Snowflakes and gunshots : the mission concludes

The snowflakes in Halifax on our return were a subtle reminder of how far away Haiti is from us both geographically and culturally. All in all a very successful mission but there is still much to be done.

Our last day was a busy one, like the others. In the OR we had 2 cases to finish off the trip: a hemiarthroplasty for a hip fracture and a washout of a gunshot wound. The latter was in a friend of the Chief Medical Officer here at HBM. He was sitting in his car in Petionville when a couple of guys opened fire. He ducked, a bullet hit his shoulder and he floored it out of there. Just random violence and a reminder of how dangerous life still is here, even in the so-called good part of town, the part that gets coverage of its gourmet food in in-flight magazines!

The rest of the team were supposed to be heading out to a resort for the delayed field trip but that had to change due to rumours of possible disturbances in the wake of post-election controversy. Instead it was off to the pool at Visa Lodge for R & R instead. I couldn't go due to an unfortunately timed bout of gastroenteritis! Spent most of the rest of Friday in my bunk or rehydrating. Poor Darrell our hardworking paramedic got sick to with a nasty febrile illness. Not sure what he has and guesses from us range from influenza to Chinkungunya, or maybe some new zombie virus!! Decided his new nickname should be 'Patient Zero'! Poor guy is supposed to be working on Sunday!!

The team had fun in the sun and returned for some Christmas festivities, as the last night coincided with several of the parties back home. Karaoke continued into the wee hours. At least I was spared a hangover the next morning!!

The return journey was uneventful if long: started at 630 local with the bus taking us to the airport until 1130 wheels down at Halifax. Plenty of time in Miami and Philadelphia airports for some final bonding time with the team. Everyone was glad to be home even if the chill in the air was brutal after a week in 30 degree heat.

As I said there is still much to be done. Over the last few days everyone has been sorting through bags of equipment and other donations that piled high which highlights one problem going forward and one that afflicts many such projects: well meaning but useless donations! There was a lot of stuff sent that wasn't needed eg IV cannulae of which they have abundant supplies and David McCartney uncovered a lot of vintage ortho plates and screws that no-one would ever think of using in 2016! Going forward there needs to be a more structured approach to needs assessment pre-mission rather than everyone piling extra stuff in their bags because 'it might come in handy'. Sadly it often does not and ends up gathering dust in storage, hiding things that are needed.

In the OR and ER when the whole TBE could work from staff to junior things ran harmoniously but in areas where it was only nursing, paramedical and resident staff from us such as PICU and ICU there were occasionally communication breakdowns and a tendency fro the Haitian staff to shrink into the background rather than get involved. To build sustainability there is a need for better integration and skill sharing. I would certainly have liked the chance to work with and share ideas with the local anaesthesia staff but they were occupied in other ORs and at present there are no anaesthesia residents around. I think we as Team Broken Earth need a more formalised 'five year plan' for education that involves all with the Haitian staff being brought to the fore. 

Overall though I feel optimistic. The infrastructure has changed by leaps and bounds since I first came. See below for pictures of the new ICU which looks like it could be in any teaching hospital in North America. I look forward to returning and watch this vision for change continue to grow and improve the health of the people of Haiti. I hope the future of the country becomes more stable and that other countries continue to support their efforts to advance the quality of life of their people. After a troubled history they are surprisingly, and inspirationally, resilient: friendly positive and hardworking. 

Let's keep the momentum  going and continue to make a difference Team Broken Earth!

Jouk lé a pwochen.....

Airway Thursday

Its the last day today and I am the only one of the team up for breakfast so far. Not surprising really as Thursday was a busy day for everyone.

I had a deceptively leisurely start to the day as the Ortho team went to the University Hospital Le Paix for rounds and teaching. This was productive and they got some good pictures of the streets of Port au Prince in daylight which we haven't managed to see properly as you know.

Then it was back to the OR when they returned for the first of the hips that awaited us. First was a young gentleman who had broken his femur and had it fixed in another hospital. He came to Bernard Mevs when it became infected and the hip prosthesis had to be removed. The plan was to open it up, clean things out and put in a new hemi-arthroplasty. However it was not to be. After a couple of hours it became clear that a hemi wouldn't work as the cup in his pelvis had lost too much bone. Dave Amirault wisely bailed out as he began to lose blood. He needs a total hip and not a straightforward one. In the absence of appropriate kit and blood transfusion back up its back to square one for him meantime.

While all this was going on we heard that a patient was being helicoptered in with a big neck mass and a compromised airway who would require my attention. He got in just as the hip case ended and I went to see him in ER. Just as advertised he had a huge mass extending into his right chest and he was struggling to breathe. We decided we couldn't wait until the arrival of Haiti's one and only ENT surgeon and decided to intubate. Great teamwork was displayed by all, led by Jason Emsley. I topicalised his airway and with the help of my right hand man Brandon passed a bougie and subsequently a tube while the patient was awake. Success! Off to ICU to safely await further review or so I thought...

Ortho were productive in my absence and took a wire out of a shoulder under local. However activities were bumped by an appendicectomy the Bitars planned to do urgently and with a neonate in the other main OR we were on hold. Our plans were further scuppered when the autoclave packed in leaving the am with no clean hip instruments! So it was back to the barracks to await repair by the redoubtable Craig. 

Meanwhile in PICU the staff were treated to the sight of a parasitic worm crawling out of a tracheostomy! Yuk! Not the sort of thing you see in Halifax!!

After some McGuyvering the hip got underway around 7. Food for the OR team was ordered as takeout from the UN. Just when I thought the day was going our way one of the others ran across from ICU to tell me that there was a problem with the neck mass patient's tube. Yikes!Left Katy in charge of my patient and ran to ICU. He had got light and his tube displaced. Reintubation was difficult but I was ultimately succesful. However ventilation was challenging due to the extension of the mass into his chest. Sadly in spite of heroic efforts he succumbed overnight. Had he lived he would have required major thoracic/ENT surgery which would not have been easy here.

We finally sat down exhausted to fajitas and lemonade around 930. They tasted especially delicious after all that adventure. The night continued to be busy on the Paeds side with a lot of sick patients to manage. Plan today is a couple of cases then we will join the rest of the team for our delayed field trips to the El Rancho resort. Fingers crossed maybe our last day will go as planned.

Blog bonus

Ok a supplementary entry to share some of the work of the rest of the team who are staffing ER, PICU etc. We have been sharing our pics over a team WhatsApp chat and some of these are too good not to share.

Marc the logistician showing his wares

The lonely wait for patients in the clinic

Our best friend Martin, bartender at the UN

Front cover of Brandon's new album: a moody collection of love songs.

Dancing on the roof

The unusual site of an empty ER

Happiness in NICU

Noreen, Michelle and Bree on the roof

Darrell demonstrates some prestidigitation

Darrell attempts to hijack an ambulance

Some views of the neighbourhood

Wednesday

St Andrews day in Port au Prince was a busy one. We started in the OR with one of the pelvic fractures who have been waiting around. In the absence of a working CT scanner ( tube en route from Miami and a talkative tech from Indiana has been staying the last few days waiting for it) and a poor supply of blood open surgery is not an option. So it was an old school solution: reduction under GA and application of a spica plaster which will stay on for 6 weeks until his acetabulum knits together. His legs are the same length now but he is likely to walk with a limp once this is over.

Next up was another chapter in my life as a reluctant paediatric anaesthetist! There always seems to be a challenging child each time I come here. This was no different. A sweet 9 year old girl in Paediatric ICU  who was hit by a car and probably sustained a basal skull fracture. She had had a few seizures but was more alert when they noticed her right hand was tight and swollen so needed decompressing. After the usual OR challenges: in this case getting a blood pressure cuff cobbled together that would work, we proceeded. Looked as if it had been the result of an interstitial IV so only minimal work was required and we dropped her back off in PICU in good condition. Again kudos to Brandon for being my essential right hand man.

Last case of the day was an anxious young guy who had a painful tumour in his foot, probably an enchondroma. Needless to say we may never know what it was as there is no path loan here. The sample is given to the patient who may choose to pay to send it to Miami for pathology! I was joined by Darrell our resident paramedic, magician and troublemaker who was very keen we noted what time he was there. I strongly suspect he wasn't so much interested in anaesthesia as obtaining an alibi!!! He is sure to be up to something. Over the last few days he has been finding strange things in his pillows: started with bottle caps then pineapples!! I think he must have plotted revenge!

All done by 3pm which was welcomed by our hard working nursing team. Everyone was able to chill before dinner at MINUSTAH. Had a very nice beef teriyaki pita but had fajita envy looking at my fellow diners so they are on the agenda for tonight. Team chilled for the evening and decided on a resort for our delayed day trip which is on for Friday before Marc put Spectre on the big TV.

As the ortho team is off for rounds at Le Paix this morning I get a leisurely start to the day before  we get to work on some fractured hips. Stay tuned!