Wednesday, January 5, 2011
Thursday, July 1, 2010


The last 2 days at work were not very busy for me. Steve decided to return to duties on Monday although he still was not completely back to normal. By Tuesday, he was feeling distinctly unwell again. Blood tests had confirmed that his illness was Dengue fever and it would take a good month to get over. On Tuesday, he was presented with a number of gifts from the anaesthetic people, much to his embarrassment. I had a similar presentation at the end of my

In the evening there were plans for people to visit to offer farewells. The surgical residents at the hospital had asked for a final meeting at a local hotel to review my visit and ask advice. It was heartening to see their gratitude for the little I had done and to hear of their concerns for the future. Frankly, I am overwhelmed by the magnitude of the problems they face. They are so keen to see changes made but where to start? What could I say? They desparately need some administrative structures in place in theatre to help them use the resources that they cannot get access to. They need simple things like sutures, dressings, instruments but the OR supplies are shut out to them through corruption and basically because no one really knows what they

do have. So they wander round with a small plastic bag of a few basic sutures and dressings they have begged and a foley catheter so they can do a catheterisation if needed. Patients have to buy their own IVs and bags of IV fluids. If they miss a drip, the patient has to send the relatives out to buy another IV cannula. These are the people who need the supplies but it is literally drip fed to them. I gave them all the sutures so kindly donated by Mercy Hospital Dunedin and they were so grateful. By sharing them around the residents, they will last a few weeks. They need books, or electronic media and opportunities to see other hospital systems but how can you afford that on $200 a month? I feel for these surgical residents who struggle against all odds to prop up a health service that is inadequate for the massive needs of the place.
The big question I have been asked by everyone as I leave is “When are you coming back?”. I feel that without the French language, I have made a limited impact, unlike Jean Claude who is already being highly respected and appreciated. Nevertheless, they have indicated that I have been helpful with the kind of teaching I have given. I have avoided the high tech discussions

that many American visitors have given as they do not have laparoscopes, CTs or any of the high tech gear, instead trying to pitch it at what they can do and that seems to have been appreciated. Will I be back? Not in June again if I can help it. They say December is cooler. But who knows what calling God has for any of us. If called to come back, I may have to. But in the meantime, I will look at various resources we can make available to these guys. My biggest encouragement in this land of voodoo infamy was to see a thriving Christian community, openly welcoming to strangers like me and very supportive of anything we can do to help their plight. To see such large congregations being fed from the Word of God so well was a great delight and my most enduring memory. Their physical health system my be overwhelming and in disarray but beneath that obvious surface, it was pleasing to see them spiritually more healthy than most

New Zealand communities. It reinforces what Paul said in 2 Cor.4:17 - “So we fix our eyes, not on what is seen, but on what is unseen. For what is seen is temporary but what is unseen is eternal.” And I think the Haitians have got it right, more so than most New Zealanders.
So home it is, and I cannot wait to enjoy cooler, even cold weather, a proper shower with plenty of hot water and the family around, especially Catherine. I ran out of video tape just as I crossed the border to Dominican Republic so there are 6 hours of tape to edit. That will keep me busy for a while.
Monday, June 28, 2010
Mission accomplished!

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





Saturday, June 26, 2010
A typical day in theatre


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

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.
Monday, June 21, 2010
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


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



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

Monday, June 14, 2010
Another week in Haiti







