This will be my final blog before I hit home. The last few days have been hectic with people wanting to say goodbye and the sudden realization that our time was at an end. On Sunday after church we spent the day at the Hotel Roi Christophe. We had breakfast there, watched the soccer on the large TV, went for a swim and generally lazed around. In the afternoon we stayed on to attend a party of an engaged couple Frantz and Cassandra who (as Robyn had been secretly told) were going to announce that they had been married recently. It started as an odd celebration. Everyone gathered in silence and waited over an hour for the couple to arrive. They slipped in unannounced – no music or anything. The sound system was not working initially, so there were more delays. Eventually they provided entertainment – a terrible rendition of Pachelbell's Canon on an electric violin with keyboard and guitar. The highlight however was when the groom’s all male choir got up to sing – fabulous harmonies with the groom as the lead singer. After much drawing out of the explanations for the celebration, the groom finally announced that he and his fiannce were married much to the shock and delight of their friends. The cake was cut and a huge meal was served but it had taken some time to get the party going.

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

final lecture on the retroperitoneum on Tuesday morning. The residents gave me a painting and a leather face mask. In the afternoon, one of the consultant surgeons, Dr Damas wanted to show Jean-Claude and me the ruins of the historic French fort Picolet. He took us in his car and we walked along the beach to the old fort built by the French in the late 1700s. There were many rusting old cannons lying around but the basic 2 tiered fortress was reasonably well preserved. It was part of a string of forts along this coast where Christopher Columbus first landed.

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.

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.