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.
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