinetwork is completed the space will be inaugurated.
In our review of the facility a high priority has been placed on a cosmetic renovation of the main floor of the hospital. This will be a relatively simple update consisting of new electrical fixtures, some plumbing repairs, door and window repairs, air conditioning repairs and paint. The contractors who did the construction in the OR renovation have looked at the project and will be giving estimates of time and expense to complete this. There are several rooms which are uninhabitable at this time due to mold and mildew (I mean you can not even breathe in them). Many others have rotted doors, bare wires, broken lights and leaky plumbing fixtures. This will be a high profile improvement project that we will need to raise some funding for.
In recent years we have not had an organized space in which to place the patients being prepared for surgery. I have made multiple appeals to have a pre-op room and finally was granted the space. This is an important part of patient safety and OR efficiency. Patients have been waiting for surgery in the hallways and entrances of the hospital. Sometimes it is confusing to keep them straight, we are not able to effectively update them on when their operations will start, sometimes moms slip their hungry children bites of food and then don’t admit it knowing that their long awaited operation will be delayed or cancelled.
When I arrived this time the designated room was in a state of disrepair without immediate plan for inhabitance. Fortunately Chad became an expert painter last summer when he painted our house and was able to take over the job and execute a one-day makeover that met the approval of Dan’s quality expectations. Patients were moved in on Monday morning utilizing 6 new gurneys. IV’s were started, gowns placed and the day of surgery progressed with a new level of patient safety, efficiency and comfort.
Trip In A Nutshell
The following is Part 4 of the March, 2015 Trip Report Series written by Scott Nelson.
Patient care, administration, and organization were the 3 main areas of focus for this trip. Dr. Mark Mildren PGY4 ortho resident, Corey Burke 3rd year medical student, John Anderson MD orthopaedic surgeon LLUSM graduate year 2000 and our two Dominican essentials Lucia Hernandez RN and Maria Adrian MD anesthesia made up the team.
John’s family – Jeannette, Joshua, and Kaitlyn as well as my son Chad also joined us and devoted most of their time towards helping Jonathan Euler and the Beehive organization. Francel had many operations lined up for us as well as a couple of days of clinic. Due to John’s sports medicine expertise several arthroscopic surgeries were performed, we also operated on a spine fracture, and did a number of hip and lower extremity operations.
Elaine Lewis who is a surgical tech living at HAH for 6 months had the operating room nicely organized and clean. This was much different than the conditions that we have been faced with on earlier trips. She motivated us to organize all of our orthopaedic equipment and other supplies, which we spent a significant amount of time doing. Corey and Mark learned more about orthopaedic implants than they ever wanted to know. A big part of doing safe surgery is knowing what you have and where it is, perhaps this is even more important than quality lighting and the room that you are working in. Elaine had hoped that I would throw away a lot more than I did, but without a reliable supply chain I convinced her to hold on to some items that we will need in the future, but this came at the expense of her thinking I am a hoarder.
I spent a significant amount of time with Edward Martin the CEO developing a business plan and working out ways for the volunteer and orthopaedic program to continue in a sustainable fashion. More about that in subsequent report. We also spent an entire day with Dan Brown the facilities manager reviewing the entire facility and creating a coordinated plan for the future use of space and how various physical plant improvement projects will be prioritized. One notable aspect of this is the plan to remodel the upstairs area of the HIV clinic (building in front area of the property) for volunteer team housing. It is a pleasant space about 3x the size of the current quarters that has several large bedrooms and a common area.
The Importance of HAH
The following post was written by Scott Nelson who returned last Friday from another visit to Hopital Adventiste d’Haiti. This is Part 3 of the March, 2015 Trip Report Series.
A few blocks away from the Basilique Notre-Dame (still in ruins noted in image above) is a local hospital for which I will keep the name anonymous. I had a good idea of what the conditions were like but never having been there I asked Dr. Alexis if we could take a tour of the orthopaedic wards. The situation was even worse than expected. Patients languishing in crowded, oppressively hot, foul smelling rooms, some of which were only lit by tiny cell phone flashlights.
One horrible case after another, many of which would have been avoided with a simple well-performed operation at the appropriate time. In some cases expensive modern external fixators were seen carelessly applied with complete neglect for postoperative care. One patient had 10 inches of his tibia debrided after a relatively straightforward tibia fracture that got infected. Now he has been there for 11 months in bed. An emergent debridement and SIGN nail could have put him back on his feet. Now, an amputation is the only reasonable option, but no one wants to tell him that so he just hangs there. His Bible and Sabbath School quarterly are at bedside.
When we arrive back at HAH, our perception of dilapidation, disorder, and poor nursing care has changed. We feel like we have just walked in to the Hilton. But the knowledge of those patients at the government hospital, still suffering even as I write this report is motivation to continue our focus on treating the underserved. As we renovate our facility and improve the level of care we have an urgent need to create a communal ward where the poorest of patients can be economically cared for.
A few weeks ago Elaine Lewis met a man who brought in a patient who needed surgical care to Hopital Adventiste d’Haiti. As it turns out the gentleman is the coordinator for the Restavek Freedom ministry in Haiti. Restavek (restavec in French) is the name for child slaves in Haiti. Children who are desperately poor are taken in by families who promise to get them an education and a better life in exchange for servanthood. The reality is far different and amounts to 300,000 child slaves in this country. According to their website, Restavek Freedom’s mission is simple, to end child slavery in Haiti.