Mission accomplished!

At last I can go home having accomplished my last goal today Saturday. Steve and Jean-Claude were to make the trip to Port au Prince today so Kim and I were left to decide what we would like to do. It was a no-brainer for both of us. It was a unanimous decision to swim in the Caribbean, to lie beneath the coconut palms sipping a cool drink, and dream of seeing Johnny Depp stroll out of the surf (Kim’s fantasy). I would not have felt complete with at least one

swim in the Caribbean Sea. So we went with 5 young people from the church and Rosita and Ma Theo who look after Robyn’s apartment. Nine of us piled into the small Toyota Lite ace van that looked as if it were on its last legs. Then we were off, the driver ducking and weaving through the traffic as we headed out of the city. It was over an hour’s journey through some unimaginable tracks they call roads. Sometimes we were at top speed swerving to avoid the potholes and then a barely visible clay speed bump would appear and it was all anchors out as we slowed to a crawl to negotiate the hump without damaging the undercarriage. There were a few mighty big

clonks at times and the driver looked a little worried as he hung out the window to see what had happened, still driving at a furious pace. Even in the rural areas there were people everywhere, hanging washing out on bushes and watching this crazy driver with 2 “blancs” heading to the beach. The inevitable happened. On a particularly rocky area the wheel under my seat (right front) began to make some weird noises. The driver stopped to discover a flat tyre. Five minutes later we were on the way again with the spare in place. Eventually we arrived at a resort at "Michelet et Menard plage". There were 2 larger groups also using the resort for a meeting. We unloaded, got changed and headed for the surf. It was fabulous – warm water, a refreshing wind and a sandy beach. There was some floaties- mainly a weed a bit like pine needles, some charcoal that they use for cooking, bits of wood and the odd shoe or plastic bottle but nothing like the pollution problem at Cap Haitien. Kim and I were in for about ¾ hour. We had some sunscreen on but it was too good not to be in. The other Haitians joined us, but they do not need sunscreen. We lazed on the sunloungers under the coconut trees. I even got a nap. Then it was lunchtime – fried chicken, rice, fried plantain, salad and a sauce. All very nice. With all that ocean, we had to have another dip and it extended out to almost an hour. However, I was very aware that the sunscreen would not be working but how could I (we) resist. So we reluctantly came in but there was another exciting bonus for us. There, on the beach was a concrete post with 4 shower heads providing fresh water - the first proper shower I had since coming here. We reveled in the hot, then warm water (nothing ever comes cold unless it has been in a freezer) for 5-10 minutes before we changed and lazed about waiting for our driver. He turned up about 4 and then it was the mad dash home. This time there were no “blancs” in the van but two “rouges”. We had both taken a fair dose of vitamin D but were content and not too sore. On the way home, the van gave out again – the battery died but the driver knew how to get another even though we were on the outskirts of the city. It took about 15 minutes but then we were on the way. So we never saw a pirate or a shark but our time in Haiti has been complete and we are content. You can ask about the “rouge” when I am home in a week.

A typical day in theatre

Today (Thursday) I felt another blog coming on. I will apologize at the outset for those of you who may be offended by the surgical details but this is an operating theatre. It was my first day in theatre with Jean-Claude (JC) also in theatre so we were able to keep an eye on each other and confer when we became frustrated. I was scheduled to do 2 haemorrhoidectomies and an inguinal hernia in a lad with no testicle on that side. JC had about 4 cases with neglected fractures to deal with. When we arrived, my theatre was occupied by the first emergency caesar of the day so I was relegated to the small room (about 3x4 meters) that acts as a 3rd operating room in such circumstances. The patient was wheelchaired in, got on the table, was tied down in a crucifix position and various pieces of apparatus strapped to her - drip, ECG, BP monitor, oxygen saturation monitor.Everyone who comes to theatre has a urinary catheter inserted in the ward. My lady who I had seen two days before with a single prolapsing pile was found to have a BP of 205/105 once on the table. When this was confirmed, the anaesthetic technician tried to get the blood pressure down with IV medication. Dr LeCompte also tried. Steve was still recovering from his dengue fever so was not around. Meanwhile JC had started his case of a child with distal radius and ulnar fracture, using K wires to fix it. For my lady however, it was back to he ward to take her normal BP meds to see if the BP came down, which it did not so that case was off for the day.

Meanwhile, the World Cup soccer match was in progress and being shown on a TV set up in what passes for CSSD. Here there are 3 sterilizers and the nurses cut up lint into large squares, then fold them up into swabs (check fives we call them in NZ), bundle them into lots of 10 and wrap them up, put 30 of these bundles into a bag and sterilize them. They do use steam marking tape to tell when the load is sterile. These gauzes are used for everything - swabbing the wounds, soaking up blood, drying hands after scrubbing (I was given two of these small squares after scrubbing to dry my hands and arms!). Many things are recycled in CSSD. They use disposable gowns over and over again, as long as they are not too bloody. The number of recycles can usually be gauged by the fading blue colour - if you are handed a white gown you know it is likely to fall to bits when you try to put it on.

Anyhow, I retreated to CSSD to watch the soccer (unfortunately, they only showed the Italy-Slovakia game, not the NZ Paraguay game). The TV ariel was an old disposable (but probably due to be recycled) diathermy draped over a disused light among the sterilizers. JC joined us in the CSSD which was open to the outside and had many visitors during the match.

People generally can walk into theatre without scrubs to visit, but they are very strict about masks being on once you are in theatre. But there are no overshoes and a mask is meant to last a few weeks. My next case also had to be done in the small room as another caesarian section had arrived in my theatre. This was to be another haemorrhoidectomy who I had not seen preop. Apparently she had been bleeding but I did not know the history. They have no proctoscopes or sigmoidoscopes so the diagnosis is made by doing a fairly invasive examination of the anus manually, usually in the knee chest position and trying to turn the anal mucosa out to see the pile. They also do haemorrhoids face down but I obliged to my preference of lithotomy position in stirrups. There was no light in this theater but I had brought my bike headlight - better than nothing. The lady had some skin tags and a fibroepithelial polyp at the dentate line but no piles in sight! I did a formal rectal exam but could not feel anything else but they were expecting me to do a haemorrhoidectomy on a lady without haemorrhoids! She did have the anal tags so I removed them and a little of the anal cushions but it was a bit unsatisfactory. They had not seen piles done this way before and fortunately there was very little bleeding so they seemed impressed at the simplicity of the procedure. They also suture their haemorrhoid wounds closed whereas I leave them open.

Then it was back to CSSD to check the TV, - game over and mostly shock at Italy's elimination from the world cup - bottom of the table below NZ. We had a long break, sitting around waiting for theatre to be cleared. Lafontain arrived with our lunch of yoghurt, pate (pastry with a tasty meat paste filling) and sprite to drink. Another caesar had come in so we waited. JC saw a child with fractured tibia and fibula that they decided to plaster it. JC’s comment was that they would be safer plastering their fractures as the infection rate is so high for open surgery that the result is worse than a more conservative approach. Meanwhile Dr Compere, one of the general surgeons had seen a private case that morning of what he thought was an anal fissure. The patient, a young man apparently was leaping off the bed as he tried to do a rectal examination (I teach the med students that it is almost pathognomonic of an anal fissure and not to persist unless you want an enemy for life). Dr. Compere wanted me to assist as he planned an lateral subcutaneous sphinterotomy (dividing a small part of the anal outlet muscle that is causing the severe pain). He does this in the prone position so it was new to me. Under spinal anaesthetic, the fissure was confirmed - as classic a fissure I have ever seen. A gauze was stuffed in the anus and a sphincterotomy done - again, I tend to use scissors to dissect and cut

the sphincter but they kept handing me the scalpel. I did the operation at the usual position (3 o'clock) around the anus and thought that it was all over. However, Dr. Compere decided to make another incision at the 9 o'clock position as well, thrusting an artery forcep into the sphincter and dissecting, but nothing was cut. The senior resident wanted to see and feel the effect of the surgery so put on some gloves to feel. We removed a small skin tag nearby. But as the diathermy was there, Dr. Compere decided it had to be used so each sphincterotomy wound got a fair dose of electrical current. Then he decided to spray the fissure with the diathermy as well whereas I let them heal by themselves. It is a lot more than I would normally do but it should be effective. I hope it is not too effective and he is left with some incontinence. For this procedure, someone had found a portable light as my headlight was ineffective. Overall, Dr. Compere was delighted he had got the diagnosis right and it had been effectively treated. There was much shaking of hands and congratulations at the end of the operation.

Then it was back to the waiting game. One hernia to go. A fourth caesar had arrived and a fractured jaw was also to be done in my theatre by a faciomaxillary surgeon. So JC and I just had to wait. CSSD was now showing the late games in the world cup - Japan beating Denmark. While we were there, we noticed it was a little cooler and then the rain came. It is meant to be the rainy season here but apart from a thunderstorm when I first arrived, there has been no rain to speak of. We waited for some hours before JC was able to plaster a fractured radius and ulna and I managed to get into theater about 4.30 to do the hernia (no closing of theatres here at 4pm). Most of the seniors had gone home (there is only one anaesthetist and she had gone home and the general anaesthetic was done by a nurse technician) and there was only a skeleton nursing staff.

Nurses do not assist in operations here. It is the junior resident who sets up the scrub table, selects the instruments, loads the scalpel blade and acts as scrub nurse. At the end of the procedure, he will cut off all the needles for disposal but there is no counting of swabs or

needles. There are no consent forms either. They had a recent case here of a patient before theatre deciding to go for a walk. His relative decided to lie on the bed. When the orderly came to get him for theatre, the relative protested but it was passed of as a reluctant patient trying to get out of the procedure. They actually got him into the theatre before the mistake was discovered. They all thought it was a huge joke.

There is a big ritual surrounding the conduct of an operation here. It starts with the scrub in the one basin in the entrance of the theatre suite. The same disposable scrub brushed we use in NZ are used but these have been recycled. A green mixture is used (not sure what it is) and the tiny tap has to be turned of with the elbow (no electronic or foot control taps here). Then it is a short walk into theatre, alcohol is liberally poured onto the wet hands, and 2 small square gauzes are given for drying the hands. A big tin is opened containing more sterile swabs and 4-5 recycled gowns. One of these is handed to you with tongs and you robe up. If you see a hole in the sleeve, just ignore it. Then the gloves are supplied, minimum size is 7 ½ . Fortunately I brought some of my own size 7 gloves. Sterilizing the patient’s skin and draping is a long established ritual. A sponge holder with a gauze is heldover the umbilicus and a nurse squirts betadine solution onto the gauze until it is dripping. The umbilicus is thoroughly cleansed then the gauze ritually run in large strokes from there almost to the knee (for a hernia). This is repeated to cleanse the skin on the opposite side (umbilicus to knee) and then a third application of the betadine to the abdomen to knee on the side of the hernia. By this stage, the patient (who has been completely exposed in the cruciform position from the start of the anaesthetic) is soaking in alcoholic betadine antiseptic. 4 small drapes are applied in a square around the hernia site and held with towel clips (if they have any). Then they open a large disposable laparotomy drape, better than most that I have seen in NZ. I suspect they have recently been supplied with these for use at this time. If they need any extra drapes, they use a resterilized disposable gown. Then the operation can begin. A diathermy plate (disposable but reused) is loosely applied to the calf. JC tried to get them to apply a bandage to make sure it had good contact but they have no bandages. Consequently, the diathermy is very temperamental and I use it as little as possible. I was then handed the “blade” to make the incision. Sometimes they do not have a scalpel handle in the set so they use an artery forcep to hold the blade. The problem is that the forceps are not that good so the blade will fold in the forcep if it is not clamped firmly.

The hernia was very straightforward with the most obvious difference with hernias in NZ is the almost complete absence of fat between the layers. These lads are lean machines! We knew therewas no testis on that side or a spermatic cord to preserve. I think the young man probably had a neonatal torsion of the testis in utero. We did check that there was no palpable intra abdominal testis before removing the sac. With no cord, I usually close the inguinal canal so I did not do my usual Maloney Darn. Instead (shock, horror) I did the old fashioned Bassinni repair, much to their delight (they think they have taught me to do hernias their way). Mind you I find it very hard communicating when I do not know the French or Creole so I was not always sure what was being said as I proceeded. It is clear that JC is making a much bigger impact by being able to speak French. There are some residents with a good grasp of English. One of the first year residents came to me to ask if I would teach him the anatomy of the inguinal canal. One of the second year residents (Gilbert) has the record for learning to do hernias in 6 months and this resident wants to beat that record. I'm not sure that after 30 years of doing hernias I can say I have mastered it completely, but that is the way here in Haiti. I was able to give some tips during the down times in my day but it was clear he has not got even a basic understanding of the anatomy yet.

By this time, JC had started his last case in the small room. It was an excision of distal ulna that was protruding through the skin after a bad fracture of the distal radius and ulna some months before. The local witchdoctor had been consulted but the bone was still sticking through the skin. JC managed to find an Esmarch bandage to act as tourniquet to reduce bleeding. During

the procedure he noted a fly landing on the sterile field. The Haitians joked that this was a new sterile species of fly they breed here.

Eventually, they day was done about 5.30pm and we took a taxis home through the light rain that was still falling at dusk. The others were waiting for their dinner (shepherd pie!). The frustrations of any hospital system are evident here. Surgeons being bumped for a more urgent case, slow turnover, inadequate preoperative assessment delaying operations, equipment failure, unnecessary rituals, are all magnified here by the lack of infrastructure. Nevertheless, they do very well for the limitations they have. It makes the complaints we make at home look stupid. We have so much but are ungrateful. They have so little, but are thankful for what little they are able to do.

This last picture above shows Dale's emotional farewell lunch at the rehabilitation centre on Tuesday. She had certainly made an impact by the time she left on Wednesday to return to NZ. I with Kim and Steve will be following next Wednesday as another physio arrives.

Teaching at the hospital, Preaching at church

What I hear you say? Two blogs in two days? He is exceeding himself! I know some of you will be wondering how I got on with my message at church yesterday so thought I should fill you in. But there are no pictures.

I have been teaching the residents with translation which is very limiting. I did a session on biliary surgery that took almost 2 hours and then one on gastric surgery for 1 and a half hours. They say they do a lot of these operations but in over 3 weeks I have not seen anything more major than a hernia and frankly, I do not see how they could cope with a gastrectomy in the theatre conditions. I think it is similar to what was happening 30 years ago in the west where surgeons overestimated the number of cases they were doing and grossly underestimated their complications. This week they want me to talk about colorectal surgery. My teaching is very limited without French or Creole. Some of the residents are very capable, but have little or no future. They would love to travel for further study. Those that have good English have a little more potential. The main job for the senior resident is to find any place where there could be an exchange of of residents for training. I have been asked about possibilities for an NZ exchange but it would be the cost that would prevent it. They earn about $200US a month in Haiti!

So what about preaching. I must admit I was rather apprehensive about the task of preaching to about 3000 Haitians with Robyn as my interpreter. We went over my notes which I had written onto my computer and she was very supportive in the tenor of the message.

On Sunday I left about 5.40 to walk to church in my jacket and tie. The service was led by a male choir which I would have loved to film but I was ushered on stage to sit near a fan which kept me very cool. It was very much appreciated in my attire and the heat. Two readings - Isa 53 and John 10 were my choices. There was a heartfelt community singing of "Bringing in the sheaves" in which they went round shaking hands and moving to the rhythm. Then I was on with Robyn translating. I called it "A message from NZ" or "Icons of NZ". I had planned to speak about 3 icons - the sheep, the kiwi and the paua. There was some consternation at the start when I spoke of icons of Haiti being the earthquake and then voodoo - almost a gasp but I quickly spoke of my delight in seeing a thriving Christian community here and turned to verses in 1 John 4:4 (Greater is he that is in you than he that is in the world) and Romans 5 (Where sin abounded, grace did more abound) and the amens started resounding. They do not listen in silence as we do in the West but where they join in the scripture readings and respond positively to any encouragement. I spoke of the icons of sheep (Isa 53 - we all go astray, John 10 - we all need a shepherd and John 1:29 - Jesus was God's lamb, slain for us) telling of the story of Shrek who avoided the shepherd's care for 6 years, becoming so heavy with wool he could hardly move. I then spoke of the kiwi, unable to fly even though it has wings. I told the story of the eagle chick raised in a hencoop, scratching around in the ground when it should be flying. The application was that Ephesians tells us that Christians are born to soar but in reality we spend our time earthbound, not realizing that we were born to fly. I encouraged them to lift their eyes to see their destiny in Jesus and there were lots of approving "Amens". At this stage, I could see were almost out of time so I dropped the last icon (the paua) and concluded with our need to recognize that whether in Haiti or in NZ, this world is not our ultimate home. We are citizens of heaven and when we gather round the lamb (Rev 5), then we will be home. Plenty of amens followed. They sang a song and the service was over, about 2 hours and 10 mins long. It was a great sense of relief. Robyn did have a coughing fit just near the end but I got a bottle of water from Kim that revived her and she was able to finish. She felt it went very well, despite missing the paua icon.

Then it was time for our weekly Sunday treat - a trip to the hotel "Roi Christophe" for our Sunday breakfast (omlette with cheese and ham for me) and then a swim in the pool. Robyn did not come this time as she felt obliged to look after Steve. I managed to honeypot Dale (caught on video). It was very relaxing as I wrote a postcard and during the breakfast saw the NZ Italy World Cup soccer match on TV 1-1 against the World champions! Wow! Here they mainly support Argentina or Brazil but there is a growing admiration for our little country doing great things among the giants

Visiting Port au Prince

There is a lot I could write about after a week of activity here. I dare not mention the "S" word again (s is for squi....) as Catherine said that she did not appreciate the detailed descriptions of my bodily functions. Suffice it to say there have been no "s" words for me in the last week. My colleague Steve has been a different matter - "s" "v" temps dehydrationbut youwill not want to know all about that. I will leave Steve to tell you when he gets better. I could tell you of the "operations in hell" this week - the only theatre light failing at the critical moment as I tried to do a hernia darn in the dark. I could mention dealing with gunshot trauma like I have never seen before. Or I could tell you of Kim our newly arrived physio getting into the rehabilitation work with Dale. But I think I will tell you of the exciting excursion to Port au Prince in the earthquake zone and hope that does not offend sensibilities.

Our flight left Cap Haitien at 6.50am so we were in a taxi heading to the airport about 5.40am - another early start. Steve did not come as he was still unwell so Robyn, Dale, Kim and I were on the flight. There were about 8 others in the 20 seater twin engine turboprop plane. As we took off to the south we did not see much of Cap Haitien but in passing through the clouds and while my video camera was running I suddenly saw the Citadel off the left wingtip about 100 meters away. This is the hilltop fort built by the King of Northern Haiti about 1812. It was quite bumpy until we got through the clouds and it was

smooth flying from there. It took about 25 mins to get to Port au Prince coming in from the sea with the city to the right, not my side. Not a lot to see of the earthquake from the air. We got into the airport to await Joshua Octeus, the president of the Evangelical church of Haiti who Robyn had asked to show us around. He had been in Dominican Republic the day before so was rather tired and was over an hour late picking us up but very apologetic. He was a delightful man. Our first priority was

breakfast so Joshua took us through the back streets of Port au Prince to Epid'or a French

pastry shop, guarded as usual with a shotgun toting guard. I chose to have a 'cold' bacon and egg burger while others had a warm ham and cheese croissant - they got the better deal.

The tour of the city was something else. 5 months after the killer quake, there were still piles of rubble everywhere and many buildings uninhabited with obvious cracks. There were still throngs of people - we could hardly imagine what it would be like with and extra 300,000 people. The United Nations were patrolling the streets but are seen as pretty ineffectual by most people. They observe but do not intervene.

Robyn was in shock as we toured - she had seen the former glory of the presidential buildings, the ministry buildings, military barracks and the cathedral, all now destroyed, just crumbling ruins. In the central parks and open spaces were thousands of tents and blue tarpaulins where families who are homeless live. There were water tankers delivering water, portaloos lined up at strategic points. I felt a very conspicious rubber necker. At times we heard shouts of "Go home" as we crept slowly

among the other traffic. After just

over 2 hours of this I had seen enough. The basic roads were in better condition, than at Cap, even some roads with 2 lanes each way and there were even traffic lights! Sometimes I felt embarrassed as we held up traffic to take photos but Joshua wanted us to see it all. On some stretches of road, the tents went for miles. It was heartbreaking. Meanwhile, many buildings were uninhabitable and others had been partly reconstructed with what looked very dubious materials.

On the journey, we had one stop where the Toyota 4WD and not started - sounded like a starter motor problem. Fortunately we were on a

slope and managed to run it down and then into gear. It started later when at Epid'or.

However, we were diverted near the airport to a very rough road and when turning back onto the main road the car stalled trying to get over a big kerb. Then it would not restart. We got out as traffic mounted the kerb to get round us. Another truck pushed us backwards to get us started but our driver had the gear in forward so it did not start. Eventually we manuvered into a place where 5 of us pushed the car for a few meters and got it going again after much yelling and screaming. We finally got back into the traffic but decided we had enough of

sightseeing to went to a restaurant near the airport where in an air conditioned room we relaxed. I had an ice cream, others had cake and coffee and plenty of water. We talked with Joshua about our impressions and his desire to set up yet another training facility of Haitians under the auspices of the church. One of the problems here is they they are training people for jobs that do not exist. There are nursing training, medical, legal etc etc but no where for them to work when trained. Furthermore, the culture does not accept the disabled as worth treating so the physios are up against it. If any training would be valuable, it would be physiotherapy (there is no training in Haiti for physio and what our physios are doing is being appeciated) but the benefits of treating disabled in a culture which sees amputees and worthless is going to be a hard task. Dr Vulcain at St Justiniens does see the benefits and is promoting what Dale and Kim are doing. But attitudes are harder to change than structures and the concern is when our physios leave, the program

will stop. We feel so impotent to deal with the overwhelming problems in a country with so great a need, so many people and yet so difficult to get even a basic change accomplished. Rubbish is a huge problem, particularly plastic which is tossed into the streets and washed into the sea when it rains. Regulations - just will not work. Electricity, fire dept, police are utterly ineffective. There have been at least 6 fires at the hospital in the last few years. The fire truck which is only mobilized once authorized from Port au Prince has always arrived to dampen the ashes. All the fires have started from electrical faults and would have been put out by a fire extinguisher easily, but there are none. An organization supplied 50 fire extinguishers for the hospital but the administration said it was not their responsibility to fit them on the walls at appropriate places. So they lie in a container and the fires continue. Steve watched a fire near theatre on an outside pole at an electrical switch. A few wires were pulled until it stopped and the wires left dangling. What can you do? It is mainly infrastructure that needs to be tackled but where to start? It seems impossible!

After about 2 hours of lounging in the restaurant, we decided to wait at the airport, even though it was 2 hours before our flight left at 4pm. We went through the security screen much like any other western airport system but without too much concern when things went beep. Robyn was very tired and tried to sleep before we boarded. The 25 minute flight was uneventful as we went through the clouds and landed at Cap.

I think it will be years before Port au Prince is cleared of the tents and some of the rebuilding of the ministries and buildings is started. They have so little and it seems as if they are totally dependent on aid. We saw a lot of "mission" based people coming in - young people clad in the same tee shirts that announced that they were doing their 2-3 week mission stint, mostly from the USA. I guess they mean well but really what can they do without the language and understanding the culture. In the meantime, we all do a little bit and maybe affect a few individuals. For them it will be worthwhile but the masses struggle on.

Another week in Haiti

Its the end of another week here in Haiti with a variety of experiences to recount. We are living in the house shown left. It belongs to Enoch a well educated and travelled (but single) Haitian who has graciously given up his bed and facilities for us. It is meant to be the wet season here but we have seen very little rain, just hot, hot, hot! It has been very difficult to cope with, especially when the power goes off at midnight and the fans stop, there is no breeze, and the mosquitoes move in for the kill. The mosquito net makes the intense heat even more intense, so one has to decide on avoiding the bites or a minor measure of comfort without the net. My worst night yet was Friday when after a meal of spaghetti bolognaise I could feel it sitting in my stomach and not moving on. After a 4 squit day a few days before, I resorted to the lomotil which stopped the squits but left me a little uncomfortable. When the squits began again on Friday, I decided to wait till the morning but never got any sleep with the heat, stomach squirms, profuse sweating, lack of fan etc. Finally at 1 am I got up to see if a squit would help - it came easily enough but did not reduce my discomfort. So I took what is called a shower here, more like a sprinkle with the odd drop thrown in (Oh how I miss my 13l/min high pressure shower of home). After 5 minutes under the sprinkle, collecting all the water in the baby's bath so it can be reused to flush the toilet, and collecting the drips that come off the faucet, I usually have half a jug of water to pour over my head as a refreshing finale. Having completed my sprinkle, I sat in the darkened lounge for a few minutes before the stomach announced "my turn" and I dashed back to the loo to empty the contents and "flush" the toilet (if you can call an ineffective American style toilet a flush) with the water I had just showered in. I struggled back to bed, but the heat had not abated and I did not get to sleep until about 4pm. The sun rises at 5pm and the fans came on about an hour later so I did get a lie in and a bit more sleep. Another lomotil and a cautious day eating has brought me back round again so today, Sunday, things are back to normal (ie no squits, settled stomach, ocean breeze and a good nights sleep last night.

Sunday is the highlight of my week as we get to have one special treat - a swim at a local hotel. Today it was at the Christophe Hotel. The swimming pool was less soupy than the one last week and I spent about 90 minutes in and out of the coolish water - probably more tepid than cool but very refreshing. This was after church (6-8am) and breakfast at the hotel. The other special treat I had for the first time here was on Saturday night when we had an icecream! I could not resist despite my settling stomach. I did not ask how much it cost.

Well, what of my week? I had previously described surgery as operating in hell. It certainly would not pass any accreditation organization in the west but they do remarkably well for the little they have. They recycle everything. Even the paper disposable gowns are resterilized until they start falling to bits. I have seen some of the donated instruments appear on the trays so that is pleasing. My teaching seems to be appreciated - next week I have to deal with colorectal operations. I have also been asked to cover the residents for emergencies next week as the surgeon superintendent, Dr Kok, will be in the USA. There are 3 final (4th) year residents who seem very knowledgeable and capable, although like most senior registrars in our system they are always keen to operate. We had a good example this week of a shooting where the bullet had entered just above the symphysis pubis and ended up in the left upper lateral thigh. They were ready to go to theater, even though there were no peritoneal signs and a catheter had not been placed in the bladder. When it finally was placed, the urine was clear indicating the bladder was intact so observation was advised. Under these 3 senior residents are about 8 other residents (trainees in surgery) all keen to get some cases under their belt. Most of them get to do dressings in the ward as their main activity, and occasionally they will be asked to come to theatre. I got to spend some time with one of them in his room in the doctors residence on the hospital site. He as a first year surgical resident earns US$200 a month, when he gets paid. Sometimes the government does not pay the staff for months (7 months recently) but they do get their accommodation supplied. When I asked their most senior resident what his future was, he smiled and looked quite wistful as he said, "All I can do is dream". He would love to do further study abroad but there are no openings, even though he is quite experienced and very capable. Jobs in Haiti are few and his future looks bleak. Trained but nowhere to go!

On Friday, I was waiting for action in theatre but nothing seemed to be happening. So I decided

to go to the clinic, but it was deserted. The charts of some patients were there but no docs! Then the penny dropped. The soccer world cup first game was on and everything stopped so it could be seen. During this time a man who had crashed his motorcycle came to A&E and I was asked to assess whether the severe laceration to upper and lower lip could be dealt with under general or local anaesthetic. I thought the latter so between the first and second games of the cup, the team swung into action. I was invited to assist with the debridement of a heavily contaminated wound which had also ripped some of the teeth and bone from his lower jaw and there were compound fractures of the alveolar ridge but the body of the mandible was intact. It was quite a plastic procedure to align the torn lips and repair what we could of the mouth but it came together quite well under local anaesthetic. Fortunately, they seem to have the range of antibiotics that we would use in a similar case in NZ.

Recreation? Yes we do have some time off for that. Saturday, the physios had to work the morning for some American bigwigs who tended to belittle their contribution (which as I have said before, I think has been the most important of the team to date). In the afternoon, we had the use of a 2 door Isuzu 4WD and decided to go to Milot which lies close to the foot of the

Citadel. This fort built in the early 1800s by a despotic Haitian ruler (Christophe) is at 30oo feet dominating the skyline and in its building cost the lives of 20000 slaves. We hope to climb it in 2 weeks. This trip was to view the palace at Sans Souci near Milot, one of 8 he built. It is a very impressive ruin. He clearly was a megalomaniac with a fortress around it and tunnels linking parts of it to the cathedral, all built on a grand scale like the castles in Europe.

On the trip to Milot, the universal joint on the drive shaft of the Isuzu broke, leaving us stranded. The friend of Robyn who loaned the

car, James known as JP, came out with 2 mechanics and had it fixed on the side of the road in no time! But that is the way it is in Haiti. If it cannot be fixed, it is pushed to the side and can be stripped for bits that others may need. All this happened near a roadworks where bulldozers were ripping up the bitumen and as fast as it was ripped up, families of surrounding houses were carting the slabs off to place around their homes as crazy paving - much better than walking through mud when it rains. They may even get some cement to fill the cracks between the slabs.

Transport here is mainly by motorbike, taptap (usually a Toyota Ute with seats and a kind of canopy over the top) or taxi. I have been told off for using a motorcycle as they can lead you anywhere (kidnappings are not uncommon here). Taptaps go certain routes out of town and roar down the rutted and speedbumped roads at incredible speeds excess passengers hanging off the back, ducking and weaving between pedestrians and the motorbikes. But the taxis are something else. They have probably been unwarrantable for years but despite the body rust,

grossly cracked windscreens, unsuspended suspensions, absence of handles on doors, ominous rubbing sounds under the car and a precariously perched "Taxi" sign on part of the roof, they seem to get us round town. It is their amazing maneuverability down streets that barely fit 2 cars in them and then there are the precariously parked vehicles and even trucks that just stop so they have t find another route. Everywhere we go, there is the toot of cars and motorbikes (some sound like sirens or foghorns) as they warn pedestrians to move of be moved! For all this congestion, it is amazing that I have not seen any accident - not that you would notice another dent in the bodywork of most vehicles.

Well I think that wraps up another week in Haiti. The picture right was taken at the Palace at Sans Souci and shows Steve Benford in blue, our English/NZ anaesthetist, Charlot, the tour guide in purple, JP, who came to fix his car that we broke and yours truly. Tonight is is a little cooler outside as I sit in the breeze and it looks as if it might rain. Our well has threatened to run dry and we have occasionally had to hand draw water up out of the well when the pump will not work - either the power has cut off again or the pump broke. All a bit uncertain but the is Haiti.

Do check out Steve Benford's detailed blog at http://frstevebenford.blogspot.com/

Singing in heaven, Operating in Hell

I have been here for 1 week now and experienced highs and lows, exemplified by the last few days. Sunday was church day, with the main service at the indigenous Evangelical church of Haiti commencing at 6am! And what a crowd! About 3000 people crammed into the building occupying 4 levels and those who were on the lowest level and at the upper levels unable to see the pulpit had closed circuit TV to view the proceedings. It was already hot when it started but there were numerous fans going. We were placed in a prime position as I was going to be introduced to the congregation. The service went on for three and a half hours. There was a lot of singing, including a great male choir. There were keyboards and a xylophone which kept the pitch right when the power went off as it did once. We were more concerned about the fans that slowed their rotational movement of precious air. But in some ways, the singing of 3000 voices was even more effective without the accompaniment. The sermon, as preparation for communion that Sunday was on Numbers chapter 5 which deals with the Levitical law of dealing with a jealous husband who accuses his wife of two timing! It was extraordinary the way he developed it into the way we should examine ourselves before we take the communion emblems. During the distribution of the emblems which took about 20 minutes each time, there was more delightful communal singing and some items. Most of the tunes were familiar to me but the Creole words were new. There was joy and enthusiasm in the faces of many of the people. I gave a short greeting from New Zealand, explaining why I was here. I have been asked to take the sermon in 2 weeks time - HELP!

Traditionally after church, people have pumpkin soup for breakfast - not just the liquid kind but laden with small potatoes, beef bones, some other veges, all very nice. Then came the highlight of the day - a trip to a local hotel that had... wait for it.... a swimming pool! Ah the bliss of being wet all over (even if it was tepid water), relaxing with a view over the bay, iced drink, ham and cheese sandwich in hand, being cooked like a lobster... oops! I tried to stay

in the shade and kept my sunhat on except when in the pool but with a lid like mine, the sun is bound to have a go at it. It is not painful or really burnt, just red. But it was worth it.

In the afternoon we were back at the church for a session on spiritual medicine led by Pastor Megy for doctors and nurses involved in the church. At this time, my stomach was starting to churn, the 'D' had manifested themselves without the 'V's so I decided to forgo any tea. I have continued to have the "squits" yesterday a 3 squit day and today only one so it is improving.

Monday was fairly quiet - a ward round, a clinic, then the chief of Surgery Dr Barrella did his weekly round. He has a good rapport with the students and is like a big cuddly teddy bear. My opinion was asked on a few cases but I am feeling a little redundant otherwise. However, they decided to give me a teaching session starting at 7am the next day with the topic of biliary surgery. I had a quick review using the RACS website library to get the main headings. I forwent breakfast to get to the hospital on the back of a motorbike about 6.45 and about 15 docs attended. I am not sure how many could understand my English but half way through, one of them started translating as he could see some listening with their eyes closed.

After almost 2 hours, I called it quits. They had 2 operations scheduled that day but there had been a city wide power cut that morning so theatre was less than functional. I was invited to do the first case- repair of an umbilical hernia. With no fans or air conditioning, in thick gowns (reused) and gloves, I could feel the sweat poring down me. They do not have theatre nurses - the surgeons do it all, including the swab count (not), checking needles and selecting instruments. Early on I asked for the sissors and was handed some enormous shears that did not cut anything. So I tried the diathermy which worked only when the power came on, for a few minutes, then cut off. I ended up using artery forceps to do the disection. Meanwhile, the lighbulb over the table could not cast a shadow and during the power cuts disappeared completely leaving me struggling to see what I was doing. Each time the power came back on, the diathermy had to be reset. Then they could not find any sutures so we waited for 5 minutes while the senior hunted some down. They had not seen a Mayo repair of an umbilical hernia before and it was not easy under the conditions and with the minimal instruments available. But I got there and was glad to get out of that steaming theatre and get a cool drink. The next operation was an inguinal hernia done by the senior resident. He asked how I repaired hernias, but decided he would do his standard "Bassini repair", a technique abandoned by most western surgeons decades ago and for all the reasons I saw demonstrated. No local anaesthetic is used, it creates enormous tension on the groin structures producing a lot of postoperative pain and has a significantly higher recurrence rate than modern techniques. I got the distinct impression that because they do not get to operate very often, and there are about 8 residents in training all wanting to get their hands on cases that my presence was depriving them of opportunity to do things themselves and I can fully understand that. I know as a junior how I longed to get cases under my belt and to have some visiting bigwig stepping into my shoes was not appreciated. Nevertheless, I feel that despite the language problem the teaching was appreciated so I think that will be my niche.

So by midday, having taught for 2 hours and operated for 3, I was exhausted, dehydrated and very sympathetic to their difficult plight. I did bring some new instruments, (Courtesy of Braun NZ) for them so I will be interested to see if any of them appear in the trays during my stay. In the meantime, they have asked for a lecture on gastric surgery in 2 days time (7am again) so I will be hitting the books as it is some years since I did any. But that is tomorrow's task.

The second physio, Kim arrived this evening so now we are a team of 4 plus Robyn. Steve has been busy much of the day doing an orthopaedic list but on Monday, he had nothing to do as the hospital had run out of oxygen because on Sunday night they had done an emergency laparotomy on a doctor who had been shot in the back. That operation used all their theatre oxygen supply. Such is the situation in Haiti. Till next time, au revoir.

To the edge of darkness

Time for another post. It has been an eventful 3 days. Last Thursday being a Catholic holiday (Fete du Dieu) we did not go to the hospital but took a tour of the area around Cap Haitien starting with a trip up a hill to a view similar to the photo heading this blog. We were driven around by Major in a Nissan Pathfinder. He took us south to some famous monuments commemorating the Black Napoleon, who led the Haitian independence against France until tricked into boarding a French ship, being captured and taken back to a French prison where he died. Further south we visited a mission that Robyn had worked with in her early days in Haiti. Wherever Robyn goes there is always someone who will yell and scream to reunite an old friendship. We were heading to a town of Plaine du No, a centre for voodoo worship. After a bumpy ride over a rutted road through a more agricultural area we came to the town where the weekly voodoo ceremony was just starting. The priests carrying poles adorned with a cross and a black flag began to weave down the central plaza in front of the catholic cathedral. In the procession of worshippers waving coloured flags was a decorated bull about to be sacrificed in the Pool du Jacques. Robyn led us through the alleyways to the shrine where the blood would be presented. Already people were gathering and the rhythms of the drum beats were rising as people gathered for the event. This was the real thing, not just a show for tourists as there were no tourists except us. Some of us were getting quite spooked by it all but this was Major's home turf and he as a Christian was not affected by it. However, he and Robyn kept an eye on us and before things really got going, we decided to leave. I was reminded of that verse in 1 John 4:4 "Greater is he that is in us than he that is in the world". I was also reminded this morning that darkness can never overcome light. On the way home we toured a Christian radio station. That evening Bernadette cooked our evening meal. We are eating very well if not too well and rather than just having European meals are tasting the local fare. Fruit, beans, rice, with various meats and fish all done very well. So much for my hope of losing some more weight!

Friday was a hospital day in which I did my first operation. I arrived at the end of a ward round to find that the patient I had been asked to see three days before was still obstructed and they decided to operate that morning. I was given the honour of "principal surgeon" but there were 3 other surgeons assisting. I had borrowed a set of surgical scrubs from Steve Benford who was anaesthetizing. The docs all provide their own theatre scrubs. Glove selection was very limited. The operating theatre looks quite good in the photo below but conditions are very primitive and infection is a big problem. The air conditioning occasionally works, many things are reused (diathermy plates etc) and some theatres do not have any light. Steve used his penlight for the operator doing a haemorrhoidectomy. We found that our lady had a cancer of the stomach

with metastases in liver, omentum and ovaries (Kruckenburg tumours). We did a gastroenterostomy to bypass the stomach blockage but there is very little else that can be done for such and advanced cancer. Not a very auspicious start for my first case!

We were finished by midday so spent the afternoon with Robyn, chatting up her bank manager, and visiting Pastor Megy. He heads the large indigenous Evangelical Church of Haiti. They recently had a prayer march for all Christians in Cap that extended for 5 miles! He asked me to preach on Sunday 20th at his church which extends over 4 levels and about 800 in the congregation. For the evening meal we went out to Kokiyaj restaurant with a view over the bay at Cap Haitien. We had accra as an entree - grated taro with dried fish, deep fried. It was very nice. I then had poulet

nationale with creole sauce, a really tough old bird but the trimmings were good. Unfortunately near the end of my meal, I failed to notice in my fork of brown rice a chilli. Once bitten it took over. Fortunately, I was already sweating from the heat so the others did not notice my discomfort as I reached for my citron drink loaded with extra ice to cool my inflamed mouth. It lasted about 10 minutes, then calmed to a pleasant glow in the mouth which was not too bad.

Today, Saturday is free so after breakfast of sausages and eggs, we went for a walk in the oppressive heat along the coast from where we are staying. It is part of an old French fort, complete with rusting cannons. There was a slight breeze and I longed to jump into the cool waters like some of the locals were. At the end of the road was a hotel where we bought cool drinks and rested for the walk home. Robyn's heart condition keeps us all

going at a pleasant pace, not like our kids who are always charging ahead wondering why the heavies cannot keep up. I got my first diarrhoea today, possibly related to the chilli incident last night. It's not too bad but I have been a little cautious on my eating today, especially after Enoch, the local lad w

hose house we are staying in ate the meal we had as a takeaway, but threw it all back at us about an hour later. He immediately felt better. The others have had some bowel issues as well but I seem to be coming right very quickly. We have spent the evening relaxing and sweating, listening to my ipod, interrupted by Robyn and Dale in a 10 tone dump truck bringing a bigger bed for Steve to sleep on. Major was at the wheel, happily careering down the darkened streets with no lights and Robyn and Dale hanging on for dear life.

For those who want to look up Steve Benfords blog site go to http://frstevebenford.blogspot.com

My first dip into the clinical arena at St Justiniens Hospital

We made it across the border into Haiti the following morning, but not without some stresses. The Haitian immigration authorities wanted to see my return ticket to prove I was going to leave. We had to trek down a muddy bank through many big trucks blocking what passed for a road to the border bridge over the dividing river to get it, only to find that they did not want to see it anymore. Some official who knew Robyn asked why she was being delayed and they decided to forget the ticket. Meanwhile, the locals just carted goods, chickens and even people across the river without any immigration control. UN soldiers "observed" the border but are considered a joke by the locals because they never intervene, just observe! The road from the border to Cap Haitien was the best we have been on- fast, no potholes and we were at the town in just over an hour. Most of the roads in the Cap are being dug up and reconstructed in a haphazard fashion so there is dirt, dust and mud everywhere.

After a fruit breakfast, we visited the hospital for introductions and I was given a rundown of the programme for each week. I met Dr Barrella, the chief of Surgery and his chief resident,
Dr Bright who speaks good English. I was asked to see a patient with a
mass in the epigastrium. They have no CT, minimal (and very expensive)
ultrasound and were debating what to do. I thought a "mini" laparotomy
for biopsy would help make the diagnosis which I think is probably
intraperitoneal spread of a tumour into the omentum, possibly gastric
or ovarian primary. When we got back to the apartment where eveyrone
had being staying up until then, I began to flag with tiredness, and
lay on a couch, quickly falling asleep and being photographed as shown
in this undignified position by Steve.

I woke to go out for dinner out at a local restaurant but after shifting our bags to where Steve and I were to stay, I completely collapsed into a deep sleep, utterly exhausted.
The next morning, after a hearty breakfast of spaghetti and eggs
cooked by Robyn, Steve and I went to the hospital where I was welcomed
onto the ward round. 3 senior residents were taking the interns on a
round where some very advanced cases were presented. My opinion was
asked for on a few cases, through interpretation. Then there was an
outpatient clinic which was quite an eyeopener. Mind you, they are
working under extreme conditions (even the Haitian doctors were
sweating drops off their faces on the patients in a windowless room
with only open doors for ventilation). They have few resources and a
massive clinic load but such treatment of people as "cases" rather
than individual people would not be tolerated back home. I was more
like a cattle yard than a clinic, with people wandering in and out, 4
interns and 2 residents peering at them in undignified states of
undress and as for that weird hairless white stranger in the corner
who was never introduced, he looked more like a mortician! I witnessed
my first rectal examination in the undignified "knee-chest" position,
popular in some clinics in America but never seen in British style
institutions like NZ. Some people really needed operations for chronic
abscess but were given yet another course of antibiotics. A little
girl with a good story for inguinal hernia was examined by he intern
lying down, and not standing up as is important. I am finding that
because I do not understand the Creole and my smattering of French is
pretty useless that I have not been able to participate as much as I
would like. Nevertheless, the staff have been very welcoming,
translating the basic clinical information into English for me and
asking for my opinion. So my contribution will be limited. It may take
more time to develop and I have yet to go to the operating theatre but
from Steve's position as anaesthetist and having been here for over a
week, he finds the conditions very primitive and sometimes
distressing, but under the difficult circumstances they do
extraordinarily well. This evening, I am much refreshed without the
exhaustion and tiredness of last evening. Tomorrow is a public holiday
(Sante Christe) here so we are having a day off from the hospital as
there is no elective work. I hope I can be of some use. It is clear
that Dale, our physiotherapist has already made a huge contribution in
the rehabilitation area and is very much appreciated. Steve has also
been doing a number of anaesthetics but I am only just starting. I
will wait to see where I can be of most use. I can see that Jean-
Claude will have a massive advantage with his French lingo in teaching
in particular. Nevertheless, it is great to be part of a team making a
contribution. And with Robyn's unflagging enthusiasm for the task
despite her health problems we are all in good heart and enjoying
great fellowship together.

Arrival in Haiti

After a fairly uneventful trip I have arrived. 11 hours Auckland to
Los Angeles with a 5 hour stopover. I almost lost my phone but the
extensive security procedures at the airport reminded me that I left
it charging back in a rest area. Fortunately there was enough time to
leave security, get the phone and go through the procedures again!
Then in was 6 hours through a second night to New York where just had
enough time for a golden arches breakfast before catching the last leg
from NY to Santiago in the Dominican Republic that shares the island
of Hispanola with Haiti. Robyn had emailed to say that they had not
got over the border the night before as they shut it early for Mothers
Day. So she designated a young pastor in Santiago, Maxnet by name, to
pick me up. There were no problems at customs and my bags arrived with
me. After following Maxnet around while he negotiated transport to a
friends place with the cheaper taxis we scurried through the small
streets at what seemed undue haste, tooting all the way to keep
motorcycles aware of our presence. Later we took an even cheaper taxi
that could cram 7 people into 4 seats into town. I ended up stiing on
the automatic gear change stick next to the driver for the ride back!
Robyn Couper eventually made contact and picked me up for the made
dash to the border. Pastor Reuben was the driver of a beatup Toyota
ute. The road was pitted with potholes and the sealed bits have the
meanest judder bars I have ever seen. The taxis scrape their
undercarriage on them. We left it a bit late but in this old ratley
ute we passed the new model Subarus, Lexus, Ravs etc. The driving
habits were very similar to the Philippines and the Jeepney drivers
there. Just barge in and pray you don't get hit. And the overtaking
manoeuvers were unbelievable, especially for oncoming traffic. It was
a wonder we did not see more accidents. We ran into rain at times and
it was stifflingly hot but in the end failed to make the border before
it closed. So we were stuck in the border town for the night. We got
some Dominican Pesos, found a hotel and had a good feed before
retiring. It will be up at 5.30 to be at the border when it opens at
7am tomorrow so we can get into Haiti itself. First impressions are
like many 3rd world countries - very messy with litter everywhere,
people doing nothing and the typical 3rd world driving habits. It will
be interesting to see the medical side tomorrow at Cap Hatien.